Dermatology Weekly

Skin appearance is a sign of internal health, and patients who have appropriate vitamin levels naturally have healthier skin. Dr. Vincent DeLeo talks with Dr. Gary Goldenberg about the data on vitamins and supplements that have been shown to improve the skin's appearance and health. Dr. Goldenberg discusses the controversies surrounding the quality of products and the need for dermatologists to remain up-to-date on products their patients may be taking already. "A discussion of nutrition and supplements really is a part of any dermatologic evaluation, just like skin care should be part of every dermatologic evaluation," advises Dr. Goldenberg.

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We bring you the latest in dermatology news and research:

1. Rituximab bests mycophenolate in pemphigus vulgaris

Rituximab showed a superior overall benefit/risk profile, compared with mycophenolate mofetil.

2. Once-daily oral JAK inhibitor for atopic dermatitis effective in phase 3 study

Abrocitinib may have taken a step closer to becoming the first once-daily oral Janus kinase 1 inhibitor to be approved for atopic dermatitis.

3. Online resources influencing cosmetic treatment choices

Rate and review websites affect almost 70% of consumers seeking providers for cosmetic procedures.

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Things you will learn in this episode:

• Patients who have good nutrition also will have appropriate vitamin levels, which contributes to having healthier skin. Dr. Goldberg explains, "Patients who have really low vitamin D levels will not be as healthy and cannot have as healthy skin as those who have more normal vitamin D levels."
• Studies have shown that internal vitamin C levels reduce oxidative stress and help with the appearance of fine wrinkles, lines, and pigmentation. "As far as topical vitamin C goes, I think that there [are] good data showing that vitamin C improves the appearance of skin. But the issue with vitamin C is the delivery of the product into the skin," advises Dr. Goldenberg. Vitamin E is one of the best antioxidants, according to Dr. Goldenberg, and is especially helpful for UV-induced oxidative stress.
• Carotenoids, which are derived from vitamin A, can help reduce oxidative stress associated with UV-induced radiation and UV-induced erythema. "We also know that carotenoids actually improve UV-damaged cells such as for patients with a history of skin cancer," says Dr. Goldenberg.
• Studies have reported that oral collagen supplements can improve skin health and appearance. However, Dr. Goldenberg remains skeptical: "It's still unclear to me if the improvement is due to the actual collagen or to the water that patients may be taking the collagen in, especially if it's a powder." Hydration is very important for skin appearance and health, he adds.
• Imedeen supplementation has some data that show antioxidant properties. Although it's too early to say that Imedeen is completely effective, studies report efficacy for skin appearance and health.
• In terms of side effects associated with vitamins and supplements, Dr. Goldenberg advises that not all supplements have the same quality, and patients should consult a nutritionist for advice on which vitamins and supplements are needed. "Not all supplements are going to have the same quality. So if you're going with the least expensive ones, they may have the least absorption. Now the most expensive ones may have the prettiest packaging and not necessarily be the highest quality of the vitamin."
• Dermatologists, as skin experts, need to be aware of the data on vitamins and supplements because diet or nutrition is a common question among patients. For example, patients with acne, psoriasis, eczema, or rosacea may inquire if their condition is caused by a supplement they take or by the lack of supplements. "[We] have to be aware of all of the positive and negative data that's out there and what I call 'pseudo' data, which is blogging, Instagram influencers, etc.," Dr. Goldenberg says.

Guests: Gary Goldenberg, MD (Icahn School of Medicine at Mount Sinai, New York, and Goldenberg Dermatology, PC, New York)

Show notes by: Jason Orszt, Melissa Sears, Elizabeth Mechcatie

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Gary Goldenberg on Twitter: @Goldenberg_Derm

There is a consumer trend to avoid additives in hair care products and consider natural alternatives. Dr. Lynn McKinley-Grant, president of the Skin of Color Society, talks with Dr. Amy McMichael about shampoo ingredients and the importance of cleansing the scalp in the skin of color population. Dr. McMichael also discusses how hairstyling practices in this population can lead to hair loss and damage to the hair shaft. "We just have to be more healthy in our choices of how we do those styles and how we cleanse our scalp and our hair when we're wearing those styles," advises Dr. McMichael.

We bring you the latest in dermatology news and research:

1. Psoriasis registry data provide evidence that adalimumab reduces mortality

2. Tape strips useful to identify biomarkers in skin of young children with atopic dermatitis

3. Short-term statin use linked to risk of skin and soft tissue infections

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Things you will learn in this episode:

• Do patients need to avoid shampoos containing sulfates and parabens? "Sulfates are just one of the many ways that we can cleanse the scalp and the hair. It is a detergent, and when that detergent is removed, in order to cleanse the hair another detergent has to be put into its place," explains Dr. McMichael There are "no data to suggest that these other detergents are better or safer or even helpful for our hair shaft." Only patients with a true allergic contact sensitization to parabens need to avoid products with this ingredient.
• Patients need to understand that the "no-poo" method and dry shampoos are not cleansing the scalp. "There's an idea that you can shampoo as infrequently as you want," says Dr. McMichael. "That's really not true. In order for your scalp to be healthy and to grow healthy hair, you need to have it cleansed. And once weekly is preferred but certainly every 2 weeks is reasonable."
• Patients may rinse their hair with water and baking soda, apple cider vinegar, and tea tree oil without knowing how they interact with the bacterial and yeast components on the scalp. "And they can be bad for the hair shaft," Dr. McMichael adds.
• Conditioners are not a good replacement for shampoo, especially for patients with a scalp condition. "Conditioners alone are not meant to cleanse," Dr. McMichael explains.
• For women of African descent, consider dandruff shampoo products that are manufactured and tested for this patient population.
• Central centrifugal cicatricial alopecia (CCCA) is the most prominent form of hair loss in the United States in women of African descent. Clinicians should help patients with or who are at risk for CCCA to minimize traction, tension, and trauma to the scalp caused by some hair care practices.
• In a recent study of more than 5,000 patients, CCCA seems to have an association with type 2 diabetes mellitus. "As we move forward, we need to start thinking about the whole patient," Dr. McMichael advises. "It's not just the scalp that we're dealing with. It's not just the hairstyle. But what is the health and underlying metabolism issue of some of these patients and can we as dermatologists be helpful in getting them to better health."
• Dermatologists in residency need more training in hair care practices of patients with skin of color that encompasses the wide cultural differences in hairstyling methods and scalp conditions across different populations.

Host: Lynn McKinley-Grant, MD (Howard University, Washington)

Guest: Amy McMichael, MD (Wake Forest University, Winston-Salem, N.C.)

Show notes by: Jason Orszt, Melissa Sears, Elizabeth Mechcatie

For more MDedge Podcasts, go to mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Atopic dermatitis (AD) is associated with various ocular comorbidities that can result in permanent vision loss if left untreated. Dr. Soo Jung Kim talks with Dr. Vincent DeLeo about the incidence of keratoconjunctivitis, keratoconus, glaucoma, retinal detachment, and other ocular conditions associated with AD. Dr. Kim offers tips on spotting these complications and managing them but also indicates when referral to an ophthalmologist is necessary.

We also bring you the latest in dermatology news and research.

1. Nivolumab-ipilimumab nets long-term survival in advanced melanoma

An update of CheckMate 067 finds that with combination nivolumab and ipilimumab therapy, 52% of patients were alive at 5 years.

2. Lifetime indoor tanning raises risk of cutaneous squamous cell carcinoma

Researchers found a dose-response association between number of indoor tanning sessions and SCC risk in Norwegian women.

3. FDA approves afamelanotide for treatment of rare condition with light-induced pain

This is the first treatment approved to help patients with erythropoietic protoporphyria increase their exposure to light.

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Things you will learn in this episode:

• Patients with AD may develop blepharitis, presenting with itching and irritation of the eyelids, as well as tearing, foreign body sensations, and even photophobia. The mainstay treatment of blepharitis is good eyelid hygiene with the use of warm compresses and gentle scrubbing of the lid margins.
• About 25%-52% of patients with AD have atopic keratoconjunctivitis. Clinicians should look out for red conjunctivae, hyperemia, and papillary hypertrophy of the conjunctivae. "Ultimately, if this is not treated in a timely manner, patients could have visual impairment," explains Dr. Kim.
• Keratoconus is the progressive thinning and bulging of the cornea that can affect the cornea's topography. "Patients experience imaging blurring as well as imaging distortions," Dr. Kim describes. "We're not exactly sure why atopic dermatitis patients develop more keratoconus, but it's been believed that chronic, habitual eye rubbing is most likely to be the cause due to the periocular itching."
• "Glaucoma is not necessarily a complication of atopic dermatitis; it's more a complication of the steroid use," explains Dr. Kim. Glaucoma in AD may be asymptomatic until advanced stages; therefore, clinicians should regularly screen patients who have a prolonged history of topical steroid application around the eye area, a family history of glaucoma, or a history of other ocular problems.
• Cataracts occur in 8%-25% of patients with AD, usually younger adults. Interior or posterior subcapsular cataracts are more common in these patients compared to nuclear and cortical cataracts, which are more common in the general population.
• Routine periodic screening by an ophthalmologist is required when patients have onset of periorbital atopic dermatitis, prolonged use of topical or systemic steroids, or a family history of cataracts.
• The incidence of retinal detachment is 4%-8% in patients with AD. "This is a lot higher than the general population, which is around 0.005%," Dr. Kim says. "This retinal detachment occurs usually more bilaterally at a younger age, compared to cases without atopic dermatitis." These patients should be quickly referred to an ophthalmologist for surgical repair.
• Patients with AD are at greater risk for herpetic ocular disease, and active ocular herpetic infections require urgent referral to an ophthalmologist.
• Dupilumab has been associated with ocular complications in patients with AD.

Host: Vincent DeLeo, MD

Guest: Soo Jung Kim, MD, PhD (Baylor College of Medicine, Houston, Texas)

Show notes by: Jason Orszt, Melissa Sears, Elizabeth Mechcatie

You can find more of our podcasts at http://www.mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Atopic dermatitis (AD) is a highly challenging dermatologic condition for U.S. military members, especially for those deployed overseas with less-than-ideal access to care. Dr. Josephine Nguyen, president of the Association of Military Dermatologists, talks with Dr. Emily Wong about the military's medical standards for evaluating individuals with AD who want to join the service. They also discuss how deployment can exacerbate symptoms of AD. "What is most important to understand regarding the military and any medical issue, including atopic dermatitis, is that we do not want a person's medical condition to worsen because of their military service, or for them not to be able to receive the medical care they need," advises Dr. Wong. "On the other hand, medical standards are in place to also ensure that the overall mission of the military can be done safely."

We also bring you the latest in dermatology news and research.

1. Apple cider vinegar soaks fall short in atopic dermatitis

Acetic acid, particularly apple cider vinegar, has become prominent among emerging natural remedies for atopic dermatitis.

2. Long-term opioid use more common in hidradenitis suppurativa

The results suggest that periodic assessment of pain and screening for long-term opioid use may be warranted.

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Mark your calendars for our upcoming MDedge Dermatology Twitter Chat on skin cancer, this Tuesday, Oct. 8, beginning at 8 p.m. EDT. You can join the discussion with Dr. Julie Amthor Croley, Dr. Candrice Heath and Dr. Anthony Rossi as they review what's new in sunscreen, skin of color, melanoma, and more.

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Things you will learn in this episode:

• Individuals with AD that persists after 12 years of age may be disqualifying to enter the military. Additionally, any history of recurrent or chronic dermatitis within the last 2 years that requires frequent treatments also is disqualifying. "I will say, in some cases, waivers are possible," Dr. Wong adds. "Usually those waivers occur when the diagnosis wasn't quite accurate to begin with. Maybe they had one case of contact dermatitis from poison ivy, but it's not actually a chronic condition."
• Atopic dermatitis is one of the main conditions that affect military service members overseas, not battle injuries.
• Military members with AD may be hard pressed to find relief from environmental factors that provoke or exacerbate symptoms.
• When military members are deployed, there are few choices for maintaining hygiene. "They certainly don't often have choice of soap," Dr. Wong says. "They don't have the ability to necessarily carry around moisturizers. So a lot of the things we typically would use to treat our atopic dermatitis patients are just simply not available."
• Access to systemic medications for AD also can be difficult.
• Stress while being deployed is a concern in military members with AD. "Military deployments create an environment – a stress – that many people have not experienced before," explains Dr. Wong. "Even if they really understand their skin and what flares their skin, they may not know what to expect in some of these environments that military members are expected to work in."
• Military uniforms and gear can exacerbate AD.
• In a deployed setting, if a service member experiences a severe exacerbation of AD that prevents him/her from performing the job, then he/she may need to leave the unit, leaving the rest of the unit unexpectedly without those skills. "That is really the impact that we try to avoid," explains Dr. Wong, "in setting some of the medical standards that we have, in making sure we appropriately evaluate and screen people before they go on deployment."
• Smallpox is considered a potential biologic weapon that could be used by adversaries. Military members receive the smallpox vaccine before being deployed overseas. However, members with a history of or current AD or any skin condition that compromises the epidermis are exempt from receiving the smallpox vaccine. If the service member has a family member at home who has AD or is pregnant, then that military member will receive the smallpox vaccine after reaching the deployed location. "Certainly, patients who are receiving the smallpox vaccination need to be very careful when around other patients with atopic dermatitis," advises Dr. Nguyen.

Host: Josephine Nguyen, MD

Guest: Emily B. Wong, MD (Uniformed Services Health Education Consortium, Joint Base San Antonio–Lackland, Tex.)

Show notes by: Jason Orszt, Melissa Sears, Elizabeth Mechcatie

You can find more of our podcasts at http://www.mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Dermatology residents may be among the least burned-out residents across specialties, but burnout syndrome still affects almost one in three dermatology residents. In this special resident takeover of the podcast, three dermatology residents — Dr. Julie Croley (@dr.skinandsmiles), Dr. Elisabeth Tracey, and Dr. Daniel Mazori — discuss sources of stress for dermatology residents as well as tools to identify and combat burnout to ultimately be a better provider. "The low-stress perception of dermatologists may counterintuitively or paradoxically make recognizing burnout within others and ourselves challenging, so I think it's important for residents and faculty to be aware that this occurs in such a high prevalence," reports Dr. Croley.

We also bring you the latest in dermatology news and research.

1. Parent survey sheds some light on suboptimal compliance with eczema medications

Nearly half of children with atopic dermatitis were not getting their medications as prescribed.

2. Meta-analysis finds platelet-rich plasma may improve hair growth

Five studies reported statistically significant increases in hair density in favor of PRP over placebo.

3. Business case for interoperability remains elusive

Bringing ownership of health data to the individual and setting a clearer definition of health IT standards are important drivers of interoperability.

Things you will learn in this episode:

• Jeffrey Benabio quipped in a Dermatology News column, "The phrase 'dermatologist burnout' may seem as oxymoronic as jumbo shrimp, yet both are real."
• Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment.
• For dermatology residents, the preliminary internship year plus the first year of residency can be the most stressful. "You have 2 years of being the least experienced person in your department," explains Dr. Tracey, "and so that adds to the stress of the sense of lack of accomplishment during that time."
• Board examinations are a top stressor for dermatology residents.
• Institutions are recognizing and addressing burnout among residents by offering wellness lectures, yoga classes, and social events to counteract the stresses of residency. Some also hold town hall meetings and forums that allow residents and other department members to raise concerns and find concrete solutions to shared problems. Formalizing feedback to residents, especially positive feedback, also is important.
• Residents — and all health care providers — need to take care of themselves to provide the best care to their patients. "It's all about balance and about creating time for those other things that are important to you and not feeling guilty about setting aside time to do those things. We don't always need to be productive and always be working," Dr. Tracey adds.
• Setting both short- and long-term goals may be helpful in preventing burnout. Don't lose sight of the ultimate goal — becoming a dermatologist — but set and focus on goals for the day or the week.
• First-year residents can help to create a positive culture within their departments. Instead of commiserating with colleagues only about a hard day, "sharing cool cases or talking about interesting things that you've learned" can create a better environment for everyone, Dr. Tracey advises.
• The idea that dermatology residents can't or don't experience burnout is a myth. "Just like a rare diagnosis, it's sometimes harder to spot than something that we see all the time," says Dr. Mazori. If a resident is starting to feel burned out, it is essential to reach out to a trusted friend or colleague to address the issues.

Hosts: Elizabeth Mechcatie, Terry Rudd

Guests: Julie Ann Amthor Croley, MD (University of Texas Medical Branch at Galveston); Elisabeth (Libby) Tracey, MD (Cleveland Clinic Foundation); Daniel R. Mazori, MD (State University of New York, Brooklyn).

Show notes by: Ann M. Hoppel, Melissa Sears, Elizabeth Mechcatie

You can find more of our podcasts at http://www.mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

The flea bite is a problem for a variety of populations — from those in natural disaster scenarios to pet owners. Dr. Vincent DeLeo talks with Dr. Dirk M. Elston about cat fleas and other issues in environmental dermatology. Dr. Elston discusses vector-borne diseases, including endemic typhus and cat-scratch disease, caused by organisms transmitted by fleas, as well as interventions to remove fleas and treat their bites. Dr. Elston also gets personal and talks about how he got interested in bugs following his time in the military.

We also bring you the latest in dermatology news and research.

1. States pass record number of laws to reel in drug prices

Measures include authorizing imported prescription drugs, screening for excessive price increases by drug companies, and establishing oversight boards to set drug prices.

2. Peanut allergy pill gets thumbs-up from FDA advisory panel

The approval of Palforzia is on condition that a black-box warning and medication guide are included in the packaging.

3. Dr. Henry W. Lim takes a closer look at new data on sunscreens.

Things you will learn in this episode:

• All fleas are vectors for disease in humans. "You see dog fleas on cats, and cat fleas on dogs," Dr. Elston explains. "You'll see poultry fleas on dogs, especially in the Carolinas. But there are certain fleas that historically have been the ones that carry most disease."
• Cat fleas (Ctenocephalides felis) can carry endemic typhus and are typically found in south Texas and southern California. Oriental rat fleas are a vector for disease in other parts of the United States, including areas of California and the Southwest.
• One of the clues for identifying endemic typhus would be a small rickettsial or black depressed eschar at the site of the original bite.
• Flea bites — presenting as papular, vesicular, intensely pruritic— tend to occur on the lower parts of the body. "The fact that they're grouped on the lower extremity, the papular vesicular or bolus quality does suggest the possibility of fleas," reports Dr. Elston.
• For houses or abodes that have long been unoccupied (e.g., 2-3 years), new owners walking on the floorboards may rapidly activate the pupae living in them.
• Flea treatments for animals include fipronil, which is applied on the animal's neck and spreads like an oil over its body. Oral agents containing ivermectin for heart worm and fleas; however, ivermectin can be fatal for some animals, such as collie dogs.
• Disease depends on the type of vector. "If you have the organism transmitted by a louse, you're likely to get endocarditis," Dr. Elston explains. "Whereas if it's a flea, you are more likely to get cat-scratch disease rather than sepsis and endocarditis."
• Long-term therapy with macrolides is a mainstay treatment of cat scratch disease.
• Children with cat-scratch disease who present with systemic disease, including neurologic disease, should be managed together with an infectious disease specialist.

Guests: Dirk M. Elston, MD (Medical University of South Carolina, Charleston); Henry W. Lim, MD (Henry Ford Medical Center, Detroit)

Show notes by Jason Orszt, Melissa Sears, and Elizabeth Mechcatie.

You can find more of our podcasts at http://www.mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Household and personal care products are common sources of contact allergy in dermatology patients. Dr. Vincent DeLeo talks with Dr. Amber Atwater and Dr. Margo Reeder and about the epidemic of allergic contact dermatitis associated with methylisothiazolinone (MI), a common preservative found in many water-based products. Dr. Reeder and Dr. Atwater discuss the emergence of MI as a contact allergen and highlight some of the common and lesser-known sources of MI exposure.

We also bring you the latest in dermatology news and research.

1. Thread lifts making a comeback, but long-term effects remain unclear

Patients with moderate skin sagging are better candidates than those with severe skin sagging.

2. New evidence supports immune system involvement in hidradenitis suppurativa

Microscopy identifies signs of immune dysregulation in the blood of hidradenitis suppurativa patients.

3. Dr. Andrew Alexis discusses topical treatment options for pigmentary disorders

Things you will learn in this episode:

• Methylisothiazolinone (MI) has been used for decades as a preservative in combination with methylchloroisothiazolinone; however, higher concentrations of MI alone have been used in personal care products beginning in the 2000s: "That's really when we began to see patients being exposed to MI and subsequently developing contact allergy," notes Dr. Reeder.
• Common sources of MI exposure include liquid and water-based products such as dish soaps, shampoos, household cleaners, hair conditioners and dyes, laundry products, and soaps and cleansers.
• Latex-based paints containing MI can result in airborne contact dermatitis from off-gassing when the paint is curing on the wall.
• Another common source of MI contact dermatitis is slime, a sticky play substance that children concoct out of household products such as glue or cleaning agents that contain MI.
• Contact allergy to MI may present in a photodistributed pattern and also has been associated with photoaggravation. Patients also may demonstrate lasting photosensitivity even when avoiding the allergen; therefore, it is important to consider including MI when performing photopatch testing.
• Two additional potentially allergenic isothiazolinones found in household products and industrial chemicals include benzisothiazolinone and octylisothiazolinone.
• The T.R.U.E. Test includes MI in a mix with methylchloroisothiazolinone but not on its own, which has been known to miss a considerable number of patients who are allergic to MI; therefore, patch testing to MI alone may be beneficial in patients with allergic contact dermatitis who test negative for MI contact allergy using the T.R.U.E. Test.
• Many patients are sensitized to MI when it is used in leave-on products. The European Union has banned MI from use in these products, but currently there are no regulations in the United States.

Hosts: Elizabeth Mechcatie, Terry Rudd, Vincent A. DeLeo, MD (Keck School of Medicine of the University of Southern California, Los Angeles)

Guests: Margo Reeder, MD (University of Wisconsin, Madison); Amber Reck Atwater, MD (Duke University, Durham, North Carolina); Andrew F. Alexis, MD, MPH (Icahn School of Medicine at Mount Sinai, New York.

Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie.

You can find more of our podcasts at http://www.mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

More patients are being admitted to the hospital with skin problems, and specialized dermatologists are needed to provide effective treatment. Dr. Vincent DeLeo talks with Dr. Michi M. Shinohara about the evolving role of the dermatology hospitalist in the inpatient setting. Dr. Shinohara highlights some key takeaways about job satisfaction and barriers to care from a recent survey of members of the Society for Dermatology Hospitalists.

We also bring you the latest dermatology news and research:

1. Cephalosporins remain empiric therapy for skin infections in pediatric atopic dermatitis

"When a patient with AD walks into your office and looks like they have an infection of their eczema, your go-to antibiotic is going to be one that targets MSSA [methicillin‐sensitive Staphylococcus aureus]."

2. Should you market your aesthetic services to the 'Me Me Me Generation'?

By 2020, spending by millennials will account for $1.4 trillion in U.S. retail sales.

Things you will learn in this episode:

• Inpatient care is getting increasingly complex, but dermatology has become more outpatient-centric overall: "There has really been a shift over time from dermatologists acting as the primary admitting service to more of a consulting service," Dr. Shinohara explains. As a result, inpatient dermatology has become more specialized, leading to the development of the dermatology hospitalist.
• The Society for Dermatology Hospitalists was created in 2009 by a group of medical dermatologists to develop the highest standards of clinical care in hospitalized patients with skin disease.
• Most requests for inpatient dermatology consultations come from medical services for conditions commonly seen in an outpatient clinic. However, the hematology/oncology service is a common source of dermatology consultations, requiring a separate knowledge base.
• Dermatology hospitalists typically dedicate 25%-50% of their time on inpatient consultations.
• Time that dermatology hospitalists spend in the hospital is fundamentally different than time spent in clinic: "You have a lot more time to think about your patients and to teach about them to your trainees," Dr. Shinohara notes. "It's really one of the few places that I find you still have the opportunity to work as a team together."
• Personal fulfillment is high among dermatology hospitalists, which can help combat burnout.
• A key challenge that dermatology hospitalists face is that most don't generate the same revenue doing consultations as they do in clinic. Financial support from medical institutions and recognition of the value of the work is crucial to the longevity of dermatology hospitalists, who tend to be a younger workforce.

Hosts: Elizabeth Mechcatie, Terry Rudd, Vincent A. DeLeo, MD (Keck School of Medicine of the University of Southern California, Los Angeles)

Guest: Michi M. Shinohara, MD (University of Washington, Seattle)

Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie.

You can find more of our podcasts at http://www.mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Psychiatric disease is seen in 30%-60% of dermatology patients. In this special resident takeover of the podcast, three dermatology residents – Dr. Elisabeth Tracey, Dr. Julie Croley, and Dr. Daniel Mazori – talk about the challenges of treating patients with both psychiatric and dermatologic disease. "In some instances, although ideally, we would like to refer [patients to a mental health professional], we do have to develop good skills during our training to be well equipped to handle these cases," explains Dr. Croley. Beginning at 4:29, they discuss common psychiatric disorders seen by dermatologists, appropriate therapies, and strategies for building a strong rapport with these patients prior to referral.

We also bring you the latest dermatology news and research.

1. Recent progress in vitiligo treatment might be heading to vitiligo cure

Clinical trials are now actively being planned to target interleukin-15, a cytokine thought to be essential for maintaining memory T cells. In murine models, this approach led to rapid and durable repigmentation without apparent adverse effects.

1. Dermatologists lack training about skin of color

The results of a small survey argue for enhanced training in treating patients with skin of color, an emphasis on culturally sensitive and competent care, and greater diversity in the dermatology workforce.

Things you will learn in this episode:

• Dermatologists often see psychiatric disease in two forms: a condition that is primary and drives a cutaneous disease or a condition that is comorbid or secondary to a dermatologic disorder.
• Delusional infestation (also known as delusions of parasitosis) is a common primary condition in dermatology. Patients with delusional infestation have a fixed false belief that an organism or other nonliving matter is present in or under the skin, which they may bring to the office in a matchbox as proof of infestation (known as the matchbox sign). Dr. Mazori adds, "Now that about 80% of Americans own smartphones, instead of the matchbox sign, I've seen patients increasingly present with photos of the specimens."
• Obsessive-compulsive disorder and other related disorders represent a broad category of primary conditions, including body dysmorphic disorder (BDD), olfactory reference syndrome, excoriation disorder, trichotillomania, and trichophagia.
• An estimated 12% of dermatology patients have BDD, which presents more commonly in cosmetic dermatology. In the general dermatology population, BDD occurs at the substantial rate of 7%.
• In patients with dermatitis artefacta, a condition in which the individual has deliberately self-afflicted skin lesions, the motive for the behavior is unconscious. This illness should be distinguished from malingering, in which patients have a conscious goal of secondary fame.
• Useful treatment modalities for primary neurodermatoses include antidepressants, antipsychotics, and cognitive-behavioral therapy.
• Selective serotonin reuptake inhibitors (SSRIs) are a first-line treatment of BDD and also may be useful for olfactory reference syndrome.
• The antipsychotics risperidone and olanzapine have achieved full or partial remission in two-thirds of delusional infestation cases.
• A mental health referral is warranted for patients who have a psychiatric condition secondary to or comorbid with a skin disorder.
• Avoid referring patients in the first visit. Build a strong therapeutic alliance or rapport to gain their trust before making a referral.
• Consider focusing on symptomatic treatments for patients. For patients with delusions of parasitosis, offer strategies to reduce skin picking.
• If a patient brings a sample of a parasite, examine it and then review the results in a matter-of-fact way. "Always try to be sympathetic," advises Dr. Mazori. "Even though we shouldn't confirm their delusions, we can still acknowledge that they're experiencing symptoms that are real."
• For pediatric patients, interview parents/guardians to elicit history and perhaps an underlying cause of a psychiatric component.
• A psychiatry-dermatology multidisciplinary clinic can help destigmatize referral to a mental health professional. "The dermatologist sees a patient with a psychiatrist," explains Dr. Tracey. "The patient feels like they are coming to see the dermatologist. Then we tell the patient [that] everyone in this clinic sees both of these providers and that's the way we are able to help these patients see a psychiatrist."

If you know someone in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255.

Hosts: Nick Andrews, Carol Nicotera-Ward

Guests: Elisabeth (Libby) Tracey, MD (Cleveland Clinic Foundation, Ohio); Julie Ann Amthor Croley, MD (The University of Texas Medical Branch at Galveston); Daniel R. Mazori, MD (State University of New York, Brooklyn).

Show notes by Jason Orszt, Melissa Sears, Kathy Scarbeck

You can find more of our podcasts at http://www.mdedge.com/podcasts.

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Julie Croley, MD, also known as @dr.skinandsmiles on Instagram, joins MDedge producer and host of the Postcall Podcast, Nick Andrews.

You can find more interviews like this on the Postcall Podcast at https://www.mdedge.com/podcasts/postcall-podcast