Cheryl J. Gustafson

Trends in Sunscreen Recommendation Among US Physicians

IMPORTANCE Sunscreen is an important part of sun protection to prevent skin cancer but may not be recommended as often as guidelines dictate. OBJECTIVE To evaluate trends in sunscreen recommendation among physicians to determine whether they are following suggested patient-education guidelines regarding sun protection, and to assess data regarding physician sunscreen recommendations to determine the association with patient demographics, physician specialty, and physician diagnosis. DESIGN, SETTING, AND PARTICIPANTS The National Ambulatory Medical Care Survey was queried to identify patient visits to nonfederal outpatient physician offices at US ambulatory care practices (January 1, 1989-December 26, 2010) during which sunscreen was recommended. MAIN OUTCOMES AND MEASURES Frequency of sunscreen recommendation. RESULTS According to the National Ambulatory Medical Care Survey, there were an estimated 18.30 billion patient visits nationwide. Physicians mentioned sunscreen at approximately 12.83 million visits (0.07%). Mention of sunscreen was reported by physicians at 0.9% of patient visits associated with a diagnosis of skin disease. Dermatologists recorded the mention of sunscreen the most (86.4% of all visits associated with sunscreen). However, dermatologists reported mentioning sunscreen at only 1.6% of all dermatology visits. Sunscreen was mentioned most frequently to white patients, particularly those in their eighth decade of life, and least frequently to children. Actinic keratosis was the most common diagnosis associated with sunscreen recommendation. CONCLUSIONS AND RELEVANCE Despite encouragement to provide patient education regarding sunscreen use and sun-protective behaviors, the rate at which physicians are mentioning sunscreen at patient visits is quite low, even for patients with a history of skin cancer. The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protective behaviors, which patients should be counseled about at outpatient visits.

Combination Therapy in Psoriasis

BackgroundPsoriasis is a chronic, systemic, inflammatory condition for which a variety of treatment modalities exist. Combinations of therapies are used often in clinical practice to enhance efficacy and reduce drug toxicities.PurposeThe purpose of this review is to assess the literature on the efficacy and safety of combination therapy in the treatment of psoriasis.MethodsMEDLINE was reviewed to identify English-language publications from 1966 to 2011 examining combination therapy in psoriasis. Fifty-three articles met inclusion criteria and were included in this review. Randomized controlled trials addressing various combinations of treatment modalities for psoriasis were included. Data from these clinical studies were summarized and the outcomes were discussed.ResultsLarge-scale, randomized controlled trials investigating the use of various combination therapies in psoriasis are limited. The strongest data support the use of combinations of vitamin D derivatives and corticosteroids as topical combinations and, to a lesser extent, the combination of other topical agents. Phototherapy and topical vitamin D derivatives as well as phototherapy in combination with oral retinoids are well supported in the literature. Combinations of systemic medications, though often used clinically, have little data to support their efficacy or safety.LimitationsOur data were limited by the small number of clinical trials examining the multiple available combinations that are used in clinical practice.ConclusionsThe use of combination treatments falls within the standard of care for psoriasis, even if these combinations have not been extensively studied in clinical trials.

The association of skin conditions with housing conditions among North Carolina Latino migrant farm workers.

Skin conditions are common among Latino migrant farm workers. Although many skin conditions are related to occupational exposures, poor housing conditions may also contribute to skin ailments in migrant farm workers.

Maternal Adherence Factors in the Treatment of Pediatric Atopic Dermatitis

E ffective control of atopic dermatitis in children requires frequent use of treatment, but adherence to topical treatment in this population is abysmal. Caregiver involvement plays a crucial role in treatment. Mothers are frequently the primary caregivers and often control medication administration. While much of the data on adherence to topical treatment regimens for chronic skin disease come from adult studies, adult impediments to adherence might also apply to mothers in the treatment of their children: inconvenience of use, time constraints, unclear or complex instructions, and fear of adverse effects. We sought to gain a better understanding of the poorly characterized maternal factors that affect medication use through a qualitative study to identify factors that influence mothers’ medication administration in the management of pediatric atopic disease.

Skin Manifestations of Outpatient Adverse Drug Events in the United States: A National Analysis

Background: Cutaneous reactions to drugs are among the most common clinical manifestations of adverse drug events (ADEs); however, data on outpatient cutaneous adverse drug events (CADEs) are limited. Purpose: To provide national estimates of outpatient CADEs and determine their most frequent causes. Methods: Outpatient CADEs recorded in the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1995 and 2005 were analyzed. The national incidence of outpatient CADEs in those seeking medical attention in the United States was estimated, and the common medication classes implicated with CADEs were identified. Results: There were a mean annual total of 635,982 CADE-related visits, resulting in an annual incidence of 2.26 CADEs per 1,000 persons. Patients took an average of 2.2 medications in addition to the one causing the CADE. The incidence of CADEs increased with age, with a peak in the age group from 70 to 79 years. The medications most frequently causing a CADE were antimicrobial agents. Dermatitis and urticaria were the two main types of skin reactions reported. Conclusions: CADEs occur less frequently in outpatients than in inpatients and result in few hospital admissions. Physicians must be particularly cognizant of the occurrence of CADEs when prescribing antimicrobial agents.

Measure of Atopic Dermatitis Disease Severity Using Actigraphy

Background: Analyzing adherence to treatment and outcomes in atopic dermatitis is limited by methods to assess continual disease severity. Atopic dermatitis significantly impacts sleep quality, and monitoring sleep through actigraphy may capture disease burden. Purpose: To assess if actigraphy monitors provide continuous measures of atopic dermatitis disease severity and to preliminarily evaluate the impact of a short-course, high-potency topical corticosteroid regimen on sleep quality. Methods: Ten patients with mild to moderate atopic dermatitis applied topical fluocinonide 0.1% cream twice daily for 5 days. Sleep data were captured over 14 days using wrist actigraphy monitors. Investigator Global Assessment (IGA) and secondary measures of disease severity were recorded. Changes in quantity of in-bed time sleep were estimated with random effects models. Results: The mean daily in-bed time, total sleep time, and wake after sleep onset (WASO) were 543.7 minutes (SEM 9.4), 466.0 minutes (SEM 7.7), and 75.0 minutes (SEM 3.4), respectively. WASO, a marker of disrupted sleep, correlated with baseline (ρ = .75) and end of treatment IGA (ρ = .70). Most patients did not have marked changes in sleep. IGA scores declined by a median change of 1 point at days 7 (p = .02) and 14 (p = .008). Conclusions: Using actigraphy, atopic dermatitis disease severity positively correlated with sleep disturbances. Actigraphy monitors were well tolerated by this cohort of atopic dermatitis subjects.

Patterns of disease and treatment of cold sores

Background: Cold sores are a common condition that can cause significant morbidity and mortality. Antivirals are the typical treatment for cold sores, but the ways in which these medications are used to treat cold sores are not well studied. Purpose: To determine the main treatments prescribed for cold sores and trends in their management over time. Methods: A retrospective analysis of the National Ambulatory Medical Care Survey database was used to analyze outpatient visits for cold sores from 1993 to 2009. Patients were included in the data analysis if they had one of the following three diagnoses reported for their reason-for-visit codes: cold sores (CS), herpes simplex (HS) or herpes simplex with cold sores (HS/CS). Results: There was a decreasing trend in the number of annual patient visits for cold sores. The majority of patients were mainly young to middle adulthood, white women. The top two most commonly prescribed medications were acyclovir followed by valacyclovir. Valacyclovir use increased in all three populations, while acyclovir use decreased. Conclusions: The trends observed may indicate that physicians are evolving their treatment strategies to implement newer antiviral medications. This may prove more efficacious for the treatment of cold sores.

Feasibility of actigraphy wristband monitoring of atopic dermatitis in children.

Actigraphy monitors are used to monitor sleep and scratching. Previous studies have implemented these monitors to evaluate behavior in adult patients with atopic dermatitis. However, such monitoring devices have been implemented in a paucity of studies involving pediatric patients with atopic dermatitis. The purpose of this study was to assess the feasibility of actigraphy monitoring in children with mild‐to‐severe atopic dermatitis.

Prevalence of psoriasis and rosacea comorbidities in the outpatient setting.

To the Editor: Psoriasis and rosacea are common, chronic inflammatory skin conditions that may affect a patient’s overall health. Whereas many psoriasis comorbidities have been identified, there are limited data for rosacea patients. Successful management of comorbidities may impact the health status and treatment outcomes among such patients. The purpose of this study was to assess the frequencies of comorbid conditions in patients with rosacea and to compare these frequencies to those of comorbidities among patients with or patients without psoriasis. This study was conducted using the MarketScan Medicaid data set, which contains individual-level health care claims, and hospital discharge information from large organizations and public health insurance programs. Overall, the database covers almost 10 million patients in the United States and captures the full continuum of care in all health care settings. Patients who were 18 years of age or older and had made at least one outpatient visit during the time period of 2003–2007 were included. Demographic information was described. Comorbidities were identified by ICD-9 codes in the outpatient data file (Table 1). The frequencies and 95% confidence intervals of the top 10 comorbidities were calculated through direct age standardization based on the number of patients associated with the following patient populations: (1) all patients without psoriasis; (2) psoriasis patients; and (3) rosacea patients. Statistical analyses were performed using Stata 12 software (StataCorp LP, College Station, TX). The total number of patients without psoriasis was 4,544,189, the total number of patients with psoriasis was 24,247, and the total number of patients with rosacea was 13,026. For all three populations, patients tended to be white and female (Table 2). The most common age category for all patients without psoriasis was 18 to 30 years; in contrast, the most common age group for patients with psoriasis or rosacea was 51 years and older. The top 10 comorbidity diagnoses based on patient counts were similar across all three patient groups. However, the frequencies of comorbidities across the three groups differed, with rosacea and psoriasis patients having the higher proportions of patients affected compared to patients without psoriasis (Table 3). Acute bronchitis/ bronchiolitis was a top 10 comorbidity unique to psoriasis patients. Unlike patients without psoriasis, patients with psoriasis or rosacea frequently experienced limb pain. These findings indicate that psoriasis and rosacea adult patients share multiple comorbidities in common with the general patient population, but these two groups have higher comorbidity burdens. Psoriasis is a systemic autoimmune disease that affects about 7.5 million people in the United States alone. It is driven by aberrant T cell– mediated activity that tips the balance of cytokine activity in the body to drive inflammation. As a result, psoriasis has many associated comorbidities, such as hypertension, type 2 diabetes, metabolic syndrome, hyperlipidemia, and obesity. Our results validate these findings as diabetes, hypertension, and hyperlipidemia were common comorbidities for psoriasis patients. Although rosacea affects an estimated 14 million people in the United States, much remains unknown about the disease process, with theories including vascular abnormalities, dermal matrix degeneration, and environmental factors. Hypertension and hyperlipidemia were among the top 10 ranked comorbidities in rosacea patients, consistent with findings from a previous study. Similar to findings from Gupta and colleagues, depressive disorder was also a common rosacea comorbidity. These findings reinforce the known inflammatory-related comorbidities associated with psoriasis and highlight the need for further study of rosacea comorbidities.

Usage of complementary and alternative medicine for management of skin disease

It is disappointing and frustrating, for both the patient and the physician, when conventional medical treatments fail to provide adequate clinical responses. Consequently, many patients are integrating complementary and alternative medicine (CAM) into their treatment regimens. A recent survey regarding the implementation of CAM with conventional therapy found that most patients believe such a combination optimizes treatment outcomes (1). Physicians are often unaware of patients’ implementation of CAM, for few physicians query patients regarding usage of herbal products and/or dietary supplements. Furthermore, physicians often feel uncertain about advising patients regarding CAM as reliable evidence supporting the usage of natural products is hard to come by. Additionally, patients may be hesitant to tell their doctor that they are using a natural treatment. Although natural products may possess beneficial effects, most have not undergone evidence-based assessment to verify their efficacy and safety. However, patients and physicians often become hopeful when new therapies, whether conventional or alternative, are introduced since these products are advertised as having the potential to provide significant reduction and/or resolution of symptoms. The implementation of CAM by patients with skin disease is relatively common. In the United States, the prevalence of CAM usage in adult patients reporting skin problems is approximately 49.4% (1). More specifically, 6% of patients using CAM are implementing it into their regimens specifically for the management of dermatological disease (1). Inflammatory skin dermatoses, especially psoriasis and atopic dermatitis, are two of the leading skin diseases associated with the usage of CMA. Over the past several years, numerous naturopathic treatments for inflammatory skin disease have been introduced. Such therapies include implementation of an anti-inflammatory diet, omega-3 fatty acid supplementation, topical herbal products (e.g., aloe vera, tea tree oil), and dietary supplements containing bioactive proteins. We recently read about a new dietary supplement recently introduced into the United States for the treatment of psoriasis and eczema. Vitamin C and concentrated mare’s milk are stated to be the product’s main ingredients. The bioactive ingredients suggested to confer antiinflammatory and antibacterial properties to the product include lysozyme, secretory IgA, and lactoferrin (2). Although there are numerous “success stories” posted on the web for this product, there is a paucity of information in the medical literature supporting the efficacy of concentrated mare’s milk in the