Jessica S. Mounessa

The role of cannabinoids in dermatology

CB1: cannabinoid 1 CB2: cannabinoid 2 PEA: palmitoylethanolamide THC: tetrahydrocannabinol T wenty-eight states currently allow for comprehensive public medical cannabis programs, and this number continues to grow. Approximately 1 in 10 adult cannabis users in the United States use it for medical purposes. Numerous studies have investigated its uses for chronic pain, spasticity, anorexia, and nausea. In recent years, researchers have also investigated its use for the treatment of dermatologic conditions including pruritus, inflammatory skin disease, and skin cancer. Perhaps the most promising role for cannabinoids is in the treatment of itch. In a study of patients with uremic pruritus on maintenance hemodialysis, topical application of a cream with structured physiologic lipids (derma membrane structure) and endogenous cannabinoids applied twice daily for 3 weeks completely eliminated pruritus in 8 of 21 patients (38%). The authors suggested that the welltolerated product might work by reducing xerosis. Stander et al further studied 22 patients with prurigo, lichen simplex, and pruritus who applied an emollient cream with palmitoylethanolamide (PEA). PEA, which stimulates anandamide (endocannabinoid) activation of cannabinoid 1 (CB1) receptors, reduced itch by 86.4% and was well tolerated by patients. Most recently, WIN 55,212-2, a cannabinoid agonist, was found to reduce serotonin-induced itching in a dose-dependent manner through intraperitoneal administration in mice. When the investigators used neurotoxins to deplete serotonin in the spinal cord, they reported no change in these results. Thus, they suggested that the cannabinoids may

Comparison of Regional and State Differences in Melanoma Rates in the United States: 2003 vs 2013

prevention programs for youth. For example, black sexual minority males reported the highest prevalence of indoor tanning, a rate equivalent if not higher than white females. Clinicians working with sexual minority males, particularly males of color, should consider assessing use of indoor tanning during routine evaluations. Future research would benefit from exploring motivations to tan among diverse groups of adolescents, as varied motives may drive sexual minorities’ use indoor tanning. For instance, appearance-based motives and the regulation of negative affect may be 2 prominent factors that predispose sexual minority youth to indoor tan.6

Disease Severity and Quality of Life Measurements in Contact Dermatitis: A Systematic Review 2005-2015.

BackgroundContact dermatitis (CD) has been assessed by numerous disease severity indices resulting in heterogeneity across published research. ObjectiveThis study aims to evaluate published CD severity scales and identify a criterion standard for assessment. MethodsScopus and Ovid MEDLINE were searched for human randomized controlled trials (RCTs) on CD severity measures published during a 10-year period. Eligible studies were English-language RCTs reporting disease severity outcome measures for CD in humans. Studies were excluded if they were duplicates, not available in English, not related to CD, not RCTs, not conducted on human subjects, or did not report relevant outcome measures. ResultsA total of 22 disease outcome measures were used in 81 included RCTs. Instrument-based measures were used in 40 (49.4%) studies, and visual assessments were used in 66 (81.5%) RCTs. Only 5 (6.2%) studies reported quality of life (QoL) outcomes. Two (2.5%) studies used a clinical severity scale, which combined both QoL and visual assessments. LimitationsThis study was limited by the exclusion of non-RCTs and gray literature. ConclusionsWide variation in CD outcome measures exists including instrument-based measures, visual assessments, and QoL outcomes. A standardized outcome measure must be generated to reduce heterogeneity.

Satisfaction with care and likelihood to recommend ratings attributed to dermatology trainees

To the Editor: The Affordable Care Act directs value-based adjustments to Medicare payments that account for quality measures, including patient satisfaction. However, federally mandated or third-party vendor surveys do not capture unique considerations for academic institutions, including trainee involvement in patient care. Trainees typically have the initial, most durable, and sometimes the most consistent contact with the patient, yet little is known about care experiences attributed to them. We sought to prospectively evaluate the factors associated with highest ratings for satisfaction-withcare (SWC) and likelihood-to-recommend (LTR) attributed to dermatology trainees at Northwell Health and 6 other institutions with accredited programs ranging in size and location. Adults (n 1⁄4 1520) participated in an anonymous survey immediately after completing an encounter with 1 of 84 trainees (Table I). Survey responses, which were based on 5-point Likert scales, were dichotomized to identify factors associated with the highest ratings. Covariates having P values\.25 in bivariate analyses were included in multivariable regression models for each primary outcome. Fixed effects indicator variables were added to account for clustering. Final regression models used complete data from 81.9% (1245/1520) of patients. Highest SWC and LTR ratings were provided to trainees in 86.7% and 83% of encounters, respectively. Patients rating their skin health as good and excellent were more likely to provide highest SWC and LTR ratings, as were those rating overall experience with the health care institution as excellent (Table II). Importantly, factors such as sex concordance, postgraduate year, continuity encounters or number of prior visits with the trainee, and expecting to see a trainee had less (or no) influence on experience ratings than factors unrelated to the trainees themselves. In a study involving family medicine trainees, 92% of patients rated their satisfaction as good to excellent. Prior studies also support the association of satisfaction with self-reported health status and with system performance. With respect to achievement of training milestones, our results on satisfaction attributed to dermatology trainees should reassure training directors, faculty, and residents. If asked, most patients might also endorse the same sense of reassurance. However, based on institutional and national benchmarking, raw scores #90 points typically translate into below target percentile scores for dermatology providers. Whether ratings attributed to dermatology trainees have an influence on experience scores ultimately assigned to the provider of record needs to be explored further. Curricular opportunities might exist for trainees aimed at improving the patient experience, in particular for patients with poor skin health. Trainees must also appreciate that, as stewards of the patient experience, their halo effect facilitates learning opportunities for others. Likewise, we may speculate that institutional reputation might afford trainees initial trust from patients. In balancing the interests of programmatic training objectives, including advancement of graduated autonomy, programs can also make a deliberate effort to educate patients on its training mission, the roles of trainees and their prior education, and the responsibilities maintained by attending physicians throughout the episode of care. Institutions must also support these educational initiatives while also recognizing the complexities accounting for the patient experience.

Comparison of Contact Allergens in Bar Soaps and Liquid Body Washes

To the Editor: Allergic contact dermatitis (ACD) describes a delayed classic T-cellYmediated (type IV) hypersensitivity immune response to external substances that contact the skin. This often manifests as pruritus, erythema, and vesiculation that may progress to lichenification, xerosis, and fissuring. Identification and avoidance of specific allergens are key to adequate management and care. Although previous studies have investigated the presence of numerous contact allergens in cleansing products, limited research on the contact allergens of specific formulations of cleansing products currently exists. We aim to identify the difference between the number and types of contact allergens found in bar soaps versus liquid body washes. We examined the top 50 bar soaps and body washes listed on Amazon.com, sorting by ‘‘relevance’’ and filtering by ‘‘avg. customer review 4 stars and up’’ on October 6, 2016. Ingredient lists were almost entirely obtained from Amazon.com, but a few were collected from Target.com, Walgreens.com, and specific product Web sites. Allergens were selected from the American Contact Dermatitis Society core allergen series, with the expertise of a coauthor. W and Fisher exact tests were used to compare allergens in bar soaps versus body washes. Liquid body washes had far more preservative and surfactant allergens compared with bar soaps (P G 0.001, Table 1). No differences in fragrances existed between bar soaps and body washes. Of the preservatives studied, methylisothiazolinone, quaternium-15, sodium benzoate, methylchloroisothiazolinone/ methylisothiazolinone, DMDM hydantoin, phenoxyethanol, and iodopropynyl butylcarbamate were particularly prevalent in body washes compared with bar soaps. Of the surfactants studied, cocamidopropyl betaine and alkyl glucosides were ubiquitous in body washes and rarely seen in bar soaps. Polyethylene glycol was found in 38% of body washes but only in 8% of bar soaps (Table 1). A number of the most common contact allergens identified by the American Contact Dermatitis Society have been identified in soaps and cleansers; however, studies investigating these allergens in bar soaps and body washes are limited. Our study revealed a significantly higher number of preservative and surfactant allergens in body washes versus bar soaps. In recent years, bar soap sales have fallen by 2.2% despite a 2.7% rise in overall bath and shower product sales. Consumers younger than 65 years are primarily responsible. For example, only one third of consumers aged 25 to 34 years are willing to wash their face with bar soap compared with 60% of those older than 65 years. Potential explanations for this include the perceived inconvenience of storing bar soaps and the perceived uncleanliness of using them. However, in a study of 16 participants who washed their hands with bar soaps inoculated with gram-negative bacteria, none of the participants had detectable levels of bacterium on their hands after washing. Limitations include an inability to specify fragrances in all products because product labels are not required to report specific fragrance compounds. Second, ingredients obtained from retailers such as Amazon.com may be subject to error, although we limited this risk by cross-checking ingredient lists found on other Web sites. Because ACD often creates a treatment challenge, health care providers will benefit from an improved understanding of potential ingredients in products commonly associated with the condition. The use of bar soaps instead of body washes may alleviate symptoms and improve quality of life in some patients with ACD.

Creating the first indoor tan-free skin smart college campus

Given the prevalence and risk associated with indoor tanning among college students, university campuses constitute a prime target for skin cancer prevention. This report identifies the successes and challenges faced in promoting a campus-wide tan-free policy through the National Council on Skin Cancer Prevention (NCSCP) Indoor Tan-Free Skin Smart Campus Initiative. Beginning in February 2016, we communicated with university faculty or staff members who have participated in skin cancer prevention via education, clinical care, or research at 20 universities regarding the steps to adopt the tan-free policy. One campus, East Tennessee State University (ETSU), successfully fulfilled all criteria and implemented the policy change to become the first US Indoor Tan-Free Skin Smart Campus. The greatest challenge faced in recruiting campuses was gaining administrative support. Reported reasons for not adopting the policy change included wanting to wait for other schools to join first and not seeing it as a top priority. Despite the importance of improving skin cancer awareness and decreasing tanning among university students, we faced several challenges in promoting campus-wide policy change. We identify a need for research on effective ways to disseminate university health policies and increased involvement of healthcare providers in policy-related work.