Jeffrey F. Scott

Stage IV Melanoma of Unknown Primary: A Population-Based Study in the United States from 1973 to 2014

Background Melanoma of unknown primary (MUP) is incompletely described on a population level. Objective We sought to characterize stage IV MUP in a population‐based cancer registry. Methods We developed a novel search algorithm to identify cases of stage IV MUP in the Surveillance, Epidemiology, and End Results 18 registries from 1973 to 2014. Cases of stage IV melanoma of known primary (MKP) served as a comparison group. Age‐standardized incidence rates, demographic characteristics, adjusted disease‐specific survival, and Cox proportional hazard models were calculated for MUP and MKP. Results A total of 322 stage IV MUP cases and 12,796 stage IV MKP cases were identified in Surveillance, Epidemiology, and End Results 18 registries from 1973 to 2014. The incidence of stage IV MUP is increasing, particularly for patients younger than 30 years of age. In multivariate analyses, age older than 50 and a lack of surgical treatment were negative prognostic factors for stage IV MUP. Relative survival, but not 5‐year adjusted disease‐specific survival, was higher for stage IV MUP than for MKP. Limitations Limitations include the retrospective study design and possible misclassification of MUP. Conclusions The incidence of stage IV MUP is increasing, and stage IV MUP shares similar prognostic factors with stage IV MKP, including age and surgical treatment.

Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United States

Importance Knowledge regarding differences in dermatologic care for patients with a broad range of dermatologic conditions is limited. Objective To elucidate nationwide differences in use of outpatient dermatologic care. Design, Setting, and Participants Retrospective analysis of nationally representative data from the 2007 to 2015 Medical Expenditure Panel Survey (MEPS) provided by the Agency for Healthcare Research and Quality. Health care use outcomes for dermatologic conditions (skin cancers, infections, dermatologic inflammatory conditions/ulcers, and other skin disorders) were examined via multivariable logistic regression analyses of outpatient and office-based dermatologist visit rates accounting for sex, age, race/ethnicity, educational level, income, insurance status, region, self-reported condition, and self-reported health status. Participants were 183 054 MEPS respondents who visited a dermatologist from 2007 to 2015. Main Outcomes and Measures The primary outcome measure was whether the patient received outpatient care for any dermatologic condition (by payment). The secondary outcomes were annual health care use by individuals with dermatologic conditions (including per capita expenditure for the visit). Results Of 183 054 MEPS respondents (mean [SD] age, 34 [23] years; 52.1% female), 19 561 (10.7%) self-reported a dermatologic condition; 9645 patients had a total of 11 761 outpatient visits to dermatologists. Hispanic (adjusted odds ratio [aOR], 0.55; 95% CI, 0.49-0.61) and black (aOR, 0.42; 95% CI, 0.38-0.46) patients were both less likely to receive outpatient care for their dermatologic condition relative to non-Hispanic white patients. Male patients were less likely to receive outpatient dermatologic care than female patients (aOR, 0.66; 95% CI, 0.62-0.70), and Midwestern patients were less likely to receive outpatient dermatologic care than Northeastern patients (aOR, 0.80; 95% CI, 0.70-0.91). Patients with Medicaid or Medicare coverage (aOR, 0.75; 95% CI, 0.68-0.83) and uninsured patients (aOR, 0.39; 95% CI, 0.33-0.47) were both less likely to receive outpatient dermatologic care than privately insured patients. Increasing educational level and income were associated with increased odds of receiving outpatient care for the dermatologic condition. Conclusions and Relevance These findings highlight wide-ranging differences in use of dermatologic care in the United States across various demographic and socioeconomic lines. Results of this study suggest an urgent need to further characterize potential dermatologic health care differences and improve use of outpatient dermatologic care among disadvantaged populations.

Primary bilateral uveal melanoma: a population‐based study and systematic review

Primary bilateral uveal melanoma (UM) is a rare and incompletely described entity. It is not known how these patients compare to those with unilateral UM.

Vitamin D as a Therapeutic Option for Sunburn: Clinical and Biologic Implications

Vitamin D3 (cholecalciferol) is a fat-soluble steroid hormone obtained from food sources and produced locally in the skin from the ultraviolet radiation (UVR)-dependent conversion of cholesterol precursors to the inactive form of vitamin D3 (Bikle, 2011). In addition to its classically described functions related to the regulation of calcium homeostasis and bone metabolism, vitamin D3 has numerous nonclassical effects, including the ability to modulate immune responses (Mora et al., 2008; Wobke et al., 2014). Specifically, vitamin D3 induces monocyte to macrophage differentiation, enhances antimicrobial activity, stimulates autophagy, and suppresses the production of proinflammatory cytokines (Liu et al., 2006; Fabri et al., 2011; Di Rosa et al., 2012; Zhang et al., 2014). However, it was previously unknown whether vitamin D3 was capable of modulating acute inflammation in humans. In a randomized, double-blinded, placebo-controlled pilot study, our group recently demonstrated that vitamin D3 reduces skin inflammation when administered to humans 1 h after sunburn (Scott et al., 2017). This commentary will attempt to outline the major clinical and biologic implications of using vitamin D as an anti-inflammatory therapeutic agent.

Metastastic vulvar squamous cell carcinoma mimicking genital herpes

Metastatic disease to the skin can be difficult to diagnose clinically because it often mimics many infectious, inflammatory, and neoplastic skin conditions. Cutaneous metastases can present as dermal or subcutaneous nodules, exophytic tumors resembling melanoma or nonmelanoma skin cancer, erythematous patches and plaques resembling erysipelas or eczema, or indurated plaques resembling morphea or scleroderma.1 Rarely, cutaneous metastases present as grouped papulo-vesicles resembling herpes group virus infections.1

Food Avoidance Diets for Dermatitis

Food allergy is relatively common in both children and adults, and its prevalence is increasing. Early exposure of food allergens onto skin with an impaired epidermal barrier predisposes to sensitization and prevents the development of oral tolerance. While immediate-type food allergies are well described, less is known about delayed-type food allergies manifesting as dermatitis. This is due, in part, to limitations with current diagnostic testing for delayed-type food allergy, including atopy patch testing. We conducted a systematic review of food avoidance diets in delayed-type food allergies manifesting as dermatitis. While beneficial in some clinical circumstances, avoidance diets should be used with caution in infants and children, as growth impairment and developmental delay may result. Ultimately, dermatitis is highly multifactorial and avoidance diets may not improve symptoms of delayed-type food allergy until combined with other targeted therapies, including restoring balance in the skin microbiome and re-establishing proper skin barrier function.

The Cost of an Itch: A Nationally Representative Retrospective Cohort Study of Pruritus-Associated Healthcare Expenditure in the United States

To the Editor: Pruritus arises from many common diseases and is reported as a symptom in [7 million outpatient visits annually in the United States. The impact of pruritus on quality of life is substantial and comparable with that of chronic pain. Although there are limited studies regarding its epidemiology, pruritus has an estimated lifetime prevalence of 25.5% and most commonly affects patients who are female, elderly, and of lower socioeconomic status. Despite the significant health and biopsychosocial burden posed by pruritus, limited information exists regarding its economic burden. As such, the goal of this study was to provide nationally representative estimates of the incremental health care burden of pruritus controlling for sociodemographic characteristics and comorbidities. In this study, we used 9 years of data from the Medical Expenditure Panel Survey (MEPS; 2007-2015), a nationally representative survey assessing patterns of utilization of outpatient care in the United States. The methods of administration for MEPS are detailed elsewhere. All analyses were done in R accounting for the complex survey design of MEPS to provide nationally representative samples. We compared sociodemographic characteristics of patients with pruritus (International Classification of Disease Ninth Revision, Clinical Modification code 698) to those without pruritus using Rao-Scott chi-squared tests. To determine the adjusted incremental inflation-adjusted expenditure (in USD) of pruritus controlling for all other factors, we constructed a 2-part linear regression model to account for the high concentration of zero expenditures in the data. Our 2-part model consists of logistic regression to predict the likelihood of nonzero expenditures and a generalized linear model to predict conditional nonzero expenditures. A generalized linear model with a gamma distribution and log-link function was used to address the positive skewness of the expenditure data. Our model was used to estimate expenditure ratios, which represented the adjusted multiplicative effect of a variable compared with the reference class. For example, an expenditure ratio of 2 would indicate that patients with pruritus had twice the health care expenditure of patients without pruritus, controlling for other factors. The advantages of this validated 2-part model have been previously described. In total, our sample included 637 patients with pruritus and 288,061 patients without pruritus. Women, older adults, nonwhite patients, Medicaid and Medicare patients, patients with less education, and patients with more comorbidities were all more likely to have pruritus (P\ .001 for all, Table I). Controlling for Charlson Comorbidity Index and all sociodemographic factors, the cost of care for patients with pruritus is 1.64 times as high as patients without pruritus (P \ .001, Table II). Although emergency room and home health service expenditures due to pruritus have increased over time, expenditures due to pruritus in both the outpatient and inpatient setting have decreased. Pruritus is a significant burden to both medical and financial health. Patientswith pruritus are estimated to face

Shedding light on the FDA's 510(k) approvals process: low-level laser therapy devices used in the treatment of androgenetic alopecia

4,843.68 (adjusted for inflation) more in annual health care expenditures than patients without pruritus, even after controlling for comorbidities and sociodemographic factors. When accounting for even the most conservative national estimates of chronic pruritus (6.1%), our data suggests that pruritus is associated with [

Transparency and Dermatologic Device Approval by the US Food and Drug Administration

90 billion per year in population-level expenditures in the United States. Strengths of this study include analysis of a large, nationally representative data set to provide cost estimates. A limitation is that unmeasured confounders might have overestimated the incremental cost, given the demographic differences between the pruritus and nonpruritus patient population found in this study. Elucidating the health care costs due to pruritus is vital, considering its association with numerous chronic diseases. Although the incremental cost associated with pruritus has remained steady, expenditures due to pruritus seem to be shifting from outpatient and inpatient settings to the emergency room and home health services. As overall health care costs continue to rise, it is critical to identify effective strategies to improve the control and management of pruritus.

Severe rheumatoid arthritis developing in conjunction with gorlin syndrome

Abstract Introduction: Low-level laser therapy has demonstrated superior efficacy relative to other nonsurgical treatment options for the treatment of androgenetic alopecia. Methods: Records from a public U.S. FDA database for premarket approval of low-level laser therapy devices approved between January 1 2000 and July 15 2018 were reviewed. Results: 47 devices received 510(k) premarket approval, with an increasing number of devices available since 2007. More options are now available and product indications have expanded for use in a wider audience, including both men and women. Discussion: Growing recognition of lasers has led to an increasing number of devices available as well as innovative options in terms of design and convenience. In the past few years, these devices have adopted broader indications for use in both men and women. However, marketed indications have not been adequately explored and current devices on the market have the potential to mislead consumers.