David G. Li

Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis

Importance Many inflammatory skin dermatoses mimic cellulitis (pseudocellulitis) and are treated with antibiotics and/or hospitalization, leading to unnecessary patient morbidity and substantial health care spending. Objective To evaluate the impact of early dermatology consultation on clinical and economic outcomes associated with misdiagnosed cellulitis. Design, Setting, and Participants This prospective cohort study enrolled patients with presumed diagnosis of cellulitis in the emergency department, in the emergency department observation unit, or within 24 hours of admission to an inpatient unit of a large urban teaching hospital between February and September 2017. Patients were provided with telephone and clinic follow-up during the 30-day postdischarge period. We screened 165 patients with the primary concern of cellulitis. Of these, we excluded 44 who required antibiotics for cutaneous, soft-tissue, and deeper-tissue and/or bone infections irrespective of cellulitis status, and 5 who were scheduled to be discharged by the emergency department. Interventions Early dermatology consultation for presumed cellulitis. Main Outcomes and Measures Primary outcomes were patient disposition and rates of antibiotic use. Results Of 116 patients (63 [54.3%] women; 91 [78.4%] non-Hispanic white; mean [SD] age, 58.4 [19.1] years), 39 (33.6%) were diagnosed with pseudocellulitis by dermatologists. Of these, 34 (87.2%) had started using antibiotics for presumed cellulitis as prescribed by the primary team at the time of enrollment. The dermatology team recommended antibiotic discontinuation in 28 of 34 patients (82.4%), and antibiotics were stopped in 26 of 28 cases (92.9%). The dermatologists also recommended discharge from planned observation or inpatient admission in 20 of 39 patients with pseudocellulitis (51.3%), and the primary team acted on this recommendation in 17 of 20 cases (85.0%). No patients diagnosed with pseudocellulitis experienced worsening condition after discharge based on phone and clinic follow-up (30 of 39 [76.9%] follow-up rate). Extrapolating the impact of dermatology consultation for presumed cellulitis nationally, we estimate 97 000 to 256 000 avoided hospitalization days, 34 000 to 91 000 patients avoiding unnecessary antibiotic exposure, and

The validity of the diagnostic code for pyoderma gangrenosum in an electronic database

80 million to

Development and pilot-testing of the Alopecia Areata Assessment Tool (ALTO)

210 million in net cost savings annually. Conclusions and Relevance Early consultation by dermatologists for patients with presumed cellulitis represents a cost-effective intervention to improve health-related outcomes through the reduction of inappropriate antibiotic use and hospitalization.

The ALT-70 Predictive Model Outperforms Thermal Imaging for the Diagnosis of Lower Extremity Cellulitis: A Prospective Evaluation

Pyoderma gangrenosum (PG) is a rare inflammatory and ulcerative neutrophilic dermatosis with an estimated incidence of 3-10 cases per million people annually.1 Given that our understanding of PG is limited by disease rarity and considerable misdiagnosis rates (~30-50%),2 establishing a method to identify cases in large databases would facilitate population-based research. This approach has been used in other dermatologic diseases,3-6 where case identification is performed by diagnosis-related queries based on the International Classification of Diseases (ICD) code. This article is protected by copyright. All rights reserved.

Evaluating the Efficacy of Topical Dapsone Treatment for Pyoderma Gangrenosum: A Retrospective Case Series

Background Alopecia areata (AA) is an autoimmune disease characterized by non-scarring hair loss. The lack of a definitive biomarker or formal diagnostic criteria for AA limits our ability to define the epidemiology of the disease. In this study, we developed and tested the Alopecia Areata Assessment Tool (ALTO) in an academic medical center to validate the ability of this questionnaire in identifying AA cases. Methods The ALTO is a novel, self-administered questionnaire consisting of 8 closed-ended questions derived by the Delphi method. This prospective pilot study was administered during a 1-year period in outpatient dermatology clinics. Eligible patients (18 years or older with chief concern of hair loss) were recruited consecutively. No patients declined to participate. The patient’s hair loss diagnosis was determined by a board-certified dermatologist. Nine scoring algorithms were created and used to evaluate the accuracy of the ALTO in identifying AA. Results 239 patients (59 AA cases and 180 non-AA cases) completed the ALTO and were included for analysis. Algorithm 5 demonstrated the highest sensitivity (89.8%) while algorithm 3 demonstrated the highest specificity (97.8%). Select questions were also effective in clarifying disease phenotype. Conclusion In this study. we have successfully demonstrated that ALTO is a simple tool capable of discriminating AA from other types of hair loss. The ALTO may be useful to identify individuals with AA within large populations.

Utility of Baseline Transaminase Monitoring During Systemic Terbinafine Therapy for Pediatric Onychomycosis

Background: We previously demonstrated that dermatology consultation substantially reduces the rates of misdiagnosis of cellulitis; however, broad implementation of dermatology consultation is impractical on account of existing practice patterns and reimbursement systems. Meanwhile, efforts to improve diagnostic accuracy have culminated in point‐of‐care tools, including the ALT‐70 predictive model for lower extremity cellulitis and thermal imaging. Objective: To prospectively evaluate the performance of the ALT‐70 predictive model and thermal imaging in diagnosing lower extremity cellulitis in a head‐to‐head comparison. Methods: We collected ALT‐70 and thermal imaging data from patients with presumed lower extremity cellulitis and compared classification measures and accuracy for the ALT‐70 predictive model, thermal imaging, and combination testing (ALT‐70 predictive model plus thermal imaging). Results: We enrolled 67 patients with ALT‐70 and thermal imaging data. The ALT‐70 predictive model conferred the highest sensitivity (97.8%) and negative predictive value (90.9%), whereas combination testing had the highest specificity (71.4%) and positive predictive value (86.6%). The ALT‐70 predictive model had improved classification measures compared with thermal imaging. Combination testing conferred a marginal benefit compared with the ALT‐70 predictive model alone. Limitations: Single‐center design may limit generalizability. Conclusion: The ALT‐70 predictive model outperformed thermal imaging in diagnosing lower extremity cellulitis. The accuracy of the ALT‐70 predictive model was high and consistent with its performance in previously published literature. Broad implementation of the ALT‐70 predictive model in clinical practice may decrease the rates of misdiagnosis of lower extremity cellulitis.

Opioid Prescribing Patterns and Complications in the Dermatology Medicare Population

Pyoderma gangrenosum (PG) is a rare, noninfectious neutrophilic dermatosis commonly associated with inflammatory bowel disease, malignant neoplasms, hematologic disorders, and inflammatory arthritis. While its pathogenesis is poorly understood, PG is thought to be a result of neutrophil dysregulation, genetic factors, and chronic inflammation. Dapsone is a nonimmunosuppressive drug used in neutrophil-mediated diseases. A topical formulation (Aczone; Allergan, Dublin, Ireland) was introduced in 2002, and while its utility in PG has not been studied, select case reports have suggested a role for oral dapsone in the treatment of PG. In this retrospective study, we examined the response of patients with PG treated with topical dapsone. A retrospective review of patients with PG treated with 5% topical dapsone at Brigham and Women’s Hospital and Massachusetts General Hospital from 2000 to 2015 was conducted using previously published methods. Each record was manually reviewed to confirm treatment with topical dapsone and to extract concurrent therapy. A course of treatment was defined as 4 weeks, and treatment response was determined based on physician documentation and images. Data were recorded in Research Electronic Data Capture (REDCap). This study was approved by the Partners Healthcare Institutional Review Board. We identified 21 patients with PG who were treated with 5% topical dapsone. Of the patients, 71.4% were female, with a mean (SD) age of 60.3 (16.6) years. The most common comorbidity was inflammatory bowel disease (57.1%), and the most common ulcer location was the lower extremities (42.9%) (Table 1). The most frequent concurrent treatments included systemic, topical, or intralesional steroids (Table 2). Of 21 patients, 18 (85.7%) had a partial response and 2 (9.5%) had a complete response. The average time to initial treatment response was 4.3 weeks and the average duration of treatment was 14.6 months. There were no adverse events. Our data suggest a role for topical dapsone as an adjunct treatment for PG. Use of topical dapsone resulted in clinically documented partial improvement in 85.7% of patients with PG and complete resolution in 9.5%. The efficacy of topical steroid therapy for patients with limited PG has already been established. These findings suggest topical dapsone to be a low-risk, steroid-sparing treatment that may be beneficial in patients with PG while avoiding exposure to systemic treatment. Given its minimal systemic absorption and strong Medical Letter 782140 CMSXXX10.1177/1203475418782140Journal of Cutaneous Medicine and SurgeryLi et al letter2018

Factors Influencing Patient Decisions Regarding Treatments for Skin Growths: A Cross-Sectional Study

Utility of Baseline Transaminase Monitoring During Systemic Terbinafine Therapy for Pediatric Onychomycosis To the Editor We applaud the important research findings by Patel et al1 regarding pediatric onychomycosis. In this study, the authors appropriately conclude that routine laboratory monitoring of children during treatment with terbinafine may be unnecessary, considering (1) the low incidence of clinically significant adverseeffects; (2)thecostsoflaboratorytests; (3)workupofspurious laboratory abnormalities; and (4) patient discomfort. We agree with these findings and propose that similar logic may be used to argue that baseline monitoring is also unnecessary. The goal of laboratory monitoring of any hepatotoxic medication is to allow clinicians to detect subclinical abnormalities for dose adjustments, while averting clinically significant druginduced liver injury (DILI).2 Similarly, baseline monitoring may aid clinicians in recognizing patients with a concealed propensity for disease that may manifest clinically after drug initiation. This approach may fail at a population level on 2 accounts. First, recent findings have suggested that isolated elevations in serum aminotransferase levels 1.5 times or more above reference range for age in asymptomatic, nonobese infants and children with minimal risk factors for liver disease are primarily benign, usually resolving within a year.3 Findings of liver biopsies in those with sustained elevations were largely unremarkable. Second, elevated transaminase levels at baseline do not predict the occurrence of terbinafineassociated DILI, although data on children are absent.4 Instead,cliniciansshouldtakeadetailedhistoryandconsider known comorbidities and risk factors prior to initiation of treatment with any drug, including terbinafine. In the absence of risk factors, broad population-based screening of children is unlikely to yield clinically meaningful findings, and its potential to reduce terbinafine-associatedmorbidityisunknown.Existingguidelines recommending baseline monitoring are likely capturing a substantial proportion of patients with normal variations in transaminase levels, leading to laboratory workup that may be unrelated to clinically relevant outcomes. Considering the low prevalence of terbinafineassociated DILI during treatment and the normal variation in baseline pediatric transaminase levels, clinicians should reconsider baseline monitoring prior to therapy. The aim of reducing morbidity from this treatment is laudable; however, data are lacking to indicate that this approach would succeed in reducing what appears to be an idiopathic outcome. Further research should aim to understand the pathophysiology of terbinafine toxic effects and develop novel indicators of patients at risk. Until then, while larger, prospective studies are necessary, it is probable that baseline transaminase monitoring prior to initiation of terbinafine therapy may be unnecessary in asymptomatic children without risk factors for liver disease.

Clinical Diagnostic Accuracy of Onychomycosis: A Multispecialty Comparison Study

Importance The ongoing opioid epidemic in the United States has been fueled by prescription opioids. Increases in opioid-related deaths and complications mandate clinicians in all fields to scrutinize their prescribing patterns. Objective To characterize the current status and potential complications of opioid prescribing practices among dermatologists for Medicare beneficiaries. Design, Setting, and Participants A cross-sectional study used Medicare Part D prescriber data to evaluate opioid prescriptions by dermatologists from January 1 to December 31, 2014. The number of prescribers, opioid claims, beneficiaries, and days supplied as well as the type of opioid and geographic location of prescribers were extracted and analyzed. The top 1% of dermatologists prescribing opioids were identified and compared with a random sample of the same size among the remaining dermatologists based on sex, geographic location, type of practice, and time in practice. A systematic literature review was conducted to estimate the outcome of opioid prescribing practices on the exposed population. Main Outcome and Measures Practice characteristics, epidemiologic factors, and consequences of opioids prescribed by dermatologists. Results Of the 12 537 dermatologists in the study, 5305 (42.3%) prescribed no opioid claims, 5408 (43.1%) prescribed 1 to 10 opioid claims, and 1824 (14.5%) prescribed more than 10 opioid claims. Among dermatologists prescribing at least 10 opioid claims, a mean of 1.0 opioid claims was given to each beneficiary, with a supply lasting a mean of 4.4 days. A total of 108 dermatologists (93.9%) in the top 1% of opioid prescribers (n = 115) work in a surgical practice. Estimates suggest that opioids prescribed by dermatologists could annually lead to 3877 to 7602 beneficiaries continuing to use opioids at 1 year and 1825 to 4209 continuing to use opioids at 3 years. A total of 9882 to 22 806 beneficiaries could experience gastrointestinal tract or central nervous system adverse effects and 588 to 999 could experience fractures. Conclusions and Relevance Opioid prescribing among dermatologists is limited and concentrated in the surgical setting, but it may be associated with a substantial number of adverse events that serve as a reminder to emphasize nonopioid pain medications in the postoperative setting.

Mass Compression from Recurrent Lymphoma Mimicking Lower Extremity Cellulitis

Variations in treatment modalities for skin growths contribute substantially to overall healthcare spending within dermatology. However, little is known regarding factors impacting patient decision-making when choosing a treatment modality. In this survey-based, cross-sectional study (n = 375, 81.9% response rate), we asked patients to rate the importance of different treatment parameters for a nonfacial skin growth, further classified into five domains: efficacy, appearance, financial impact, visit duration, and productivity. Although patients generally prioritized treatment efficacy when selecting a treatment modality, they emphasized different aspects of the treatment experience as a function of age, gender, race, insurance status, and history of malignancy. Patients over age 50 were less likely to consider treatment impact on finances as being “important”, but more so efficacy and visit duration. Women were more likely to value efficacy and appearance. Patients without private insurance were more likely to cite efficacy and impact on productivity as being “important”. While the underlying reasons for these variations differ across patients, these findings help explain variations in treatment selection among patients choosing between treatments for skin growths and may ultimately lead to improved shared decision-making.