Christine S. Ahn

To test or not to test? An updated evidence-based assessment of the value of screening and monitoring tests when using systemic biologic agents to treat psoriasis and psoriatic arthritis

BACKGROUND Safety profiles of systemic biologic agents for the treatment of psoriasis and psoriatic arthritis (PsA) encompass a wide spectrum of adverse events. To date, no uniform evidence-based guidelines exist regarding screening and monitoring patients who are undergoing biologic therapy. OBJECTIVE We sought to identify studies evaluating screening and monitoring tests in the treatment of psoriasis and PsA with systemic biologic agents, and to propose evidence-based practical guidelines. METHODS The MEDLINE database was searched to identify data on risks associated with adalimumab, etanercept, infliximab, and ustekinumab. Articles were reviewed and graded according to methods developed by the US Preventative Services Task Force. RESULTS Evidence was strongest (grade B) for tuberculosis screening. Interferon-gamma release assay was preferable to tuberculin skin testing. Among known hepatitis B virus carriers, the evidence grade was C for monitoring liver function tests and viral load. LIMITATIONS This study was limited by the lack of high-quality controlled trials evaluating screening and monitoring tests in patients treated with biologic agents. CONCLUSIONS Baseline tuberculosis testing remains the only screening test with strong evidence to support its practice. Other screening and monitoring tests commonly performed in patients who are taking biologic agents are supported only in certain clinical settings or lack evidence to support or recommend against their practice.

Mycosis fungoides: an updated review of clinicopathologic variants.

Abstract:Mycosis fungoides (MF) is the most common primary cutaneous T-cell lymphoma. Although it was first described in 1833, our understanding of this disease has continued to evolve. From a diagnostic perspective, the diagnosis of MF can be challenging particularly in the early stages of the disease, because of overlap between the histological features of early MF lesions and many other inflammatory dermatoses. Furthermore, there has been an emergence of numerous clinicopathologic and immunohistochemical variants of MF reported in the literature. Although the prognostic significance of some of the rare variants is still not fully understood, certain variants, such as folliculotropic and bullous MF, have demonstrated less indolent clinical courses compared with classic MF and necessitate aggressive therapeutic measures. Thus, it is important for dermatologists and dermatopathologists to be knowledgeable of the widely varied clinical, histological, and immunohistochemical presentations of MF to arrive at a prompt and accurate diagnosis and initiate appropriate treatment.

The National Ambulatory Medical Care Survey: A resource for understanding the outpatient dermatology treatment

Abstract Background: The National Ambulatory Care Survey (NAMCS) collects information on outpatient medical care in the United States. Key characteristics of the NAMCS methodology are not well recognized. We describe the NAMCS survey design and patient visits to dermatologists and to present information on the validity of the NAMCS data by comparing key features of the dermatologist sample to other surveys of dermatologists. Methods: NAMCS data on dermatologists and skin-related visits from 1993 to 2010 were analyzed and compared to the Dermatology Physician Profile Survey (DPPS), a survey by the American Academy of Dermatology. Results: A total of 29 554 patient visits to dermatologists were sampled from 1993 to 2010. On average, 118 dermatologists were sampled annually to participate in the NAMCS, and response rates ranged from 47 to 77%. The NAMCS and the DPPS found similar dermatologist demographics, practice settings and reimbursement sources. Conclusion: Overall, the NAMCS achieves high-response rates and provides a generalizable sample that has been used in scores of studies of dermatology outpatient treatment. In a time of changing health care delivery systems, NAMCS is valuable for understanding how physicians care for patients with skin disease.

Dermatoscopy for melanoma and pigmented lesions.

This article presents an overview of the history and development of dermatoscopy over the last 2 decades. The common dermatoscopic diagnostic algorithms are discussed, including classic pattern analysis, the ABCD rule (asymmetry, border, color, and dermatoscopic structures), 7-point checklist, and Menzies method, as well as a new method by the authors (ASAP: a simple and practical approach). In addition, evidence on the clinical impact and challenges of dermatoscopy for the diagnosis and management of pigmented lesions and the importance of training are reviewed.

Noncosmetic skin-related procedures performed in the United States: an analysis of national ambulatory medical care survey data from 1995 to 2010.

BACKGROUND Demand for dermatologic care is increasing alongside a known shortage of physicians in the dermatology workforce. Changes in the volume of dermatologic procedures over time and the physician specialties involved in skin‐related procedural care are not well characterized. OBJECTIVE To determine the frequency of dermatologic procedures performed in the United States between 1995 and 2010 and to analyze the changes in the procedures and physicians performing procedures over time. METHODS The annual volume of skin‐related procedures performed by physician specialties and the rate of procedures performed per physician was determined from data from the National Ambulatory Medical Care Survey (NAMCS) between 1995 to 2004 and 2007 to 2010. RESULTS Dermatologists and primary care physicians performed most procedures (54.7% and 19.5%, respectively). CONCLUSIONS Dermatologists perform a larger volume of procedures than in the past, although the proportion of procedures performed by dermatologists is unchanged, and other physician specialties are performing more skin‐related procedures to meet increasing demand.

The life cycles and biological end pathways of dermal fillers

There is an increased demand for soft tissue augmentation procedures. A wide range of products can provide correction through different mechanisms and it is important for clinicians to understand the biological pathways of each material. This study presents a systematic review of the pathways of commonly used fillers, with consideration of the complications associated with each.

Adherence in dermatology

Abstract Non-adherence to treatment and medical recommendations is one of the leading causes of treatment failure, poor clinical outcomes, and increased healthcare utilization. Although non-adherence is observed across all medical specialties, adherence to treatment in dermatology deserves special attention given the multiple different routes of treatment. Adherence can be measured using subjective methods (patient reporting and questionnaires) or objective methods (pill counts, electronic chips, and pharmacy records). Adherence to dermatologic treatments varies based on the specific condition but is poor for systemic therapies and even worse with topical agents. Among the factors that influence adherence, duration of treatment, complexity of regimen, and access play a large role. Interventions to improve adherence can range from simplifying treatment regimens to scheduling more frequent office visits. Due to the profound effect on cost, healthcare outcomes, and mortality, understanding and improving adherence is equally as important as making the correct diagnosis and prescribing the correct treatment.

Melanocytic Nevi of Special Sites.

Abstract:Melanocytic nevi located on specific regions of the body can demonstrate unusual histopathological features such as asymmetry, irregular nesting patterns, pagetoid spread, cytologic atypia, and rarely, mitotic activity. However, despite these features that may raise concern for malignant melanoma, these lesions follow a benign clinical course and do not require intervention. Also known as nevi of special sites or nevi with site-related atypia, these melanocytic nevi were initially described on acral sites and genitalia. Now, additional anatomical sites with known site-related atypia include the ear, conjunctivae, scalp, breast, flexural skin, legs, and back and shoulder. This continuing medical education article presents a review of the histopathological characteristics of special site nevi based on anatomic location. It is imperative for dermatologists, pathologists, and dermatopathologists to distinguish benign melanocytic nevi with site-related atypia from malignant melanoma to avoid unnecessary surgical intervention or treatment.

Cosmetic procedures performed in the United States: a 16-year analysis.

Background Cosmetic procedures, particularly those that are minimally invasive, are in demand. The physician specialties performing these procedures are not well‐characterized. Objective To examine changes in the frequency of cosmetic dermatologic procedures performed in the United States from 1995 to 2010 and the physician specialties performing them. Methods The volume of cosmetic procedures performed by physician specialties and the types of cosmetic procedures performed were determined from data from the National Ambulatory Medical Care Survey (NAMCS) from 1995 to 2010. Results Cosmetic procedures constituted 8.7% of all skin procedures and have increased since 1995 (p < .001). Botulinum toxin injections were the most frequently performed cosmetic procedure and increased at the greatest rate over time. Plastic surgeons performed the largest proportion of cosmetic procedures (36.1%), followed by dermatologists (33.7%), but other specialties have been performing an increasing proportion of cosmetic procedures. This study was limited to the provision of outpatient procedures, and the nationally representative data of the NAMCS is subject to sample bias. Conclusions Plastic surgeons and other physicians performed the majority of outpatient cosmetic procedures. Dermatologists performed one‐third of ambulatory cosmetic procedures from 1995 to 2010. This broadening spectrum of physicians and nonphysicians providing cosmetic procedures may have important implications for patient safety.

Services Available and Their Effectiveness

This article describes the range of services available for patients with skin disease in the United States. Within the structure of health care systems, 4 levels of care are characterized and discussed: self-care and management, generalist care, specialist care, and subspecialist care. Within each level, this article discusses the profiles of individuals involved in delivering medical care, the location or setting in which these services are provided, the capacity and specific activities of care providers, and current literature on the efficacy of these different levels of care.