Mayra B. C. Maymone

Evaluating the Strength of Clinical Recommendations in the Medical Literature: GRADE, SORT, and AGREE

The medical community relies on scientific evidence to guide clinical practice. Evidence from systematic reviews, randomized controlled clinical trials (RCTs), case–control or cohort studies, observational studies, and expert opinions are used to make disease-specific practice recommendations. More than 100 grading systems are used to rate the strength of these recommendations (West et al., 2002). A centralized and transparent method for evaluating and comparing these studies with the goal of translating evidence-based medicine to clinical practice guidelines is the cornerstone of two such validation scales: the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and Strength of Recommendation Taxonomy (SORT).

Sun-protective behaviors in patients with cutaneous hyperpigmentation: A cross-sectional study

Background: Disorders of hyperpigmentation are seen commonly in clinical practice. Despite numerous studies investigating sun‐protective habits among healthy persons, little is known about these behaviors within patient populations with hyperpigmentation disorders. Objective: We sought to examine photo‐protective behaviors and their associations in individuals with disorders of hyperpigmentation. Methods: This cross‐sectional study was conducted with 404 adults who complained of cutaneous hyperpigmentation. Results: About 67.5% reported using a product containing sunscreen, and 91% endorsed using one with a sun protection factor of 21 or higher. Among the participants, 48.5% were not sure if their sunscreen provided broad‐spectrum protection, and only 7.6% reapplied every 2 hours. The odds of a patient with melasma using sunscreen were 6.7 times the odds of a patient with postinflammatory hyperpigmentation using sunscreen (P < .001). Additional predictors for sunscreen use were female sex (OR = 3.8, P = .0004) and disease duration of ≥1 year (OR = 2.1, P = .003). In a multivariate analysis, the odds ratio of sunscreen use among African Americans compared to whites was 0.31 (P = .008). Limitations: Limitations included recall bias, question misinterpretation, and reporter bias. Conclusion: Patients diagnosed with postinflammatory hyperpigmentation, men, and those with disease duration <1 year reported lower sunscreen usage. These groups might benefit from increased counseling on sun‐protective behaviors.

Assessing the safety of superficial chemical peels in darker skin: A retrospective study

Background: Chemical peels have shown efficacy in the treatment of acne, photoaging, and pigmentary dyschromias; however, studies evaluating side effects, particularly in patients with skin of color, are limited. Objective: We sought to determine the frequency of side effects and complications associated with superficial chemical peels in patients with skin types III‐VI. Methods: A 5‐year single center retrospective analysis was performed. Results: Of 473 chemical peel treatments included in this study, 18 (3.8%) were associated with short‐term (≤2 weeks) or long‐term (>2 weeks) complications. The most frequent complications were crusting (2.3%), postinflammatory hyperpigmentation (1.9%), and erythema (1.9%). All side effects resolved within 8 months of treatment and were located on the face. When stratified by season, side effects were noted to be less common during the winter. In the adjusted model, Fitzpatrick skin type VI was associated with a higher odds of side effects (odds ratio 5.14, 95% confidence interval 1.21–21.8; P = .0118). Limitations: Single center retrospective design. Conclusion: In this study, superficial chemical peels performed on patients with skin types III‐VI had a relatively low complication rate, and skin type VI had higher odds of experiencing an adverse event. Side effects were noted to be less frequent during the winter months.

Effect of stimuli on sun protective habits: A randomized double-blind controlled study

Visual imagery has been shown to improve adherence to health messages but has scarcely been investigated in sun protection campaigns.

Dermatoses caused by cultural practices: Therapeutic cultural practices

&NA; With globalization and widespread immigration, physicians increasingly encounter patients from varying backgrounds and diverse customs. Although certain cultural practices are widely performed, there is limited medical literature describing their dermatologic and systemic effects and complications. Population diversity and sharing of traditions make it increasingly important for dermatologists to understand the role of cultural practices and recognize physiologic and pathologic sequelae. In addition, dermatologists are often adjured to assess skin findings that may be mistaken for abuse. Child abuse misdiagnosis can be traumatizing to all those involved, and immigrant families with limited English proficiency may have difficulty explaining their traditional practices. The first article of this 2‐part continuing medical education series begins with a review of therapeutic cultural practices, including traditional Chinese medicine, Ayurveda, acupuncture, cupping, moxibustion, and coining, and the clinically relevant complications that may occur. Therapeutic practices can cause a range of complications, including contact dermatitis, heavy metal toxicity, and severe cutaneous adverse reactions.

Research Techniques Made Simple: Web-Based Survey Research in Dermatology: Conduct and Applications

Web-based surveys, or e-surveys, are surveys designed and delivered using the internet. The use of these survey tools is becoming increasingly common in medical research. Their advantages are appealing to surveyors because they allow for rapid development and administration of surveys, fast data collection and analysis, low cost, and fewer errors due to manual data entry than telephone or mailed questionnaires. Internet surveys may be used in clinical and academic research settings with improved speed and efficacy of data collection compared with paper or verbal survey modalities. However, limitations such as potentially low response rates, demographic biases, and variations in computer literacy and internet access remain areas of concern. We aim to briefly describe some of the currently available Web-based survey tools, focusing on advantages and limitations to help guide their use and application in dermatologic research.

Correlating the Dermatology Life Quality Index and Skin Discoloration Impact Evaluation Questionnaire tools in disorders of hyperpigmentation

Figure 1. Correlation between the Dermatology Life Quality Index (DLQI) and the Skin Discoloration Impact Evaluation Questionnaire (SDIEQ). Panel (a) demonstrates the positive correlation (rs = 0.64, P < 0.01) for the total study population between the DLQI and SDIEQ stratified by skin type. Furthermore, there remained positive correlations when the study population was stratified by: (b) sex; (c) age; and (d) skin disorder.

Appearance-based vs health-based sun protective messages: A randomized, double-blind controlled study

Appearance‐based messages have shown promise in improving sun protection habits among Caucasians but have scarcely been investigated in Hispanic populations.

Selfies—Living in the Era of Filtered Photographs

We live in an era of edited selfies and ever-evolving standards of beauty. The advent and popularity of image-based social media have put Photoshop and filters in everyone’s arsenal. A few swipes on Snapchat can give your selfie a crown of flowers or puppy ears. A little adjusting on Facetune can smoothen out skin, and make teeth look whiter and eyes and lips bigger. A quick share on Instagram, and the likes and comments start rolling in. These filters and edits have become the norm, altering people’s perception of beauty worldwide. Earlier, photo-editing technology was widely available only for celebrities. Models and actors were made to look perfect in magazines and ads, but the general public did not have easy access to methods to alter their own appearance. They instead were left to idolize the standard of beauty present in the media, although most were aware of the editing and alterations that went into making celebrities look flawless.1 Today, with apps like Snapchat and Facetune, that same level of perfection is accessible to everyone. Now, it is not just celebrities propagating beauty standards: it is a classmate, a coworker, or a friend. The pervasiveness of these filtered images can take a toll on one’s self esteem, make one feel inadequate for not looking a certain way in the real world, and may even act as a trigger and lead to body dysmorphic disorder (BDD). Body dysmorphic disorder is an excessive preoccupation with a perceived flaw in appearance, classified on the obsessive-compulsive spectrum.2 The disorder is more than an insecurity or a lack of confidence. Those with BDD often go to great lengths to hide their imperfections, engage in repetitive behaviors like skin picking or grooming, and may visit dermatologists or plastic surgeons frequently, hoping to change their appearance. A recent study3 analyzed the effect of edited selfies on body dissatisfaction among adolescent girls and found that those who manipulated their photos more reported a higher level of concern with their bodies and an overestimation of body shape and weight. The study also suggested that those with a dysmorphic body image may seek out social media as a means of validating their attractiveness. Finally, those with a higher level of engagement on social media—including those actively trying to present a specific image of oneself or analyzing and commenting on other’s photos—may have a higher level of body dissatisfaction.3 The desire for cosmetic surgery is an important component of BDD. It is known that the angle and close distance at which selfies are taken may distort facial dimensions and lead to dissatisfaction.4 Patients may seek surgery hoping to look better in selfies and social media. Plastic surgeons first identified this trend in the 2017 Annual American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) survey. Current data show that 55% of surgeons report seeing patients who request surgery to improve their appearance in selfies, up from 42% in 2015. The survey also noted an increase in the number of patients sharing their surgical process and results on social media.5 In addition, excessive scrutiny of selfies is also changing the presenting concerns of patients. Prior to the popularity of selfies, the most common complaint from those seeking rhinoplasty was the hump of the dorsum of the nose. Today, nasal and facial asymmetry is the more common presenting concern. Along with rhinoplasties, hair transplants and eyelid surgical procedures are also popular requests to improve selfie appearance.6 Previously, patients would bring images of celebrities to their consultations to emulate their attractive features. A new phenomenon, dubbed “Snapchat dysmorphia,” has patients seeking out cosmetic surgery to look like filtered versions of themselves instead, with fuller lips, bigger eyes, or a thinner nose.7 This is an alarming trend because those filtered selfies often present an unattainable look and are blurring the line of reality and fantasy for these patients. In such cases, the choice of action is not surgery, which will not improve or may even worsen underlying BDD if present. The typical treatment consists of psychological interventions, such as cognitive behavioral therapy, as well as medications, such as selective serotonin reuptake inhibitors, often in combination. Management of the disorder should also include an empathetic and nonjudgmental approach by the clinician.2 Overall, social media apps, such as Snapchat and Facetune, are providing a new reality of beauty for today’s society. These apps allow one to alter his or her appearance in an instant and conform to an unrealistic and often unattainable standard of beauty. While filters that add flowers or animal ears to a photograph are clearly an embellishment, other edits may be subtler and instead promote a pressure to look a certain way. It can be argued that these apps are making us lose touch with reality because we expect to look perfectly primped and filtered in real life as well. Filtered selfies especially can have harmful effects on adolescents or those with BDD because these groups may more severely internalize this beauty standard. It is important for clinicians to understand the implications of social media on body image and self-esteem to better treat and counsel their patients. VIEWPOINT

Colors Beyond the Visible

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