Rosacea

WAIKOLOA, HAWAII – The best way to approach a patient with rosacea is to look at the individual symptoms, according to Linda Stein Gold, MD, director of dermatology research at Henry Ford Hospital in Detroit.

Vidyard Video

Papules and pustules need an oral or topical anti-inflammatory drug. Background erythema requires an alpha adrenergic agonist. Telangiectasia is best handled by a laser device, and if a patient has a phyma, “you’ve got to use a surgical approach,” she said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation. It sounds simple, but there are decisions to be made about what drugs and formulations to use, and when, and when to combine them.

In an interview, Dr. Stein Gold shared her approach to treatment, along with the latest on using ivermectin and brimonidine together, plus her thoughts on new medications under development and the role of the Demodex mite in rosacea.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

aotto@mdedge.com

WAIKOLOA, HAWAII – The best way to approach a patient with rosacea is to look at the individual symptoms, according to Linda Stein Gold, MD, director of dermatology research at Henry Ford Hospital in Detroit.

Vidyard Video

Papules and pustules need an oral or topical anti-inflammatory drug. Background erythema requires an alpha adrenergic agonist. Telangiectasia is best handled by a laser device, and if a patient has a phyma, “you’ve got to use a surgical approach,” she said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation. It sounds simple, but there are decisions to be made about what drugs and formulations to use, and when, and when to combine them.

In an interview, Dr. Stein Gold shared her approach to treatment, along with the latest on using ivermectin and brimonidine together, plus her thoughts on new medications under development and the role of the Demodex mite in rosacea.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

aotto@mdedge.com

WAIKOLOA, HAWAII – The best way to approach a patient with rosacea is to look at the individual symptoms, according to Linda Stein Gold, MD, director of dermatology research at Henry Ford Hospital in Detroit.

Vidyard Video

Papules and pustules need an oral or topical anti-inflammatory drug. Background erythema requires an alpha adrenergic agonist. Telangiectasia is best handled by a laser device, and if a patient has a phyma, “you’ve got to use a surgical approach,” she said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation. It sounds simple, but there are decisions to be made about what drugs and formulations to use, and when, and when to combine them.

In an interview, Dr. Stein Gold shared her approach to treatment, along with the latest on using ivermectin and brimonidine together, plus her thoughts on new medications under development and the role of the Demodex mite in rosacea.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

aotto@mdedge.com

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Rosacea has several known comorbidities, but the widespread use of their relative, rather than absolute, risks “may result in overestimation of the clinical importance of exposures,” Leonardo A. Tjahjono and his associates wrote.

For a patient with rosacea, the relative risk of hepatic cancer is 1.42, but the attributable risk and the number needed to harm (NNH), which provide “a clearer, absolute picture regarding the association” with rosacea, are 0.46 per 10,000 patient-years and 21,645, respectively. The relative risk of comorbid breast cancer is 1.25, compared with an attributable risk of 6.23 per 10,000 patient-years and an NNH of 1,606, Mr. Tjahjono of Wake Forest University in Winston-Salem, N.C., and his associates reported in the Journal of the American Academy of Dermatology.


Physician misconceptions based on patients’ relative risks of comorbidities may lead to increased cancer screenings, which “can provide great benefit in a proper context; however, they are not without consequences. For example, 0.7 % of liver biopsies result in severe intraperitoneal hematoma,” the investigators said.

The absolute risks – calculated by the investigators using cohort studies that were conducted from June 1, 2008, to June 1, 2018 – present “a better understanding regarding rosacea’s impact on public health and clinical settings, “ they wrote.

rfranki@mdedge.com

SOURCE: Tjahjono LA et al. J Am Acad Dermatol. 2019 Jan 14. doi: 10.1016/j.jaad.2019.01.013.

Rosacea has several known comorbidities, but the widespread use of their relative, rather than absolute, risks “may result in overestimation of the clinical importance of exposures,” Leonardo A. Tjahjono and his associates wrote.

For a patient with rosacea, the relative risk of hepatic cancer is 1.42, but the attributable risk and the number needed to harm (NNH), which provide “a clearer, absolute picture regarding the association” with rosacea, are 0.46 per 10,000 patient-years and 21,645, respectively. The relative risk of comorbid breast cancer is 1.25, compared with an attributable risk of 6.23 per 10,000 patient-years and an NNH of 1,606, Mr. Tjahjono of Wake Forest University in Winston-Salem, N.C., and his associates reported in the Journal of the American Academy of Dermatology.


Physician misconceptions based on patients’ relative risks of comorbidities may lead to increased cancer screenings, which “can provide great benefit in a proper context; however, they are not without consequences. For example, 0.7 % of liver biopsies result in severe intraperitoneal hematoma,” the investigators said.

The absolute risks – calculated by the investigators using cohort studies that were conducted from June 1, 2008, to June 1, 2018 – present “a better understanding regarding rosacea’s impact on public health and clinical settings, “ they wrote.

rfranki@mdedge.com

SOURCE: Tjahjono LA et al. J Am Acad Dermatol. 2019 Jan 14. doi: 10.1016/j.jaad.2019.01.013.

Rosacea has several known comorbidities, but the widespread use of their relative, rather than absolute, risks “may result in overestimation of the clinical importance of exposures,” Leonardo A. Tjahjono and his associates wrote.

For a patient with rosacea, the relative risk of hepatic cancer is 1.42, but the attributable risk and the number needed to harm (NNH), which provide “a clearer, absolute picture regarding the association” with rosacea, are 0.46 per 10,000 patient-years and 21,645, respectively. The relative risk of comorbid breast cancer is 1.25, compared with an attributable risk of 6.23 per 10,000 patient-years and an NNH of 1,606, Mr. Tjahjono of Wake Forest University in Winston-Salem, N.C., and his associates reported in the Journal of the American Academy of Dermatology.


Physician misconceptions based on patients’ relative risks of comorbidities may lead to increased cancer screenings, which “can provide great benefit in a proper context; however, they are not without consequences. For example, 0.7 % of liver biopsies result in severe intraperitoneal hematoma,” the investigators said.

The absolute risks – calculated by the investigators using cohort studies that were conducted from June 1, 2008, to June 1, 2018 – present “a better understanding regarding rosacea’s impact on public health and clinical settings, “ they wrote.

rfranki@mdedge.com

SOURCE: Tjahjono LA et al. J Am Acad Dermatol. 2019 Jan 14. doi: 10.1016/j.jaad.2019.01.013.

Patients were more likely to use branded topical medications for treatment of rosacea, and almost a quarter used a combination of topical therapies, according to a retrospective analysis of claims data published in the Journal of the American Academy of Dermatology.

“We found the mean annual cost of topical therapy for branded medications per person was nearly twice the cost of generics, despite the rise in generic drug costs,” Hadar Lev-Tov, MD, from the department of dermatology and cutaneous surgery at the University of Miami and his colleagues wrote in their study, published as a letter to the editor. “Thus, there is an opportunity to save healthcare costs, nearly $7.5 million annually, for this cohort.”

Dr. Lev-Tov and his colleagues performed an analysis of the MarketScan Commercial Claims and Encounters database to determine real-world costs and usage of rosacea medication and identified 72,173 adults with two or more claims for rosacea who visited a primary care provider, dermatologist, or ophthalmologist over 18 months, from January 2005 through December 2014. The majority of these patients – 62,074 (86%) – received topical medication therapy, while 4,463 (6%) of patients received oral therapy only. Of the patients who received topical therapy, 47,035 (75.8%) received single agent topical therapy and 15,039 (24.2%) patients used combination topical therapy. Metronidazole and azelaic acid were the most common combination used.

The researchers noted that this was “an important proportion” of patients who used combination topical therapy, despite it not being discussed in most guidelines. In addition, they added, “these medications are thought to work by similar mechanisms (anti-inflammatory, antioxidant, and KLK5 modulation) and to our knowledge have not been studied together.”

More patients were treated with branded topical medications (50,334) than with generics (39,621). With regard to price (calculated as the sum of insurance payments, copay, and deductible for each medication over 1 year), the mean annual cost of the branded topical medication was $308.02, compared with $160.37 for generic medications (P less than .0001). The researchers noted switching to a generic medication for treatment of rosacea would potentially save $147.65 per patient a year. (Costs were reported in 2015 US dollars.)

The researchers said their study was limited by lack of Medicare and Medicaid claims data, the retrospective study design, and dependence on an ICD-9 code only for diagnosis of rosacea, but they noted that 92% of patients received a diagnosis from a dermatologist. In addition, they recommended more studies be conducted on the cost-effectiveness of rosacea therapy when comparing systemic medications and topical therapies.

This study was funded in part by a grant from the American Acne and Rosacea Society. The authors report no relevant conflicts of interest.

SOURCE: Lev-Tov H et al. J Am Acad Dermatol. 2018. doi: 10.1016/j.jaad.2018.09.039.

Patients were more likely to use branded topical medications for treatment of rosacea, and almost a quarter used a combination of topical therapies, according to a retrospective analysis of claims data published in the Journal of the American Academy of Dermatology.

“We found the mean annual cost of topical therapy for branded medications per person was nearly twice the cost of generics, despite the rise in generic drug costs,” Hadar Lev-Tov, MD, from the department of dermatology and cutaneous surgery at the University of Miami and his colleagues wrote in their study, published as a letter to the editor. “Thus, there is an opportunity to save healthcare costs, nearly $7.5 million annually, for this cohort.”

Dr. Lev-Tov and his colleagues performed an analysis of the MarketScan Commercial Claims and Encounters database to determine real-world costs and usage of rosacea medication and identified 72,173 adults with two or more claims for rosacea who visited a primary care provider, dermatologist, or ophthalmologist over 18 months, from January 2005 through December 2014. The majority of these patients – 62,074 (86%) – received topical medication therapy, while 4,463 (6%) of patients received oral therapy only. Of the patients who received topical therapy, 47,035 (75.8%) received single agent topical therapy and 15,039 (24.2%) patients used combination topical therapy. Metronidazole and azelaic acid were the most common combination used.

The researchers noted that this was “an important proportion” of patients who used combination topical therapy, despite it not being discussed in most guidelines. In addition, they added, “these medications are thought to work by similar mechanisms (anti-inflammatory, antioxidant, and KLK5 modulation) and to our knowledge have not been studied together.”

More patients were treated with branded topical medications (50,334) than with generics (39,621). With regard to price (calculated as the sum of insurance payments, copay, and deductible for each medication over 1 year), the mean annual cost of the branded topical medication was $308.02, compared with $160.37 for generic medications (P less than .0001). The researchers noted switching to a generic medication for treatment of rosacea would potentially save $147.65 per patient a year. (Costs were reported in 2015 US dollars.)

The researchers said their study was limited by lack of Medicare and Medicaid claims data, the retrospective study design, and dependence on an ICD-9 code only for diagnosis of rosacea, but they noted that 92% of patients received a diagnosis from a dermatologist. In addition, they recommended more studies be conducted on the cost-effectiveness of rosacea therapy when comparing systemic medications and topical therapies.

This study was funded in part by a grant from the American Acne and Rosacea Society. The authors report no relevant conflicts of interest.

SOURCE: Lev-Tov H et al. J Am Acad Dermatol. 2018. doi: 10.1016/j.jaad.2018.09.039.

Patients were more likely to use branded topical medications for treatment of rosacea, and almost a quarter used a combination of topical therapies, according to a retrospective analysis of claims data published in the Journal of the American Academy of Dermatology.

“We found the mean annual cost of topical therapy for branded medications per person was nearly twice the cost of generics, despite the rise in generic drug costs,” Hadar Lev-Tov, MD, from the department of dermatology and cutaneous surgery at the University of Miami and his colleagues wrote in their study, published as a letter to the editor. “Thus, there is an opportunity to save healthcare costs, nearly $7.5 million annually, for this cohort.”

Dr. Lev-Tov and his colleagues performed an analysis of the MarketScan Commercial Claims and Encounters database to determine real-world costs and usage of rosacea medication and identified 72,173 adults with two or more claims for rosacea who visited a primary care provider, dermatologist, or ophthalmologist over 18 months, from January 2005 through December 2014. The majority of these patients – 62,074 (86%) – received topical medication therapy, while 4,463 (6%) of patients received oral therapy only. Of the patients who received topical therapy, 47,035 (75.8%) received single agent topical therapy and 15,039 (24.2%) patients used combination topical therapy. Metronidazole and azelaic acid were the most common combination used.

The researchers noted that this was “an important proportion” of patients who used combination topical therapy, despite it not being discussed in most guidelines. In addition, they added, “these medications are thought to work by similar mechanisms (anti-inflammatory, antioxidant, and KLK5 modulation) and to our knowledge have not been studied together.”

More patients were treated with branded topical medications (50,334) than with generics (39,621). With regard to price (calculated as the sum of insurance payments, copay, and deductible for each medication over 1 year), the mean annual cost of the branded topical medication was $308.02, compared with $160.37 for generic medications (P less than .0001). The researchers noted switching to a generic medication for treatment of rosacea would potentially save $147.65 per patient a year. (Costs were reported in 2015 US dollars.)

The researchers said their study was limited by lack of Medicare and Medicaid claims data, the retrospective study design, and dependence on an ICD-9 code only for diagnosis of rosacea, but they noted that 92% of patients received a diagnosis from a dermatologist. In addition, they recommended more studies be conducted on the cost-effectiveness of rosacea therapy when comparing systemic medications and topical therapies.

This study was funded in part by a grant from the American Acne and Rosacea Society. The authors report no relevant conflicts of interest.

SOURCE: Lev-Tov H et al. J Am Acad Dermatol. 2018. doi: 10.1016/j.jaad.2018.09.039.

Caffeinated coffee intake is linked to a decreased incidence of rosacea, results of a large, observational study suggest.

Lynda Banzi/MDedge News

Increased levels of caffeinated coffee consumption were associated with progressively lower levels of incident rosacea in a study of more than 82,000 participants representing more than 1.1 million person-years of follow-up.

By contrast, caffeine from other foods was not associated with rosacea incidence, reported Wen-Qing Li, PhD, of the department of dermatology at Brown University, Providence, R.I., and his coinvestigators. Those findings may have implications for the “causes and clinical approach” to rosacea.

“Our findings do not support limiting caffeine intake as a preventive strategy for rosacea,” they concluded in the study, published in JAMA Dermatology.

This is not the first study looking for potential links between rosacea and caffeine or coffee intake. However, previous studies didn’t distinguish between caffeinated coffee versus other beverages, and only one previous study made a distinction between the amounts of caffeine and coffee consumed, according to the authors.


Their research was based on data from the Nurses’ Health Study II, a prospective cohort study started in 1989. They looked specifically at 82,737 women who, in 2005, responded to the question about whether they had been diagnosed with rosacea. They identified 4,945 incident rosacea cases over the 1,120,051 person-years of follow-up.

A significant inverse association was found between caffeinated coffee intake and rosacea: Individuals who consumed four or more servings a day had a significantly lower risk of rosacea, compared with those who consumed one or fewer servings per month (hazard ratio, 0.77; 95% confidence interval, 0.69-0.87; P less than .001). They also found a dose-dependent effect, with the absolute risk of rosacea decreased by 131 per 100,000 person-years with at least four daily servings of caffeinated coffee, compared with under one serving a month.

National Rosacea Society

By contrast, decaffeinated coffee was not associated with a reduced risk of rosacea, and in further analysis, the investigators found that there was no significant inverse association when they looked just at caffeine intake from sources other than coffee, such as chocolate, tea, and soda.

Caffeine could influence rosacea incidence by one of several mechanisms, including its effect on vascular contractility, the investigators hypothesized. “Increased caffeine intake may decrease vasodilation and consequently lead to diminution of rosacea symptoms.”

However, caffeine also has documented immunosuppressant effects that could possibly decrease rosacea-associated inflammation and has been shown to modulate hormone levels. “Hormonal factors have been implicated in the development of rosacea, and caffeine can modulate hormone levels,” they wrote.

Two study authors reported disclosures related to AbbVie, Amgen, Astellas Pharma, Janssen, Merck, Novartis, and Pfizer, among others. Funding for the study came from several sources, including National Institutes of Health grants for the Nurses’ Health Study II.
 

SOURCE: Li W-Q et al. JAMA Dermatol. 2018 Oct 17. doi: 10.1001/jamadermatol.2018.3301.

Caffeinated coffee intake is linked to a decreased incidence of rosacea, results of a large, observational study suggest.

Lynda Banzi/MDedge News

Increased levels of caffeinated coffee consumption were associated with progressively lower levels of incident rosacea in a study of more than 82,000 participants representing more than 1.1 million person-years of follow-up.

By contrast, caffeine from other foods was not associated with rosacea incidence, reported Wen-Qing Li, PhD, of the department of dermatology at Brown University, Providence, R.I., and his coinvestigators. Those findings may have implications for the “causes and clinical approach” to rosacea.

“Our findings do not support limiting caffeine intake as a preventive strategy for rosacea,” they concluded in the study, published in JAMA Dermatology.

This is not the first study looking for potential links between rosacea and caffeine or coffee intake. However, previous studies didn’t distinguish between caffeinated coffee versus other beverages, and only one previous study made a distinction between the amounts of caffeine and coffee consumed, according to the authors.


Their research was based on data from the Nurses’ Health Study II, a prospective cohort study started in 1989. They looked specifically at 82,737 women who, in 2005, responded to the question about whether they had been diagnosed with rosacea. They identified 4,945 incident rosacea cases over the 1,120,051 person-years of follow-up.

A significant inverse association was found between caffeinated coffee intake and rosacea: Individuals who consumed four or more servings a day had a significantly lower risk of rosacea, compared with those who consumed one or fewer servings per month (hazard ratio, 0.77; 95% confidence interval, 0.69-0.87; P less than .001). They also found a dose-dependent effect, with the absolute risk of rosacea decreased by 131 per 100,000 person-years with at least four daily servings of caffeinated coffee, compared with under one serving a month.

National Rosacea Society

By contrast, decaffeinated coffee was not associated with a reduced risk of rosacea, and in further analysis, the investigators found that there was no significant inverse association when they looked just at caffeine intake from sources other than coffee, such as chocolate, tea, and soda.

Caffeine could influence rosacea incidence by one of several mechanisms, including its effect on vascular contractility, the investigators hypothesized. “Increased caffeine intake may decrease vasodilation and consequently lead to diminution of rosacea symptoms.”

However, caffeine also has documented immunosuppressant effects that could possibly decrease rosacea-associated inflammation and has been shown to modulate hormone levels. “Hormonal factors have been implicated in the development of rosacea, and caffeine can modulate hormone levels,” they wrote.

Two study authors reported disclosures related to AbbVie, Amgen, Astellas Pharma, Janssen, Merck, Novartis, and Pfizer, among others. Funding for the study came from several sources, including National Institutes of Health grants for the Nurses’ Health Study II.
 

SOURCE: Li W-Q et al. JAMA Dermatol. 2018 Oct 17. doi: 10.1001/jamadermatol.2018.3301.

Caffeinated coffee intake is linked to a decreased incidence of rosacea, results of a large, observational study suggest.

Lynda Banzi/MDedge News

Increased levels of caffeinated coffee consumption were associated with progressively lower levels of incident rosacea in a study of more than 82,000 participants representing more than 1.1 million person-years of follow-up.

By contrast, caffeine from other foods was not associated with rosacea incidence, reported Wen-Qing Li, PhD, of the department of dermatology at Brown University, Providence, R.I., and his coinvestigators. Those findings may have implications for the “causes and clinical approach” to rosacea.

“Our findings do not support limiting caffeine intake as a preventive strategy for rosacea,” they concluded in the study, published in JAMA Dermatology.

This is not the first study looking for potential links between rosacea and caffeine or coffee intake. However, previous studies didn’t distinguish between caffeinated coffee versus other beverages, and only one previous study made a distinction between the amounts of caffeine and coffee consumed, according to the authors.


Their research was based on data from the Nurses’ Health Study II, a prospective cohort study started in 1989. They looked specifically at 82,737 women who, in 2005, responded to the question about whether they had been diagnosed with rosacea. They identified 4,945 incident rosacea cases over the 1,120,051 person-years of follow-up.

A significant inverse association was found between caffeinated coffee intake and rosacea: Individuals who consumed four or more servings a day had a significantly lower risk of rosacea, compared with those who consumed one or fewer servings per month (hazard ratio, 0.77; 95% confidence interval, 0.69-0.87; P less than .001). They also found a dose-dependent effect, with the absolute risk of rosacea decreased by 131 per 100,000 person-years with at least four daily servings of caffeinated coffee, compared with under one serving a month.

National Rosacea Society

By contrast, decaffeinated coffee was not associated with a reduced risk of rosacea, and in further analysis, the investigators found that there was no significant inverse association when they looked just at caffeine intake from sources other than coffee, such as chocolate, tea, and soda.

Caffeine could influence rosacea incidence by one of several mechanisms, including its effect on vascular contractility, the investigators hypothesized. “Increased caffeine intake may decrease vasodilation and consequently lead to diminution of rosacea symptoms.”

However, caffeine also has documented immunosuppressant effects that could possibly decrease rosacea-associated inflammation and has been shown to modulate hormone levels. “Hormonal factors have been implicated in the development of rosacea, and caffeine can modulate hormone levels,” they wrote.

Two study authors reported disclosures related to AbbVie, Amgen, Astellas Pharma, Janssen, Merck, Novartis, and Pfizer, among others. Funding for the study came from several sources, including National Institutes of Health grants for the Nurses’ Health Study II.
 

SOURCE: Li W-Q et al. JAMA Dermatol. 2018 Oct 17. doi: 10.1001/jamadermatol.2018.3301.

MONTEREY, CALIF. – Julie C. Harper, MD, likes to warn her patients with acne about an unexpected possible side effect of treatment with isotretinoin. “You may become a dermatologist.”

After all, that’s exactly how Dr. Harper herself was inspired to pursue a career in dermatology. As a teenager, she had acne and was treated with isotretinoin three times. The experience was so influential that she went into dermatology with a specific goal of treating acne.

“I love all of it, and in my practice I treat everything,” said Dr. Harper, “but I have a special interest in helping people with acne be as clear as they can be.” Indeed, she helped found the American Acne and Rosacea Society, which she now serves as president.

Dr. Harper, who practices in Birmingham, Ala., spoke about her approach to acne and rosacea in an interview following one of her presentations at the annual Coastal Dermatology Symposium.

DERMATOLOGY NEWS: What drew you to focus on rosacea in addition to acne?

Dr. Harper: Acne and rosacea are often coupled together because both of them affect the face, and they create red bumps on the skin. But they’re very distinct diagnoses, and their pathogenesis is completely different. My interest in treating rosacea was secondary to acne, but I love to treat them both.

DN: Are they both equally challenging to treat?

Dr. Harper: In some ways, rosacea is more challenging to treat.

With acne, we have a pretty good algorithm for how we treat it. We can end with isotretinoin, which for many people is a cure. But we really don’t have that last step in rosacea.

DN: What are you doing differently with rosacea than you might not have done a few years ago?

Dr. Harper: More combination therapy. The trend is more toward a comprehensive combination approach to treat everything we see in rosacea: Hit this as hard as you can. Hit everything you see. Part of that is because we have some newer drugs like the alpha-adrenergic agonists that work differently than anything we’ve had before.

We have a couple of good combination studies. One study examined ivermectin plus brimonidine (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Those two worked better together if you did not delay the brimonidine for 4 weeks and only used it with the ivermectin for part of the study.


There are also the newer studies that look at doxycycline plus ivermectin and compare it with ivermectin plus placebo. The combination works better, and it works faster (Adv Ther. 2016;33[9]:1481-1501; unpublished clinical trial data on file with Galderma, NCT03075891).

On top of those treatments, we may need to add laser for background redness, or an oral beta-blocker for flushing if the patient still complains of the symptoms.

DN: What’s most challenging to treat in rosacea?

Dr. Harper: The redness and phymatous changes are the hardest. Once you get phymatous changes, you have to do a physical modality.

Most of us think that if we treat rosacea aggressively up front, maybe we can prevent the phymatous changes. Prevention is key, just like prevention of acne scarring is easier than getting rid of scars once you have it.

Other than phyma, it’s the redness. Even the Food and Drug Administration–approved products we have for redness don’t work for flushing. Patients stand up to give up a presentation and “Oh no, here comes a red face.” That’s the hardest part to manage.

DN: How do beta-blockers fare at treating flushing?

Dr. Harper: They can help, but I don’t know that they can knock it out completely.

And we should remember that there are no FDA-approved beta-blockers to treat this. Most of the data we have are small case reports or case series. We don’t have a lot of data.

DN: Is there anything that’s used too much in rosacea?

Dr. Harper: Probably metronidazole. I understand why it’s used. It’s not a bad drug. But we have better drugs now.

I think we use metronidazole whenever things aren’t covered by insurance. And we use it to do too many things. Don’t try to make metronidazole do everything.

Metronidazole is FDA-approved for papules and pustules. It wasn’t ever intended to help with flushing and background erythema, and you’ll need to use something else with it.

DN: What’s coming down the line for rosacea?

Dr. Harper: We’ve got a couple new antibiotics: a new topical antibiotic and another oral antibiotic.

DN: Let’s talk about acne. Do you think isotretinoin is underused?

Dr. Harper: We should be using more of it. Why do we hold this drug hostage from our patients? In many people, it will cure their acne if they take it for just 5-6 months.

Are we worried about inflammatory bowel disease? The most recent studies say that’s not really an association. Are we worried about depression? We’ve had a meta-analysis that suggests if you take all that data, depression – if anything – gets better in people who take isotretinoin (Am J Gastroenterol. 2014 Apr;109[4]:563-9; J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.e9).

We need to take [the risk with pregnancy] seriously. But we need to be putting more people on the drug and giving them the opportunity to be clear.

 

DN: What should be used less in acne?

Dr. Harper: We should use less antibiotics and more of everything else – more hormonal treatments, more isotretinoin, more topical retinoids.

That doesn’t mean no antibiotics. But instead of doing three repetitive courses of antibiotics, do one. If acne recurs, go to isotretinoin. Go to an alternative.

DN: What about spironolactone in acne?

Dr. Harper: It’s a blood pressure medicine, but it’s got an antiandrogenic qualities. It blocks the androgen receptor so it’s like getting the benefits of the birth control pill without the estrogen. It can be very beneficial for acne in women.

Its use increased from 2004 to 2013, and people are getting the hang of it. But when you compare it with the number of antibiotics prescribed, antibiotics are written a whole lot more (J Am Acad Dermatol. 2017 Sep;77[3],456-63.e4).

DN: Is there anything that is especially helpful in treating men?

Dr. Harper: Part of the way that birth control and spironolactone work is by decreasing sebum, and we don’t have anything like that for men. But potentially, there may be a topical antiandrogen product that decreases sebum.

DN: How do you deal with patients who are in a lot of distress because of acne or rosacea?

Dr. Harper: You listen to them and tell them you hear what they’re saying. “I understand that you want to be clear, and I’ll help you do that.”

Listen to why they’re not doing well and why they’re frustrated with what they’ve used. They might say, “I don’t use what you gave me because I don’t like the way it feels.” Or, “the drug that you prescribed is too expensive.”

If they’re really doing everything you said, and they’re not doing well, in both of those conditions it may be time for isotretinoin.

In acne, I’ve never seen it fail. It doesn’t work as predictably in rosacea, but it does pretty well if you do low-dose, intermittent isotretinoin.

DN: Do you ever try treatments that are unexpected for acne and rosacea?

Dr. Harper: If you use the right combination of what we have, and try to target pathogenesis, I don’t think we have to go off the reservation very often. We can get good results with what we have available.

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications. Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, La Roche–Posay, and Ortho Pharmaceutical, and has served as an investigator for Bayer.

MONTEREY, CALIF. – Julie C. Harper, MD, likes to warn her patients with acne about an unexpected possible side effect of treatment with isotretinoin. “You may become a dermatologist.”

After all, that’s exactly how Dr. Harper herself was inspired to pursue a career in dermatology. As a teenager, she had acne and was treated with isotretinoin three times. The experience was so influential that she went into dermatology with a specific goal of treating acne.

“I love all of it, and in my practice I treat everything,” said Dr. Harper, “but I have a special interest in helping people with acne be as clear as they can be.” Indeed, she helped found the American Acne and Rosacea Society, which she now serves as president.

Dr. Harper, who practices in Birmingham, Ala., spoke about her approach to acne and rosacea in an interview following one of her presentations at the annual Coastal Dermatology Symposium.

DERMATOLOGY NEWS: What drew you to focus on rosacea in addition to acne?

Dr. Harper: Acne and rosacea are often coupled together because both of them affect the face, and they create red bumps on the skin. But they’re very distinct diagnoses, and their pathogenesis is completely different. My interest in treating rosacea was secondary to acne, but I love to treat them both.

DN: Are they both equally challenging to treat?

Dr. Harper: In some ways, rosacea is more challenging to treat.

With acne, we have a pretty good algorithm for how we treat it. We can end with isotretinoin, which for many people is a cure. But we really don’t have that last step in rosacea.

DN: What are you doing differently with rosacea than you might not have done a few years ago?

Dr. Harper: More combination therapy. The trend is more toward a comprehensive combination approach to treat everything we see in rosacea: Hit this as hard as you can. Hit everything you see. Part of that is because we have some newer drugs like the alpha-adrenergic agonists that work differently than anything we’ve had before.

We have a couple of good combination studies. One study examined ivermectin plus brimonidine (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Those two worked better together if you did not delay the brimonidine for 4 weeks and only used it with the ivermectin for part of the study.


There are also the newer studies that look at doxycycline plus ivermectin and compare it with ivermectin plus placebo. The combination works better, and it works faster (Adv Ther. 2016;33[9]:1481-1501; unpublished clinical trial data on file with Galderma, NCT03075891).

On top of those treatments, we may need to add laser for background redness, or an oral beta-blocker for flushing if the patient still complains of the symptoms.

DN: What’s most challenging to treat in rosacea?

Dr. Harper: The redness and phymatous changes are the hardest. Once you get phymatous changes, you have to do a physical modality.

Most of us think that if we treat rosacea aggressively up front, maybe we can prevent the phymatous changes. Prevention is key, just like prevention of acne scarring is easier than getting rid of scars once you have it.

Other than phyma, it’s the redness. Even the Food and Drug Administration–approved products we have for redness don’t work for flushing. Patients stand up to give up a presentation and “Oh no, here comes a red face.” That’s the hardest part to manage.

DN: How do beta-blockers fare at treating flushing?

Dr. Harper: They can help, but I don’t know that they can knock it out completely.

And we should remember that there are no FDA-approved beta-blockers to treat this. Most of the data we have are small case reports or case series. We don’t have a lot of data.

DN: Is there anything that’s used too much in rosacea?

Dr. Harper: Probably metronidazole. I understand why it’s used. It’s not a bad drug. But we have better drugs now.

I think we use metronidazole whenever things aren’t covered by insurance. And we use it to do too many things. Don’t try to make metronidazole do everything.

Metronidazole is FDA-approved for papules and pustules. It wasn’t ever intended to help with flushing and background erythema, and you’ll need to use something else with it.

DN: What’s coming down the line for rosacea?

Dr. Harper: We’ve got a couple new antibiotics: a new topical antibiotic and another oral antibiotic.

DN: Let’s talk about acne. Do you think isotretinoin is underused?

Dr. Harper: We should be using more of it. Why do we hold this drug hostage from our patients? In many people, it will cure their acne if they take it for just 5-6 months.

Are we worried about inflammatory bowel disease? The most recent studies say that’s not really an association. Are we worried about depression? We’ve had a meta-analysis that suggests if you take all that data, depression – if anything – gets better in people who take isotretinoin (Am J Gastroenterol. 2014 Apr;109[4]:563-9; J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.e9).

We need to take [the risk with pregnancy] seriously. But we need to be putting more people on the drug and giving them the opportunity to be clear.

 

DN: What should be used less in acne?

Dr. Harper: We should use less antibiotics and more of everything else – more hormonal treatments, more isotretinoin, more topical retinoids.

That doesn’t mean no antibiotics. But instead of doing three repetitive courses of antibiotics, do one. If acne recurs, go to isotretinoin. Go to an alternative.

DN: What about spironolactone in acne?

Dr. Harper: It’s a blood pressure medicine, but it’s got an antiandrogenic qualities. It blocks the androgen receptor so it’s like getting the benefits of the birth control pill without the estrogen. It can be very beneficial for acne in women.

Its use increased from 2004 to 2013, and people are getting the hang of it. But when you compare it with the number of antibiotics prescribed, antibiotics are written a whole lot more (J Am Acad Dermatol. 2017 Sep;77[3],456-63.e4).

DN: Is there anything that is especially helpful in treating men?

Dr. Harper: Part of the way that birth control and spironolactone work is by decreasing sebum, and we don’t have anything like that for men. But potentially, there may be a topical antiandrogen product that decreases sebum.

DN: How do you deal with patients who are in a lot of distress because of acne or rosacea?

Dr. Harper: You listen to them and tell them you hear what they’re saying. “I understand that you want to be clear, and I’ll help you do that.”

Listen to why they’re not doing well and why they’re frustrated with what they’ve used. They might say, “I don’t use what you gave me because I don’t like the way it feels.” Or, “the drug that you prescribed is too expensive.”

If they’re really doing everything you said, and they’re not doing well, in both of those conditions it may be time for isotretinoin.

In acne, I’ve never seen it fail. It doesn’t work as predictably in rosacea, but it does pretty well if you do low-dose, intermittent isotretinoin.

DN: Do you ever try treatments that are unexpected for acne and rosacea?

Dr. Harper: If you use the right combination of what we have, and try to target pathogenesis, I don’t think we have to go off the reservation very often. We can get good results with what we have available.

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications. Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, La Roche–Posay, and Ortho Pharmaceutical, and has served as an investigator for Bayer.

MONTEREY, CALIF. – Julie C. Harper, MD, likes to warn her patients with acne about an unexpected possible side effect of treatment with isotretinoin. “You may become a dermatologist.”

After all, that’s exactly how Dr. Harper herself was inspired to pursue a career in dermatology. As a teenager, she had acne and was treated with isotretinoin three times. The experience was so influential that she went into dermatology with a specific goal of treating acne.

“I love all of it, and in my practice I treat everything,” said Dr. Harper, “but I have a special interest in helping people with acne be as clear as they can be.” Indeed, she helped found the American Acne and Rosacea Society, which she now serves as president.

Dr. Harper, who practices in Birmingham, Ala., spoke about her approach to acne and rosacea in an interview following one of her presentations at the annual Coastal Dermatology Symposium.

DERMATOLOGY NEWS: What drew you to focus on rosacea in addition to acne?

Dr. Harper: Acne and rosacea are often coupled together because both of them affect the face, and they create red bumps on the skin. But they’re very distinct diagnoses, and their pathogenesis is completely different. My interest in treating rosacea was secondary to acne, but I love to treat them both.

DN: Are they both equally challenging to treat?

Dr. Harper: In some ways, rosacea is more challenging to treat.

With acne, we have a pretty good algorithm for how we treat it. We can end with isotretinoin, which for many people is a cure. But we really don’t have that last step in rosacea.

DN: What are you doing differently with rosacea than you might not have done a few years ago?

Dr. Harper: More combination therapy. The trend is more toward a comprehensive combination approach to treat everything we see in rosacea: Hit this as hard as you can. Hit everything you see. Part of that is because we have some newer drugs like the alpha-adrenergic agonists that work differently than anything we’ve had before.

We have a couple of good combination studies. One study examined ivermectin plus brimonidine (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Those two worked better together if you did not delay the brimonidine for 4 weeks and only used it with the ivermectin for part of the study.


There are also the newer studies that look at doxycycline plus ivermectin and compare it with ivermectin plus placebo. The combination works better, and it works faster (Adv Ther. 2016;33[9]:1481-1501; unpublished clinical trial data on file with Galderma, NCT03075891).

On top of those treatments, we may need to add laser for background redness, or an oral beta-blocker for flushing if the patient still complains of the symptoms.

DN: What’s most challenging to treat in rosacea?

Dr. Harper: The redness and phymatous changes are the hardest. Once you get phymatous changes, you have to do a physical modality.

Most of us think that if we treat rosacea aggressively up front, maybe we can prevent the phymatous changes. Prevention is key, just like prevention of acne scarring is easier than getting rid of scars once you have it.

Other than phyma, it’s the redness. Even the Food and Drug Administration–approved products we have for redness don’t work for flushing. Patients stand up to give up a presentation and “Oh no, here comes a red face.” That’s the hardest part to manage.

DN: How do beta-blockers fare at treating flushing?

Dr. Harper: They can help, but I don’t know that they can knock it out completely.

And we should remember that there are no FDA-approved beta-blockers to treat this. Most of the data we have are small case reports or case series. We don’t have a lot of data.

DN: Is there anything that’s used too much in rosacea?

Dr. Harper: Probably metronidazole. I understand why it’s used. It’s not a bad drug. But we have better drugs now.

I think we use metronidazole whenever things aren’t covered by insurance. And we use it to do too many things. Don’t try to make metronidazole do everything.

Metronidazole is FDA-approved for papules and pustules. It wasn’t ever intended to help with flushing and background erythema, and you’ll need to use something else with it.

DN: What’s coming down the line for rosacea?

Dr. Harper: We’ve got a couple new antibiotics: a new topical antibiotic and another oral antibiotic.

DN: Let’s talk about acne. Do you think isotretinoin is underused?

Dr. Harper: We should be using more of it. Why do we hold this drug hostage from our patients? In many people, it will cure their acne if they take it for just 5-6 months.

Are we worried about inflammatory bowel disease? The most recent studies say that’s not really an association. Are we worried about depression? We’ve had a meta-analysis that suggests if you take all that data, depression – if anything – gets better in people who take isotretinoin (Am J Gastroenterol. 2014 Apr;109[4]:563-9; J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.e9).

We need to take [the risk with pregnancy] seriously. But we need to be putting more people on the drug and giving them the opportunity to be clear.

 

DN: What should be used less in acne?

Dr. Harper: We should use less antibiotics and more of everything else – more hormonal treatments, more isotretinoin, more topical retinoids.

That doesn’t mean no antibiotics. But instead of doing three repetitive courses of antibiotics, do one. If acne recurs, go to isotretinoin. Go to an alternative.

DN: What about spironolactone in acne?

Dr. Harper: It’s a blood pressure medicine, but it’s got an antiandrogenic qualities. It blocks the androgen receptor so it’s like getting the benefits of the birth control pill without the estrogen. It can be very beneficial for acne in women.

Its use increased from 2004 to 2013, and people are getting the hang of it. But when you compare it with the number of antibiotics prescribed, antibiotics are written a whole lot more (J Am Acad Dermatol. 2017 Sep;77[3],456-63.e4).

DN: Is there anything that is especially helpful in treating men?

Dr. Harper: Part of the way that birth control and spironolactone work is by decreasing sebum, and we don’t have anything like that for men. But potentially, there may be a topical antiandrogen product that decreases sebum.

DN: How do you deal with patients who are in a lot of distress because of acne or rosacea?

Dr. Harper: You listen to them and tell them you hear what they’re saying. “I understand that you want to be clear, and I’ll help you do that.”

Listen to why they’re not doing well and why they’re frustrated with what they’ve used. They might say, “I don’t use what you gave me because I don’t like the way it feels.” Or, “the drug that you prescribed is too expensive.”

If they’re really doing everything you said, and they’re not doing well, in both of those conditions it may be time for isotretinoin.

In acne, I’ve never seen it fail. It doesn’t work as predictably in rosacea, but it does pretty well if you do low-dose, intermittent isotretinoin.

DN: Do you ever try treatments that are unexpected for acne and rosacea?

Dr. Harper: If you use the right combination of what we have, and try to target pathogenesis, I don’t think we have to go off the reservation very often. We can get good results with what we have available.

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications. Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, La Roche–Posay, and Ortho Pharmaceutical, and has served as an investigator for Bayer.

Rosacea in skin of color is likely underdetected and suboptimally managed due to misperceptions that the condition is rare in this population, according to the authors of a clinical review article on the topic.

“Current reports of rosacea in patients with skin of color may point to a large pool of undiagnosed patients,” said Andrew F. Alexis, MD, chairman of the department of dermatology, Mount Sinai St. Luke’s and Mount Sinai West, New York, and his coauthors.

Increased awareness of rosacea in these patients may reduce disparities in disease management, they wrote in the review, published in the Journal of the American Academy of Dermatology, which outlines strategies for timely diagnosis and effective treatment of rosacea in skin of color.

The erroneous perception that rosacea does not occur in skin of color may arise from epidemiologic reports, which frequently position it as a disease that occurs in fair-skinned individuals of Northern European or Celtic background, they said.

The reported prevalence of rosacea in skin of color varies worldwide and is as high as 10%, according to the authors. Moreover, a recent U.S. medical care survey found that 3.9% of rosacea patients were Hispanic or Latino, 2.3% were Asian or Pacific Islander, and 2% were black.

Jerry Tan, MD, University of Western Ontario/National Rosacea Society

Jerry Tan, MD, University of Western Ontario/National Rosacea Society

Ncoza Dlova, MD, chief specialist and head of the department of dermatology, Nelson R. Mandela School of Medicine, Durban, South Africa/National Rosacea Society

SOURCE: Alexis AF et al. J Am Acad Dermatol. 2018 Sep 18. pii: S0190-9622(18)32576-3. doi: 10.1016/j.jaad.2018.08.049.

Rosacea in skin of color is likely underdetected and suboptimally managed due to misperceptions that the condition is rare in this population, according to the authors of a clinical review article on the topic.

“Current reports of rosacea in patients with skin of color may point to a large pool of undiagnosed patients,” said Andrew F. Alexis, MD, chairman of the department of dermatology, Mount Sinai St. Luke’s and Mount Sinai West, New York, and his coauthors.

Increased awareness of rosacea in these patients may reduce disparities in disease management, they wrote in the review, published in the Journal of the American Academy of Dermatology, which outlines strategies for timely diagnosis and effective treatment of rosacea in skin of color.

The erroneous perception that rosacea does not occur in skin of color may arise from epidemiologic reports, which frequently position it as a disease that occurs in fair-skinned individuals of Northern European or Celtic background, they said.

The reported prevalence of rosacea in skin of color varies worldwide and is as high as 10%, according to the authors. Moreover, a recent U.S. medical care survey found that 3.9% of rosacea patients were Hispanic or Latino, 2.3% were Asian or Pacific Islander, and 2% were black.

Jerry Tan, MD, University of Western Ontario/National Rosacea Society

Jerry Tan, MD, University of Western Ontario/National Rosacea Society

Ncoza Dlova, MD, chief specialist and head of the department of dermatology, Nelson R. Mandela School of Medicine, Durban, South Africa/National Rosacea Society

SOURCE: Alexis AF et al. J Am Acad Dermatol. 2018 Sep 18. pii: S0190-9622(18)32576-3. doi: 10.1016/j.jaad.2018.08.049.

Rosacea in skin of color is likely underdetected and suboptimally managed due to misperceptions that the condition is rare in this population, according to the authors of a clinical review article on the topic.

“Current reports of rosacea in patients with skin of color may point to a large pool of undiagnosed patients,” said Andrew F. Alexis, MD, chairman of the department of dermatology, Mount Sinai St. Luke’s and Mount Sinai West, New York, and his coauthors.

Increased awareness of rosacea in these patients may reduce disparities in disease management, they wrote in the review, published in the Journal of the American Academy of Dermatology, which outlines strategies for timely diagnosis and effective treatment of rosacea in skin of color.

The erroneous perception that rosacea does not occur in skin of color may arise from epidemiologic reports, which frequently position it as a disease that occurs in fair-skinned individuals of Northern European or Celtic background, they said.

The reported prevalence of rosacea in skin of color varies worldwide and is as high as 10%, according to the authors. Moreover, a recent U.S. medical care survey found that 3.9% of rosacea patients were Hispanic or Latino, 2.3% were Asian or Pacific Islander, and 2% were black.

Jerry Tan, MD, University of Western Ontario/National Rosacea Society

Jerry Tan, MD, University of Western Ontario/National Rosacea Society

Ncoza Dlova, MD, chief specialist and head of the department of dermatology, Nelson R. Mandela School of Medicine, Durban, South Africa/National Rosacea Society

SOURCE: Alexis AF et al. J Am Acad Dermatol. 2018 Sep 18. pii: S0190-9622(18)32576-3. doi: 10.1016/j.jaad.2018.08.049.

MONTEREY, CALIF. – Rosacea may be one disease, but it often requires more than one treatment, a dermatologist said at the annual Coastal Dermatology Symposium. Don’t assume you can just prescribe one drug like you might with acne, she advised.

“Treat everything that you see,” said dermatologist Julie C. Harper, MD, of Birmingham, Ala. “That may mean a laser or something you’re using off-label. Different lesions and signs of rosacea will require multiple modes of treatment.”

Dr. Harper offered these other pearls to consider when treating rosacea:

• Don’t get hung up on subtypes.

The four subtypes of rosacea should be used to classify lesions, not people, she said. That’s because patients can fall into more than one of the four categories – erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea, she noted.

“Document the redness you see and ask them what’s bothering them the most,” she said. And ask yourself, she added, “Do I have them on everything that I should have them on?”

• Talk to patients about triggers.

For the first visit, “we have to talk to patients about skin care and triggers,” Dr. Harper noted. According to the American Academy of Dermatology, common rosacea triggers include sunlight, hairspray, heat, stress, alcohol, and spicy foods.

• Consider an ivermectin-brimonidine combination.

“Targeting inflammation in papules and pustules doesn’t necessarily translate to less background erythema,” Dr. Harper said. What to do? She pointed to a 2017 study that examined a combination treatment of ivermectin 1% topical cream (Soolantra) and brimonidine 0.33% topical gel (Mirvaso) for patients with rosacea with moderate to severe persistent erythema and inflammatory lesions. Ivermectin is indicated for inflammatory lesions, while brimonidine treats persistent erythema.

Rosacea.org

At week 12, the proportion of patients who achieved investigator global assessment of clear or almost clear was 55.8% in the combination group, versus 36.8% of those in the vehicle group (P = .007), according to the study (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Dr. Harper highlighted the effect of brimonidine when added to ivermectin. “In a period of 3 hours,” she said, “we had twice as many people fall into clear or almost clear.”

• Consider adding botulinum toxin to your toolbox.

This “really does work,” Dr. Harper said. She pointed to a 2015 report of botulinum toxin use in two cases of refractory flushing and erythema and a 2012 report of 13 cases in patients with the same symptoms (Dermatology. 2015;230:299-301; J Drugs Dermatol. 2012 Dec;11[12]:e76-9). Dr. Harper said that she usually uses the full 50-unit dose of Botox.

• Consider a beta-blocker.

According to a 2018 report, the beta-blocker carvedilol (Coreg) showed benefit when added to other treatments in five patients with facial flushing and persistent erythema.

• Keep isotretinoin in mind.

A 2016 report suggested low-dose isotretinoin had value for difficult-to-treat papulopustular rosacea. As Dr. Harper noted, 57% of those who took isotretinoin reached the primary endpoint, versus 10% of those taking the placebo. However, relapses over 4 months were common, which is a sign that it may be wise to prescribe low doses over the long term, but not in females of child-bearing potential, she said.

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.

Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, LaRoche Posay, and Ortho and has served as investigator for Bayer.

MONTEREY, CALIF. – Rosacea may be one disease, but it often requires more than one treatment, a dermatologist said at the annual Coastal Dermatology Symposium. Don’t assume you can just prescribe one drug like you might with acne, she advised.

“Treat everything that you see,” said dermatologist Julie C. Harper, MD, of Birmingham, Ala. “That may mean a laser or something you’re using off-label. Different lesions and signs of rosacea will require multiple modes of treatment.”

Dr. Harper offered these other pearls to consider when treating rosacea:

• Don’t get hung up on subtypes.

The four subtypes of rosacea should be used to classify lesions, not people, she said. That’s because patients can fall into more than one of the four categories – erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea, she noted.

“Document the redness you see and ask them what’s bothering them the most,” she said. And ask yourself, she added, “Do I have them on everything that I should have them on?”

• Talk to patients about triggers.

For the first visit, “we have to talk to patients about skin care and triggers,” Dr. Harper noted. According to the American Academy of Dermatology, common rosacea triggers include sunlight, hairspray, heat, stress, alcohol, and spicy foods.

• Consider an ivermectin-brimonidine combination.

“Targeting inflammation in papules and pustules doesn’t necessarily translate to less background erythema,” Dr. Harper said. What to do? She pointed to a 2017 study that examined a combination treatment of ivermectin 1% topical cream (Soolantra) and brimonidine 0.33% topical gel (Mirvaso) for patients with rosacea with moderate to severe persistent erythema and inflammatory lesions. Ivermectin is indicated for inflammatory lesions, while brimonidine treats persistent erythema.

Rosacea.org

At week 12, the proportion of patients who achieved investigator global assessment of clear or almost clear was 55.8% in the combination group, versus 36.8% of those in the vehicle group (P = .007), according to the study (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Dr. Harper highlighted the effect of brimonidine when added to ivermectin. “In a period of 3 hours,” she said, “we had twice as many people fall into clear or almost clear.”

• Consider adding botulinum toxin to your toolbox.

This “really does work,” Dr. Harper said. She pointed to a 2015 report of botulinum toxin use in two cases of refractory flushing and erythema and a 2012 report of 13 cases in patients with the same symptoms (Dermatology. 2015;230:299-301; J Drugs Dermatol. 2012 Dec;11[12]:e76-9). Dr. Harper said that she usually uses the full 50-unit dose of Botox.

• Consider a beta-blocker.

According to a 2018 report, the beta-blocker carvedilol (Coreg) showed benefit when added to other treatments in five patients with facial flushing and persistent erythema.

• Keep isotretinoin in mind.

A 2016 report suggested low-dose isotretinoin had value for difficult-to-treat papulopustular rosacea. As Dr. Harper noted, 57% of those who took isotretinoin reached the primary endpoint, versus 10% of those taking the placebo. However, relapses over 4 months were common, which is a sign that it may be wise to prescribe low doses over the long term, but not in females of child-bearing potential, she said.

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.

Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, LaRoche Posay, and Ortho and has served as investigator for Bayer.

MONTEREY, CALIF. – Rosacea may be one disease, but it often requires more than one treatment, a dermatologist said at the annual Coastal Dermatology Symposium. Don’t assume you can just prescribe one drug like you might with acne, she advised.

“Treat everything that you see,” said dermatologist Julie C. Harper, MD, of Birmingham, Ala. “That may mean a laser or something you’re using off-label. Different lesions and signs of rosacea will require multiple modes of treatment.”

Dr. Harper offered these other pearls to consider when treating rosacea:

• Don’t get hung up on subtypes.

The four subtypes of rosacea should be used to classify lesions, not people, she said. That’s because patients can fall into more than one of the four categories – erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea, she noted.

“Document the redness you see and ask them what’s bothering them the most,” she said. And ask yourself, she added, “Do I have them on everything that I should have them on?”

• Talk to patients about triggers.

For the first visit, “we have to talk to patients about skin care and triggers,” Dr. Harper noted. According to the American Academy of Dermatology, common rosacea triggers include sunlight, hairspray, heat, stress, alcohol, and spicy foods.

• Consider an ivermectin-brimonidine combination.

“Targeting inflammation in papules and pustules doesn’t necessarily translate to less background erythema,” Dr. Harper said. What to do? She pointed to a 2017 study that examined a combination treatment of ivermectin 1% topical cream (Soolantra) and brimonidine 0.33% topical gel (Mirvaso) for patients with rosacea with moderate to severe persistent erythema and inflammatory lesions. Ivermectin is indicated for inflammatory lesions, while brimonidine treats persistent erythema.

Rosacea.org

At week 12, the proportion of patients who achieved investigator global assessment of clear or almost clear was 55.8% in the combination group, versus 36.8% of those in the vehicle group (P = .007), according to the study (J Drugs Dermatol. 2017 Sep 1;16[9]:909-16). Dr. Harper highlighted the effect of brimonidine when added to ivermectin. “In a period of 3 hours,” she said, “we had twice as many people fall into clear or almost clear.”

• Consider adding botulinum toxin to your toolbox.

This “really does work,” Dr. Harper said. She pointed to a 2015 report of botulinum toxin use in two cases of refractory flushing and erythema and a 2012 report of 13 cases in patients with the same symptoms (Dermatology. 2015;230:299-301; J Drugs Dermatol. 2012 Dec;11[12]:e76-9). Dr. Harper said that she usually uses the full 50-unit dose of Botox.

• Consider a beta-blocker.

According to a 2018 report, the beta-blocker carvedilol (Coreg) showed benefit when added to other treatments in five patients with facial flushing and persistent erythema.

• Keep isotretinoin in mind.

A 2016 report suggested low-dose isotretinoin had value for difficult-to-treat papulopustular rosacea. As Dr. Harper noted, 57% of those who took isotretinoin reached the primary endpoint, versus 10% of those taking the placebo. However, relapses over 4 months were common, which is a sign that it may be wise to prescribe low doses over the long term, but not in females of child-bearing potential, she said.

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.

Dr. Harper disclosed speaker/advisor relationships with Allergan, Bayer, BioPharmX, Galderma, LaRoche Posay, and Ortho and has served as investigator for Bayer.

Dual-frequency ultrasound (DFU) may be an effective option for patients with treatment-resistant rosacea, according to a new study in Dermatologic Surgery.

In the study, a retrospective medical record analysis of 42 rosacea patients, DFU improved symptoms, including erythema index (EI) and transepithelial water loss (TEWL), and also improved outcomes on the patient self-assessment (PSA), reported Jun Yeong Park, MD, and coauthors, from the department of dermatology, Hallym University Sacred Heart Hospital in Anyang, South Korea.

Of the 42 patients, 26 had erythematotelangiectatic rosacea, 14 had papulopustular rosacea, and 2 had mixed disease; their mean age was 48 years, and they had had rosacea for a mean of 2 years. Patients had started DFU treatment between September 2016 and December 2016, and were not taking oral medication (besides antihistamines), topical ointments, or other laser treatments at the time. Most had been treated with various systemic therapies, topical therapies, or lasers, but had not had adequate improvement of flushing and erythema.

Patients received DFU treatment of the entire face twice per week for the first week, followed by one-week intervals, for a total of 12 weeks. Each treatment session lasted 10 minutes, and included DFU frequencies of 3/4.5 MHz at an ultrasound intensity of 2.0W/cm² for 5 minutes, followed by 4.5 MHz at an intensity of 2.0W/cm². Responses to treatment were based on EI, TEWL values (measured on three different sites on each cheek according to guidelines established by the European Group for Efficacy Measurements on Cosmetics and Other Topical Products), and PSA. PSA was completed on a scale of 0 (absent) to 4 (severe) for erythema, itching sensation, and burning sensation.

At 12 weeks follow-up, the mean EI dropped from 16.3 at baseline to 12.7 at 12 weeks (P less than .01). Mean TEWL values dropped from a baseline of 35.8 g m^–1 h^–1 to 22.8 g m^–1 h^–1 at 12 weeks (P less than .01).

When evaluated by rosacea subtype, a slightly higher reduction in the group with papulopustular rosacea was seen for EI and TEWL, compared with those with the erythematotelangiectatic subtype, but the differences were not statistically significant for either, the authors reported.

Between baseline and 12 weeks, the PSA values for erythema decreased from 2.6 to 1.1. Itching and burning grades also decreased, from 2.4 to 0.4 and from 2.4 to 0.3, respectively.

The findings verify that there were “improvements in the barrier function of patients with refractory rosacea, based on the TEWL level before and after treatment,” the authors noted. “Therefore, DFU may be an additional treatment option for rosacea that is resistant to other treatments.”

This study is the first to evaluate DFU in patients with refractory rosacea “who did not show signs of recovery after undergoing previous therapies,” they noted.

No disclosures were reported.

SOURCE: Park J et al. Dermatol Surg 2018 Sep;44(9):1209-15. doi: 10.1097/DSS.0000000000001552.

Dual-frequency ultrasound (DFU) may be an effective option for patients with treatment-resistant rosacea, according to a new study in Dermatologic Surgery.

In the study, a retrospective medical record analysis of 42 rosacea patients, DFU improved symptoms, including erythema index (EI) and transepithelial water loss (TEWL), and also improved outcomes on the patient self-assessment (PSA), reported Jun Yeong Park, MD, and coauthors, from the department of dermatology, Hallym University Sacred Heart Hospital in Anyang, South Korea.

Of the 42 patients, 26 had erythematotelangiectatic rosacea, 14 had papulopustular rosacea, and 2 had mixed disease; their mean age was 48 years, and they had had rosacea for a mean of 2 years. Patients had started DFU treatment between September 2016 and December 2016, and were not taking oral medication (besides antihistamines), topical ointments, or other laser treatments at the time. Most had been treated with various systemic therapies, topical therapies, or lasers, but had not had adequate improvement of flushing and erythema.

Patients received DFU treatment of the entire face twice per week for the first week, followed by one-week intervals, for a total of 12 weeks. Each treatment session lasted 10 minutes, and included DFU frequencies of 3/4.5 MHz at an ultrasound intensity of 2.0W/cm² for 5 minutes, followed by 4.5 MHz at an intensity of 2.0W/cm². Responses to treatment were based on EI, TEWL values (measured on three different sites on each cheek according to guidelines established by the European Group for Efficacy Measurements on Cosmetics and Other Topical Products), and PSA. PSA was completed on a scale of 0 (absent) to 4 (severe) for erythema, itching sensation, and burning sensation.

At 12 weeks follow-up, the mean EI dropped from 16.3 at baseline to 12.7 at 12 weeks (P less than .01). Mean TEWL values dropped from a baseline of 35.8 g m^–1 h^–1 to 22.8 g m^–1 h^–1 at 12 weeks (P less than .01).

When evaluated by rosacea subtype, a slightly higher reduction in the group with papulopustular rosacea was seen for EI and TEWL, compared with those with the erythematotelangiectatic subtype, but the differences were not statistically significant for either, the authors reported.

Between baseline and 12 weeks, the PSA values for erythema decreased from 2.6 to 1.1. Itching and burning grades also decreased, from 2.4 to 0.4 and from 2.4 to 0.3, respectively.

The findings verify that there were “improvements in the barrier function of patients with refractory rosacea, based on the TEWL level before and after treatment,” the authors noted. “Therefore, DFU may be an additional treatment option for rosacea that is resistant to other treatments.”

This study is the first to evaluate DFU in patients with refractory rosacea “who did not show signs of recovery after undergoing previous therapies,” they noted.

No disclosures were reported.

SOURCE: Park J et al. Dermatol Surg 2018 Sep;44(9):1209-15. doi: 10.1097/DSS.0000000000001552.

Dual-frequency ultrasound (DFU) may be an effective option for patients with treatment-resistant rosacea, according to a new study in Dermatologic Surgery.

In the study, a retrospective medical record analysis of 42 rosacea patients, DFU improved symptoms, including erythema index (EI) and transepithelial water loss (TEWL), and also improved outcomes on the patient self-assessment (PSA), reported Jun Yeong Park, MD, and coauthors, from the department of dermatology, Hallym University Sacred Heart Hospital in Anyang, South Korea.

Of the 42 patients, 26 had erythematotelangiectatic rosacea, 14 had papulopustular rosacea, and 2 had mixed disease; their mean age was 48 years, and they had had rosacea for a mean of 2 years. Patients had started DFU treatment between September 2016 and December 2016, and were not taking oral medication (besides antihistamines), topical ointments, or other laser treatments at the time. Most had been treated with various systemic therapies, topical therapies, or lasers, but had not had adequate improvement of flushing and erythema.

Patients received DFU treatment of the entire face twice per week for the first week, followed by one-week intervals, for a total of 12 weeks. Each treatment session lasted 10 minutes, and included DFU frequencies of 3/4.5 MHz at an ultrasound intensity of 2.0W/cm² for 5 minutes, followed by 4.5 MHz at an intensity of 2.0W/cm². Responses to treatment were based on EI, TEWL values (measured on three different sites on each cheek according to guidelines established by the European Group for Efficacy Measurements on Cosmetics and Other Topical Products), and PSA. PSA was completed on a scale of 0 (absent) to 4 (severe) for erythema, itching sensation, and burning sensation.

At 12 weeks follow-up, the mean EI dropped from 16.3 at baseline to 12.7 at 12 weeks (P less than .01). Mean TEWL values dropped from a baseline of 35.8 g m^–1 h^–1 to 22.8 g m^–1 h^–1 at 12 weeks (P less than .01).

When evaluated by rosacea subtype, a slightly higher reduction in the group with papulopustular rosacea was seen for EI and TEWL, compared with those with the erythematotelangiectatic subtype, but the differences were not statistically significant for either, the authors reported.

Between baseline and 12 weeks, the PSA values for erythema decreased from 2.6 to 1.1. Itching and burning grades also decreased, from 2.4 to 0.4 and from 2.4 to 0.3, respectively.

The findings verify that there were “improvements in the barrier function of patients with refractory rosacea, based on the TEWL level before and after treatment,” the authors noted. “Therefore, DFU may be an additional treatment option for rosacea that is resistant to other treatments.”

This study is the first to evaluate DFU in patients with refractory rosacea “who did not show signs of recovery after undergoing previous therapies,” they noted.

No disclosures were reported.

SOURCE: Park J et al. Dermatol Surg 2018 Sep;44(9):1209-15. doi: 10.1097/DSS.0000000000001552.

As technology continues to advance, so too does its accessibility to the general population. In 2013, 56% of Americans owned a smartphone versus 77% in 2017.¹With the increase in mobile applications (apps) available, it is no surprise that the market has extended into the medical field, with dermatology being no exception.² The majority of dermatology apps can be classified as teledermatology apps, followed by self-surveillance, disease guide, and reference apps. Additional types of dermatology apps include dermoscopy, conference, education, photograph storage and sharing, and journal apps, and others.² In this study, we examined Apple App Store rankings to determine the types of dermatology apps that are most popular among patients and physicians.

METHODS

A popular app rankings analyzer (App Annie) was used to search for dermatology apps along with their App Store rankings.³ Although iOS is not the most popular mobile device operating system, we chose to evaluate app rankings via the App Store because iPhones are the top-selling individual phones of any kind in the United States.⁴

We performed our analysis on a single day (July 14, 2018) given that app rankings can change daily. We incorporated the following keywords, which were commonly used in other dermatology app studies: dermatology, psoriasis, rosacea, acne, skin cancer, melanoma, eczema, and teledermatology. The category ranking was defined as the rank of a free or paid app in the App Store’s top charts for the selected country (United States), market (Apple), and device (iPhone) within their app category (Medical). Inclusion criteria required a ranking in the top 1500 Medical apps and being categorized in the App Store as a Medical app. Exclusion criteria included apps that focused on cosmetics, private practice, direct advertisements, photograph editing, or claims to cure skin disease, as well as non–English-language apps. The App Store descriptions were assessed to determine the type of each app (eg, teledermatology, disease guide) and target audience (patient, physician, or both).

Another search was performed using the same keywords but within the Health and Fitness category to capture potentially more highly ranked apps among patients. We also conducted separate searches within the Medical category using the keywords billing, coding, and ICD (International Classification of Diseases) to evaluate rankings for billing/coding apps, as well as EMR and electronic medical records for electronic medical record (EMR) apps.

RESULTS

The initial search yielded 851 results, which was narrowed down to 29 apps after applying the exclusion criteria. Of note, prior to application of the exclusion criteria, one dermatology app that was considered to be a direct advertisement app claiming to cure acne was ranked fourth of 1500 apps in the Medical category. However, the majority of the search results were excluded because they were not popular enough to be ranked among the top 1500 apps. There were more ranked dermatology apps in the Medical category targeting patients than physicians; 18 of 29 (62%) qualifying apps targeted patients and 11 (38%) targeted physicians (Tables 1 and 2). No apps targeted both groups. The most common type of ranked app targeting patients was self-surveillance (11/18), and the most common type targeting physicians was reference (8/11). The highest ranked app targeting patients was a teledermatology app with a ranking of 184, and the highest ranked app targeting physicians was educational, ranked 353. The least common type of ranked apps targeting patients were “other” (2/18 [11%]; 1 prescription and 1 UV monitor app) and conference (1/18 [6%]). The least common type of ranked apps targeting physicians were education (2/11 [18%]) and dermoscopy (1/11 [9%]).

Our search of the Health and Fitness category yielded 6 apps, all targeting patients; 3 (50%) were self-surveillance apps, and 3 (50%) were classified as other (2 UV monitors and a conferencing app for cancer emotional support)(Table 3).

Our search of the Medical category for billing/coding and EMR apps yielded 232 and 164 apps, respectively; of them, 49 (21%) and 54 (33%) apps were ranked. These apps did not overlap with the dermatology-related search criteria; thus, we were not able to ascertain how many of these apps were used specifically by health care providers in dermatology.

COMMENT

Patient Apps

The most common apps used by patients are fitness and nutrition tracker apps categorized as Health and Fitness^5,6; however, the majority of ranked dermatology apps are categorized as Medical per our findings. In a study of 557 dermatology patients, it was found that among the health-related apps they used, the most common apps after fitness/nutrition were references, followed by patient portals, self-surveillance, and emotional assistance apps.⁶ Our search was consistent with these findings, suggesting that the most desired dermatology apps by patients are those that allow them to be proactive with their health. It is no surprise that the top-ranked app targeting patients was a teledermatology app, followed by multiple self-surveillance apps. The highest ranked self-surveillance app in the Health and Fitness category focused on monitoring the effects of nutrition on symptoms of diseases including skin disorders, while the highest ranked (as well as the majority of) self-surveillance apps in the Medical category encompassed mole monitoring and cancer risk calculators.

Benefits of the ranked dermatology apps in the Medical and Health and Fitness categories targeting patients include more immediate access to health care and education. Despite this popularity among patients, Masud et al⁷ demonstrated that only 20.5% (9/44) of dermatology apps targeting patients may be reliable resources based on a rubric created by the investigators. Overall, there remains a research gap for a standardized scientific approach to evaluating app validity and reliability.

Teledermatology
Teledermatology apps are the most common dermatology apps,² allowing for remote evaluation of patients through either live consultations or transmittance of medical information for later review by board-certified physicians.⁸ Features common to many teledermatology apps include accessibility on Android (Google Inc) and iOS as well as a web version. Security and Health Insurance Portability and Accountability Act compliance is especially important and is enforced through user authentications, data encryption, and automatic logout features. Data is not stored locally and is secured on a private server with backup. Referring providers and consultants often can communicate within the app. Insurance providers also may cover teledermatology services, and if not, the out-of-pocket costs often are affordable.

The highest-ranked patient app (ranked 184 in the Medical category) was a teledermatology app that did not meet the American Telemedicine Association standards for teledermatology apps.⁹ The popularity of this app among patients may have been attributable to multiple ease-of-use and turnaround time features. The user interface was simplistic, and the design was appealing to the eye. The entry field options were minimal to avoid confusion. The turnaround time to receive a diagnosis depended on 1 of 3 options, including a more rapid response for an increased cost. Ease of use was the highlight of this app at the cost of accuracy, as the limited amount of information that users were required to provide physicians compromised diagnostic accuracy in this app.

For comparison, we chose a nonranked (and thus less frequently used) teledermatology app that had previously undergone scientific evaluation using 13 evaluation criteria specific to teledermatology.¹⁰ The app also met the American Telemedicine Association standard for teledermatology apps.⁹ The app was originally a broader telemedicine app but featured a section specific to teledermatology. The user interface was simple but professional, almost resembling an EMR. The input fields included a comprehensive history that permitted a better evaluation of a lesion but might be tedious for users. This app boasted professionalism and accuracy, but from a user standpoint, it may have been too time-consuming.

Striking a balance between ensuring proper care versus appealing to patients is a difficult but important task. Based on this study, it appears that popular patient apps may in fact have less scientific rationale and therefore potentially less accuracy.

Self-surveillance
Although self-surveillance apps did not account for the highest-ranked app, they were the most frequently ranked app type in our study. Most of the ranked self-surveillance apps in the Medical category were for monitoring lesions over time to assess for changes. These apps help users take photographs that are well organized in a single, easy-to-find location. Some apps were risk calculators that assessed the risk for malignancies using a questionnaire. The majority of these self-surveillance apps were specific to skin cancer detection. Of note, one of the ranked self-surveillance apps assessed drug effectiveness by monitoring clinical appearance and symptoms. The lowest ranked self-surveillance app in the top 1500 ranked Medical apps in our search monitored cancer symptoms not specific to dermatology. Although this app had a low ranking (1380/1500), it received a high number of reviews and was well rated at 4.8 out of 5 stars; therefore, it seemed more helpful than the other higher-ranked apps targeting patients, which had higher rankings but minimal to no reviews or ratings. A comparison of the ease-of-use features of all the ranked patient-targeted self-surveillance apps in the Medical category is provided in Table 4.

Physician Apps

After examining the results of apps targeting physicians, we realized that the data may be accurate but may not be as representative of all currently practicing dermatology providers. Given the increased usage of apps among younger age groups,¹¹ our data may be skewed toward medical students and residents, supported by the fact that the top-ranked physician app in our study was an education app and the majority were reference apps. Future studies are needed to reexamine app ranking as this age group transitions from entry-level health care providers in the next 5 to 10 years. These findings also suggest less frequent app use among more veteran health care providers within our specific search parameters. Therefore, we decided to do subsequent searches for available billing/coding and EMR apps, which were many, but as mentioned above, none were specific to dermatology.

General Dermatology References
Most of the dermatology reference apps were formatted as e-books; however, other apps such as the Amazon Kindle app (categorized under Books) providing access to multiple e-books within one app were not included. Some apps included study aid features (eg, flash cards, quizzes), and topics spanned both dermatology and dermatopathology. Apps provide a unique way for on-the-go studying for dermatologists in training, and if the usage continues to grow, there may be a need for increased formal integration in dermatology education in the future.

Journals
Journal apps were not among those listed in the top-ranked apps we evaluated, which we suspect may be because journals were categorized differently from one journal to the next; for example, the Journal of the American Academy of Dermatology was ranked 1168 in the Magazines and Newspapers category. On the other hand, Dermatology World was ranked 1363 in the Reference category. An article’s citation affects the publishing journal’s impact factor, which is one of the most important variables in measuring a journal’s influence. In the future, there may be other variables that could aid in understanding journal impact as it relates to the journal’s accessibility.

Limitations

Our study did not look at Android apps. The top chart apps in the Android and Apple App Stores use undisclosed algorithms likely involving different characteristics such as number of downloads, frequency of updates, number of reviews, ratings, and more. Thus, the rankings across these different markets would not be comparable. Although our choice of keywords stemmed from the majority of prior studies looking at dermatology apps, our search was limited due to the use of these specific keywords. To avoid skewing data by cross-comparison of noncomparable categories, we could not compare apps in the Medical category versus those in other categories.

CONCLUSION

There seems to be a disconnect between the apps that are popular among patients and the scientific validity of the apps. As app usage increases among dermatology providers, whose demographic is shifting younger and younger, apps may become more incorporated in our education, and as such, it will become more critical to develop formal scientific standards. Given these future trends, we may need to increase our current literature and understanding of apps in dermatology with regard to their impact on both patients and health care providers.

As technology continues to advance, so too does its accessibility to the general population. In 2013, 56% of Americans owned a smartphone versus 77% in 2017.¹With the increase in mobile applications (apps) available, it is no surprise that the market has extended into the medical field, with dermatology being no exception.² The majority of dermatology apps can be classified as teledermatology apps, followed by self-surveillance, disease guide, and reference apps. Additional types of dermatology apps include dermoscopy, conference, education, photograph storage and sharing, and journal apps, and others.² In this study, we examined Apple App Store rankings to determine the types of dermatology apps that are most popular among patients and physicians.

METHODS

A popular app rankings analyzer (App Annie) was used to search for dermatology apps along with their App Store rankings.³ Although iOS is not the most popular mobile device operating system, we chose to evaluate app rankings via the App Store because iPhones are the top-selling individual phones of any kind in the United States.⁴

We performed our analysis on a single day (July 14, 2018) given that app rankings can change daily. We incorporated the following keywords, which were commonly used in other dermatology app studies: dermatology, psoriasis, rosacea, acne, skin cancer, melanoma, eczema, and teledermatology. The category ranking was defined as the rank of a free or paid app in the App Store’s top charts for the selected country (United States), market (Apple), and device (iPhone) within their app category (Medical). Inclusion criteria required a ranking in the top 1500 Medical apps and being categorized in the App Store as a Medical app. Exclusion criteria included apps that focused on cosmetics, private practice, direct advertisements, photograph editing, or claims to cure skin disease, as well as non–English-language apps. The App Store descriptions were assessed to determine the type of each app (eg, teledermatology, disease guide) and target audience (patient, physician, or both).

Another search was performed using the same keywords but within the Health and Fitness category to capture potentially more highly ranked apps among patients. We also conducted separate searches within the Medical category using the keywords billing, coding, and ICD (International Classification of Diseases) to evaluate rankings for billing/coding apps, as well as EMR and electronic medical records for electronic medical record (EMR) apps.

RESULTS

The initial search yielded 851 results, which was narrowed down to 29 apps after applying the exclusion criteria. Of note, prior to application of the exclusion criteria, one dermatology app that was considered to be a direct advertisement app claiming to cure acne was ranked fourth of 1500 apps in the Medical category. However, the majority of the search results were excluded because they were not popular enough to be ranked among the top 1500 apps. There were more ranked dermatology apps in the Medical category targeting patients than physicians; 18 of 29 (62%) qualifying apps targeted patients and 11 (38%) targeted physicians (Tables 1 and 2). No apps targeted both groups. The most common type of ranked app targeting patients was self-surveillance (11/18), and the most common type targeting physicians was reference (8/11). The highest ranked app targeting patients was a teledermatology app with a ranking of 184, and the highest ranked app targeting physicians was educational, ranked 353. The least common type of ranked apps targeting patients were “other” (2/18 [11%]; 1 prescription and 1 UV monitor app) and conference (1/18 [6%]). The least common type of ranked apps targeting physicians were education (2/11 [18%]) and dermoscopy (1/11 [9%]).

Our search of the Health and Fitness category yielded 6 apps, all targeting patients; 3 (50%) were self-surveillance apps, and 3 (50%) were classified as other (2 UV monitors and a conferencing app for cancer emotional support)(Table 3).

Our search of the Medical category for billing/coding and EMR apps yielded 232 and 164 apps, respectively; of them, 49 (21%) and 54 (33%) apps were ranked. These apps did not overlap with the dermatology-related search criteria; thus, we were not able to ascertain how many of these apps were used specifically by health care providers in dermatology.

COMMENT

Patient Apps

The most common apps used by patients are fitness and nutrition tracker apps categorized as Health and Fitness^5,6; however, the majority of ranked dermatology apps are categorized as Medical per our findings. In a study of 557 dermatology patients, it was found that among the health-related apps they used, the most common apps after fitness/nutrition were references, followed by patient portals, self-surveillance, and emotional assistance apps.⁶ Our search was consistent with these findings, suggesting that the most desired dermatology apps by patients are those that allow them to be proactive with their health. It is no surprise that the top-ranked app targeting patients was a teledermatology app, followed by multiple self-surveillance apps. The highest ranked self-surveillance app in the Health and Fitness category focused on monitoring the effects of nutrition on symptoms of diseases including skin disorders, while the highest ranked (as well as the majority of) self-surveillance apps in the Medical category encompassed mole monitoring and cancer risk calculators.

Benefits of the ranked dermatology apps in the Medical and Health and Fitness categories targeting patients include more immediate access to health care and education. Despite this popularity among patients, Masud et al⁷ demonstrated that only 20.5% (9/44) of dermatology apps targeting patients may be reliable resources based on a rubric created by the investigators. Overall, there remains a research gap for a standardized scientific approach to evaluating app validity and reliability.

Teledermatology
Teledermatology apps are the most common dermatology apps,² allowing for remote evaluation of patients through either live consultations or transmittance of medical information for later review by board-certified physicians.⁸ Features common to many teledermatology apps include accessibility on Android (Google Inc) and iOS as well as a web version. Security and Health Insurance Portability and Accountability Act compliance is especially important and is enforced through user authentications, data encryption, and automatic logout features. Data is not stored locally and is secured on a private server with backup. Referring providers and consultants often can communicate within the app. Insurance providers also may cover teledermatology services, and if not, the out-of-pocket costs often are affordable.

The highest-ranked patient app (ranked 184 in the Medical category) was a teledermatology app that did not meet the American Telemedicine Association standards for teledermatology apps.⁹ The popularity of this app among patients may have been attributable to multiple ease-of-use and turnaround time features. The user interface was simplistic, and the design was appealing to the eye. The entry field options were minimal to avoid confusion. The turnaround time to receive a diagnosis depended on 1 of 3 options, including a more rapid response for an increased cost. Ease of use was the highlight of this app at the cost of accuracy, as the limited amount of information that users were required to provide physicians compromised diagnostic accuracy in this app.

For comparison, we chose a nonranked (and thus less frequently used) teledermatology app that had previously undergone scientific evaluation using 13 evaluation criteria specific to teledermatology.¹⁰ The app also met the American Telemedicine Association standard for teledermatology apps.⁹ The app was originally a broader telemedicine app but featured a section specific to teledermatology. The user interface was simple but professional, almost resembling an EMR. The input fields included a comprehensive history that permitted a better evaluation of a lesion but might be tedious for users. This app boasted professionalism and accuracy, but from a user standpoint, it may have been too time-consuming.

Striking a balance between ensuring proper care versus appealing to patients is a difficult but important task. Based on this study, it appears that popular patient apps may in fact have less scientific rationale and therefore potentially less accuracy.

Self-surveillance
Although self-surveillance apps did not account for the highest-ranked app, they were the most frequently ranked app type in our study. Most of the ranked self-surveillance apps in the Medical category were for monitoring lesions over time to assess for changes. These apps help users take photographs that are well organized in a single, easy-to-find location. Some apps were risk calculators that assessed the risk for malignancies using a questionnaire. The majority of these self-surveillance apps were specific to skin cancer detection. Of note, one of the ranked self-surveillance apps assessed drug effectiveness by monitoring clinical appearance and symptoms. The lowest ranked self-surveillance app in the top 1500 ranked Medical apps in our search monitored cancer symptoms not specific to dermatology. Although this app had a low ranking (1380/1500), it received a high number of reviews and was well rated at 4.8 out of 5 stars; therefore, it seemed more helpful than the other higher-ranked apps targeting patients, which had higher rankings but minimal to no reviews or ratings. A comparison of the ease-of-use features of all the ranked patient-targeted self-surveillance apps in the Medical category is provided in Table 4.

Physician Apps

After examining the results of apps targeting physicians, we realized that the data may be accurate but may not be as representative of all currently practicing dermatology providers. Given the increased usage of apps among younger age groups,¹¹ our data may be skewed toward medical students and residents, supported by the fact that the top-ranked physician app in our study was an education app and the majority were reference apps. Future studies are needed to reexamine app ranking as this age group transitions from entry-level health care providers in the next 5 to 10 years. These findings also suggest less frequent app use among more veteran health care providers within our specific search parameters. Therefore, we decided to do subsequent searches for available billing/coding and EMR apps, which were many, but as mentioned above, none were specific to dermatology.

General Dermatology References
Most of the dermatology reference apps were formatted as e-books; however, other apps such as the Amazon Kindle app (categorized under Books) providing access to multiple e-books within one app were not included. Some apps included study aid features (eg, flash cards, quizzes), and topics spanned both dermatology and dermatopathology. Apps provide a unique way for on-the-go studying for dermatologists in training, and if the usage continues to grow, there may be a need for increased formal integration in dermatology education in the future.

Journals
Journal apps were not among those listed in the top-ranked apps we evaluated, which we suspect may be because journals were categorized differently from one journal to the next; for example, the Journal of the American Academy of Dermatology was ranked 1168 in the Magazines and Newspapers category. On the other hand, Dermatology World was ranked 1363 in the Reference category. An article’s citation affects the publishing journal’s impact factor, which is one of the most important variables in measuring a journal’s influence. In the future, there may be other variables that could aid in understanding journal impact as it relates to the journal’s accessibility.

Limitations

Our study did not look at Android apps. The top chart apps in the Android and Apple App Stores use undisclosed algorithms likely involving different characteristics such as number of downloads, frequency of updates, number of reviews, ratings, and more. Thus, the rankings across these different markets would not be comparable. Although our choice of keywords stemmed from the majority of prior studies looking at dermatology apps, our search was limited due to the use of these specific keywords. To avoid skewing data by cross-comparison of noncomparable categories, we could not compare apps in the Medical category versus those in other categories.

CONCLUSION

There seems to be a disconnect between the apps that are popular among patients and the scientific validity of the apps. As app usage increases among dermatology providers, whose demographic is shifting younger and younger, apps may become more incorporated in our education, and as such, it will become more critical to develop formal scientific standards. Given these future trends, we may need to increase our current literature and understanding of apps in dermatology with regard to their impact on both patients and health care providers.

As technology continues to advance, so too does its accessibility to the general population. In 2013, 56% of Americans owned a smartphone versus 77% in 2017.¹With the increase in mobile applications (apps) available, it is no surprise that the market has extended into the medical field, with dermatology being no exception.² The majority of dermatology apps can be classified as teledermatology apps, followed by self-surveillance, disease guide, and reference apps. Additional types of dermatology apps include dermoscopy, conference, education, photograph storage and sharing, and journal apps, and others.² In this study, we examined Apple App Store rankings to determine the types of dermatology apps that are most popular among patients and physicians.

METHODS

A popular app rankings analyzer (App Annie) was used to search for dermatology apps along with their App Store rankings.³ Although iOS is not the most popular mobile device operating system, we chose to evaluate app rankings via the App Store because iPhones are the top-selling individual phones of any kind in the United States.⁴

We performed our analysis on a single day (July 14, 2018) given that app rankings can change daily. We incorporated the following keywords, which were commonly used in other dermatology app studies: dermatology, psoriasis, rosacea, acne, skin cancer, melanoma, eczema, and teledermatology. The category ranking was defined as the rank of a free or paid app in the App Store’s top charts for the selected country (United States), market (Apple), and device (iPhone) within their app category (Medical). Inclusion criteria required a ranking in the top 1500 Medical apps and being categorized in the App Store as a Medical app. Exclusion criteria included apps that focused on cosmetics, private practice, direct advertisements, photograph editing, or claims to cure skin disease, as well as non–English-language apps. The App Store descriptions were assessed to determine the type of each app (eg, teledermatology, disease guide) and target audience (patient, physician, or both).

Another search was performed using the same keywords but within the Health and Fitness category to capture potentially more highly ranked apps among patients. We also conducted separate searches within the Medical category using the keywords billing, coding, and ICD (International Classification of Diseases) to evaluate rankings for billing/coding apps, as well as EMR and electronic medical records for electronic medical record (EMR) apps.

RESULTS

The initial search yielded 851 results, which was narrowed down to 29 apps after applying the exclusion criteria. Of note, prior to application of the exclusion criteria, one dermatology app that was considered to be a direct advertisement app claiming to cure acne was ranked fourth of 1500 apps in the Medical category. However, the majority of the search results were excluded because they were not popular enough to be ranked among the top 1500 apps. There were more ranked dermatology apps in the Medical category targeting patients than physicians; 18 of 29 (62%) qualifying apps targeted patients and 11 (38%) targeted physicians (Tables 1 and 2). No apps targeted both groups. The most common type of ranked app targeting patients was self-surveillance (11/18), and the most common type targeting physicians was reference (8/11). The highest ranked app targeting patients was a teledermatology app with a ranking of 184, and the highest ranked app targeting physicians was educational, ranked 353. The least common type of ranked apps targeting patients were “other” (2/18 [11%]; 1 prescription and 1 UV monitor app) and conference (1/18 [6%]). The least common type of ranked apps targeting physicians were education (2/11 [18%]) and dermoscopy (1/11 [9%]).

Our search of the Health and Fitness category yielded 6 apps, all targeting patients; 3 (50%) were self-surveillance apps, and 3 (50%) were classified as other (2 UV monitors and a conferencing app for cancer emotional support)(Table 3).

Our search of the Medical category for billing/coding and EMR apps yielded 232 and 164 apps, respectively; of them, 49 (21%) and 54 (33%) apps were ranked. These apps did not overlap with the dermatology-related search criteria; thus, we were not able to ascertain how many of these apps were used specifically by health care providers in dermatology.

COMMENT

Patient Apps

The most common apps used by patients are fitness and nutrition tracker apps categorized as Health and Fitness^5,6; however, the majority of ranked dermatology apps are categorized as Medical per our findings. In a study of 557 dermatology patients, it was found that among the health-related apps they used, the most common apps after fitness/nutrition were references, followed by patient portals, self-surveillance, and emotional assistance apps.⁶ Our search was consistent with these findings, suggesting that the most desired dermatology apps by patients are those that allow them to be proactive with their health. It is no surprise that the top-ranked app targeting patients was a teledermatology app, followed by multiple self-surveillance apps. The highest ranked self-surveillance app in the Health and Fitness category focused on monitoring the effects of nutrition on symptoms of diseases including skin disorders, while the highest ranked (as well as the majority of) self-surveillance apps in the Medical category encompassed mole monitoring and cancer risk calculators.

Benefits of the ranked dermatology apps in the Medical and Health and Fitness categories targeting patients include more immediate access to health care and education. Despite this popularity among patients, Masud et al⁷ demonstrated that only 20.5% (9/44) of dermatology apps targeting patients may be reliable resources based on a rubric created by the investigators. Overall, there remains a research gap for a standardized scientific approach to evaluating app validity and reliability.

Teledermatology
Teledermatology apps are the most common dermatology apps,² allowing for remote evaluation of patients through either live consultations or transmittance of medical information for later review by board-certified physicians.⁸ Features common to many teledermatology apps include accessibility on Android (Google Inc) and iOS as well as a web version. Security and Health Insurance Portability and Accountability Act compliance is especially important and is enforced through user authentications, data encryption, and automatic logout features. Data is not stored locally and is secured on a private server with backup. Referring providers and consultants often can communicate within the app. Insurance providers also may cover teledermatology services, and if not, the out-of-pocket costs often are affordable.

The highest-ranked patient app (ranked 184 in the Medical category) was a teledermatology app that did not meet the American Telemedicine Association standards for teledermatology apps.⁹ The popularity of this app among patients may have been attributable to multiple ease-of-use and turnaround time features. The user interface was simplistic, and the design was appealing to the eye. The entry field options were minimal to avoid confusion. The turnaround time to receive a diagnosis depended on 1 of 3 options, including a more rapid response for an increased cost. Ease of use was the highlight of this app at the cost of accuracy, as the limited amount of information that users were required to provide physicians compromised diagnostic accuracy in this app.

For comparison, we chose a nonranked (and thus less frequently used) teledermatology app that had previously undergone scientific evaluation using 13 evaluation criteria specific to teledermatology.¹⁰ The app also met the American Telemedicine Association standard for teledermatology apps.⁹ The app was originally a broader telemedicine app but featured a section specific to teledermatology. The user interface was simple but professional, almost resembling an EMR. The input fields included a comprehensive history that permitted a better evaluation of a lesion but might be tedious for users. This app boasted professionalism and accuracy, but from a user standpoint, it may have been too time-consuming.

Striking a balance between ensuring proper care versus appealing to patients is a difficult but important task. Based on this study, it appears that popular patient apps may in fact have less scientific rationale and therefore potentially less accuracy.

Self-surveillance
Although self-surveillance apps did not account for the highest-ranked app, they were the most frequently ranked app type in our study. Most of the ranked self-surveillance apps in the Medical category were for monitoring lesions over time to assess for changes. These apps help users take photographs that are well organized in a single, easy-to-find location. Some apps were risk calculators that assessed the risk for malignancies using a questionnaire. The majority of these self-surveillance apps were specific to skin cancer detection. Of note, one of the ranked self-surveillance apps assessed drug effectiveness by monitoring clinical appearance and symptoms. The lowest ranked self-surveillance app in the top 1500 ranked Medical apps in our search monitored cancer symptoms not specific to dermatology. Although this app had a low ranking (1380/1500), it received a high number of reviews and was well rated at 4.8 out of 5 stars; therefore, it seemed more helpful than the other higher-ranked apps targeting patients, which had higher rankings but minimal to no reviews or ratings. A comparison of the ease-of-use features of all the ranked patient-targeted self-surveillance apps in the Medical category is provided in Table 4.

Physician Apps

After examining the results of apps targeting physicians, we realized that the data may be accurate but may not be as representative of all currently practicing dermatology providers. Given the increased usage of apps among younger age groups,¹¹ our data may be skewed toward medical students and residents, supported by the fact that the top-ranked physician app in our study was an education app and the majority were reference apps. Future studies are needed to reexamine app ranking as this age group transitions from entry-level health care providers in the next 5 to 10 years. These findings also suggest less frequent app use among more veteran health care providers within our specific search parameters. Therefore, we decided to do subsequent searches for available billing/coding and EMR apps, which were many, but as mentioned above, none were specific to dermatology.

General Dermatology References
Most of the dermatology reference apps were formatted as e-books; however, other apps such as the Amazon Kindle app (categorized under Books) providing access to multiple e-books within one app were not included. Some apps included study aid features (eg, flash cards, quizzes), and topics spanned both dermatology and dermatopathology. Apps provide a unique way for on-the-go studying for dermatologists in training, and if the usage continues to grow, there may be a need for increased formal integration in dermatology education in the future.

Journals
Journal apps were not among those listed in the top-ranked apps we evaluated, which we suspect may be because journals were categorized differently from one journal to the next; for example, the Journal of the American Academy of Dermatology was ranked 1168 in the Magazines and Newspapers category. On the other hand, Dermatology World was ranked 1363 in the Reference category. An article’s citation affects the publishing journal’s impact factor, which is one of the most important variables in measuring a journal’s influence. In the future, there may be other variables that could aid in understanding journal impact as it relates to the journal’s accessibility.

Limitations

Our study did not look at Android apps. The top chart apps in the Android and Apple App Stores use undisclosed algorithms likely involving different characteristics such as number of downloads, frequency of updates, number of reviews, ratings, and more. Thus, the rankings across these different markets would not be comparable. Although our choice of keywords stemmed from the majority of prior studies looking at dermatology apps, our search was limited due to the use of these specific keywords. To avoid skewing data by cross-comparison of noncomparable categories, we could not compare apps in the Medical category versus those in other categories.

CONCLUSION

There seems to be a disconnect between the apps that are popular among patients and the scientific validity of the apps. As app usage increases among dermatology providers, whose demographic is shifting younger and younger, apps may become more incorporated in our education, and as such, it will become more critical to develop formal scientific standards. Given these future trends, we may need to increase our current literature and understanding of apps in dermatology with regard to their impact on both patients and health care providers.