Category: NPPA Perspectives in Dermatology

Healthcare Provider Administration of Biologics for Patients with Plaque Psoriasis: Literature Review and Clinical Considerations

J Clin Aestet Dermatol 2023;16(12 Suppl 2):S20–S25 by Matthew Brunner, MHS, PA-C, DFAAPA; Keri Holyoak, MPH, MSHS, PA-C; and Douglas DiRuggiero, DMSc, MHS, PA-C Mr. Brunner is with the Elevate-Derm Conference and Dermatology and Skin Surgery Center P.C. in Stockbridge, Georgia. Ms. Holyoak is with the Dermatology Center of Salt Lake in Midvale, Utah. Dr. DiRuggiero is with the Skin Cancer and Cosmetic Dermatology Center in Rome, Georgia. FUNDING: Funding was provided by Sun Pharma. DISCLOSURES: Mr. Brunner currently has a financial relationship and/or commercial interest(s) that may have a direct interest in this activity with the following entities: AbbVie, Amgen, Arcutis Biotherapeutics, Boehringer Ingelheim, Bristol Myers Squibb, Castle Biosciences, Dermavant Sciences, InCyte, Janssen, LEO Pharma, Lilly, Novartis, Ortho Dermatologics, Pfizer, Sanofi, Sun Pharma, and UCB. Ms. Holyoak currently has a financial relationship and/or commercial interest(s) that may have a direct interest in this activity with the following entities: Castle Biosciences, Dermavant Sciences, Galderma, InCyte, LEO Pharma, Pfizer, Sanofi, and Regeneron Pharmaceuticals. Dr. DiRuggiero serves as a speaker and is an advisory board member for Amgen, AbbVie, Arcutis Biotherapeutics, Bristol Myers Squibb, EPI Health, InCyte, Janssen, Lilly, Novartis, Sanofi, Regeneron Pharmaceuticals, and UCB. ABSTRACT: Objective. Plaque psoriasis is a chronic, inflammatory, immune-mediated skin disease. Biologic therapies markedly improve skin disease severity and health-related quality of life for patients with moderate-to-severe plaque psoriasis. All but two of the biologics approved in the United States for moderate-to-severe plaque psoriasis may be self-administered by adult patients via subcutaneous injection. This review discusses rationales for choosing healthcare provider (HCP) administration over self-administration of biologics for patients with plaque psoriasis, including treatment adherence, patient preference, and practical considerations.  Methods. PubMed was searched for “psoriasisAND biologic AND administration AND (office OR provider OR profession).”  The most relevant results and additional papers identified from the references were included in the review.  Results. Although many patients prefer self-administration, others may benefit from HCP administration. Key considerations in the choice between HCP vs. self-administration of biologics for plaque psoriasis treatment include adherence, patient preferences, and practical concerns. Patient characteristics that may make HCP administration of biologic therapies for treatment of plaque psoriasis preferable to at-home self-administration are discussed.  Limitations. There are few published studies specific to HCP administration of biologics for treatment of psoriasis.  Conclusion. Administration of biologics by an HCP may improve treatment adherence and clinical outcomes compared to self-administration in selected patients with plaque psoriasis. Keywords: Adherence, HCP administration of injectable biologics, plaque psoriasis, self-administration of injectable biologics Targeted therapies, such as biologics, markedly improve disease severity and health-related quality of life for patients with moderate-to-severe plaque psoriasis.1,2 Home-based therapies for dermatologic conditions are increasingly available due to their convenience and cost-effectiveness.3 All but two biologics approved in the United States (US) for moderate-to-severe plaque psoriasis may now be either self-administered by adult patients via subcutaneous (SC) injection or administered by a healthcare provider (HCP): infliximab and tildrakizumab both require HCP administration—infliximab by intravenous (IV) infusion and tildrakizumab by SC injection per the approved labeling (Table 1).4–14  Although many patients prefer self-administration, others may benefit from administration by their dermatology provider or at an alternative site of care, such as an infusion center. Therefore, patients and providers should engage in shared decision-making to inform treatment selection and optimize clinical outcomes.15-17 Here, we review the evidence supporting HCP vs. self-administration of biologic therapies for plaque psoriasis and offer examples of patients for whom HCP administration might provide better experiences and outcomes compared with self-administration.  Candidates for HCP Administration­—Patient Vignettes Hypothetical Patient 1. A 35-year-old female patient presented with moderate-to-severe psoriasis involving the elbows, knees, and scalp (Psoriasis Area and Severity Index [PASI] score: 14). She was started on treatment with a tumor necrosis factor (TNF) inhibitor self-administered via SC injection. After months of therapy, the patient discontinued treatment despite initial improvement, reporting that she became tired of self-administering injections and experienced difficulty receiving pharmacy shipments due to work travel. She asked about alternatives to storing and injecting biologic therapies at home. The patient’s health insurance plan provided limited pharmacy benefits. Hypothetical Patient 2. A 76-year-old male patient presented with moderate-to-severe psoriasis involving the scalp, trunk, and elbows (PASI score: 15). When counseled regarding potential treatment choices, he described his fear of needles and difficulty with manipulating syringes for self-injection of past medications. The patient also admitted to occasionally forgetting to administer shots of previous medications. The patient was widowed and living alone, reporting there was no one available at home to help him with injections. He described experiencing mild injection site reactions with his previous medications and expressed concern that more severe adverse reactions might occur when self-injecting at home. The patient was insured under Medicare Part B, but not Part D. Advantages and limitations of Self-administration The availability of different administration methods of biologics gives patients with psoriasis treatment options for their individual comfort levels, convenience, and insurance requirements.18, 19 Higher adherence and longer drug survival have been reported with HCP vs. at-home administration of psoriasis treatments; this may have been due to increased awareness (based on missed appointments) and the opportunity for the HCP to intervene.20, 21 Enhancing the patient-HCP relationship through frequent in-person contact may also improve adherence by increasing patient accountability.22 However, self-administration may be beneficial when office visits are limited. In an analysis of claims data during the COVID-19 pandemic, incidence of 14-day gaps in treatment increased by 55.1 percent (P<0.01) for patients using HCP-administered biologics for psoriasis, with no similar decrease in adherence for patients using biologics dispensed by pharmacies.23 Poor patient experiences and problems with self-injection may decrease patient adherence and treatment efficacy.24–26 Specific challenges for self-injection include needle phobia, fear and anxiety, concerns about injection site reactions, and limited visual acuity and hand dexterity.24–27 Patients not provided with appropriate training for self-injection may rely on the product’s instructions for use and turn to a trial-and-error approach to self-administer their medication, which can result in habitualizing self-injection errors.26 Even patients who receive training can make errors, and the dosing intervals of biologics (Table 1) mean

Pearls from the Scope—What Your Dermatopathologist Wants You to Know: Direct Immunofluorescence

J Clin Aesthet Dermatol. 2023;16(12 Suppl 2):S33–S35 by Maria R. Robinson, MD, MBA, FAAD Dr. Robinson is a board-certified dermatologist and dermatopathologist with over 15 years of experience across the academic, private practice, and telehealth sectors. She has a passion for education, and is the founder of www.dermpathforapc.com, an innovative online dermatopathology CME course for advanced practice clinicians.   FUNDING: No funding was provided for this article. DISCLOSURES: Dr. Robinson reports no conflicts of interest relevant to the content of this article.  ABSTRACT: Direct immunofluorescence (DIF) is a valuable diagnostic tool in the dermatology clinic. The proper use of a biopsy for DIF is dependent on several factors, including appropriate clinical indication, correct clinical site selection, and proper specimen handling and transport. Improper use of DIF can lead to false negatives, decreased diagnostic yield, and poor resource utilization. This article provides instruction on the appropriate indications and biopsy site selection for DIF. Three examples of skin diseases in which DIF would be particular useful when making a diagnosis are provided. Direct immunofluorescence (DIF) is a valuable and well-established tool often used in the dermatology clinic. It helps confirm certain diagnoses by detecting the presence of different immune complexes in the skin at various locations, such as the dermo-epidermal junction or dermal blood vessels.1,2  Like with other biopsy techniques, the value of DIF is dependent on various factors, such as appropriate indication, site selection, specimen handling and transport, and use in a cost-effective manner.1–4 When it comes to using DIF in clinic, gaps in clinician knowledge and practice can negatively influence results. This can lead to false negatives, decreased diagnostic yield, poor utilization of resources, and ultimately negatively affect patient care.  Indications for DIF in dermatology DIF is valuable when specific skin diseases are being considered in the differential diagnosis (Table 1). Depending on the disease process, DIF findings may be specific and diagnostic or they may be highly characteristic or suggestive of certain skin conditions.5 This is why DIF should be used in conjunction with histopathology and a thorough clinical history to improve diagnostic yield.2 Notably, DIF is not useful for eczematous dermatitis and its various subtypes.  Biopsy site selection When performing a biopsy for DIF, correct site selection is critical for accurate results, and it varies depending on the suspected disease entity.3,5 Biopsies for DIF and histologic evaluation with hematoxylin & eosin (H&E) are often done at the same patient encounter. Doing this can help expedite the final results, since H&E and DIF correlations are often performed. Additionally, a single visit can be more convenient for the patient.   Autoimmune blistering diseases For autoimmune blistering diseases, the biopsy for DIF should be done on perilesional skin (normal looking skin) within 1cm of the bulla. Biopsies from the lower extremity have been associated with a higher likelihood of false-negative results, particularly with bullous pemphigoid. For this reason, this anatomic site should be avoided if possible.3  For the H&E biopsy, if the lesion is small, the entire lesion should be removed with a deep saucerization or punch biopsy. For a large bulla, the biopsy should be from the edge of the blister and contain both portions of the blister and intact skin (Figure 1). Both methods provide the dermatopathologist with enough tissue to evaluate the entire depth of the pathologic changes, which results in a more specific diagnosis or differential diagnosis.  Vasculitis For vasculitis, the biopsy for DIF should be a punch biopsy or deep shave in the center of a newer lesion (ideally less than 24 hours old). For an H&E biopsy, a punch biopsy or deep shave in the center of a well-established purpuric older lesion is ideal (ideally around 72 hours)(Figure 2).3 Connective tissue disease For connective tissue disease, such as lupus erythematosus and dermatomyositis, the biopsy for DIF and H&E should both be a punch biopsy of lesional skin that is established and still active (Figure 3). For DIF, the immune deposits are best shown in lesions that are greater than six months old.3 A punch biopsy is preferred over a shave biopsy for evaluation of the deep infiltrate.   Clinical case review The following clinical case highlights the correct locations for both DIF and H&E biopsies. A 72-year-old man presented with a widespread, pruritic eruption consisting of numerous erythematous bullae. The biopsy for H&E could be a punch biopsy or deep shave of the edge of an active blister (small blue circle, Figure 4) or of an entire blister (large blue circle, Figure 4). The biopsy for DIF should be a punch biopsy or deep shave of uninvolved perilesional skin within 1cm of a bulla (green circle, Figure 4).  Specimen handling After obtaining a biopsy from the appropriate site, correct tissue handling and transport is necessary for optimal and accurate results.   Biopsy tissue obtained for DIF should be placed in Michel’s or Zeus’s transport medium for preservation and transport. If these are not available, specimens transported on normal saline-soaked gauze can be used with two caveats: the laboratory must accept this type of specimen, and the specimen has to be delivered within 24 to 48 hours. Specimens transported in Michel’s medium can stay at room temperature for at least two weeks without loss of signal.1,3 At times, DIF specimens are inadvertently placed into formalin for transport. If this happens, the tissue may be retrievable depending on the suspected disease and the amount of time in the formalin. For example, pemphigus will have negative results even with a brief exposure to formalin (2 minutes). However, bullous pemphigoid and dermatitis herpetiformis can survive up to 10 minutes without disrupting the signal. Occasionally, a regular biopsy specimen for H&E is mistakenly placed in Michel’s medium for transport. In this situation, the tissue can simply be transferred into formalin without affecting the tissue’s quality or preservation.1 Conclusion In the right clinical context and with the proper clinical site selection, biopsy technique, and specimen handling, DIF is an important diagnostic tool available to clinicians. If the submitting clinician has

Life and Career Coaching for NPs and PAs— The Secret to Preventing Clinical Burnout: Start a Side Hustle!

J Clin Aesthet Dermatol. 2023;16(9 Suppl 2):S17–S18 by Kasey D’Amato PA-C, MPAP, Katie Plessinger, PA-C, and Danielle Spatholt, PA-C Ms. D’Amato is President, Certified PA Consulting, in  Ft. Lauderdale, Florida. Ms. Plessinger is a consultant with Certified PA Consulting in Ft. Lauderdale, Florida. Ms. Spatholt is a consultant with Certified PA Consulting in Ft. Lauderdale, Florida. FUNDING: No funding was provided for this article. DISCLOSURES: All authors are employees of Certified PA Consulting. As we know, burnout has become all too commonplace in healthcare. This state of physical and emotional exhaustion and feeling of loss of control or lack of forward progress sends some providers running to escape clinical medicine. There is a solution to revitalize your career without giving up clinical medicine—finding a side hustle that excites you!  Burnout is the result of chronic workplace stress and is defined as increasing exhaustion, negative feelings and cynicism, and decreased professional efficacy.1 Burnout happens when our personal and career values do not align with our employer’s business values. The most fulfilled nurse practitioners (NPs) and physician assistants (PAs) work with a coach or self-reflect to define their own values and seek out career opportunities that match their own values.  The flexibility of the NP+PA career structure provides the perfect conditions to cultivate a side hustle. Additional income is not the only potential benefit of this endeavor; side hustles can increase fulfillment by allowing you to have control over a project. They can provide a sense of forward momentum and progress when you feel like you have hit a plateau. We see this phenomenon commonly in PAs and NPs who have reached the 5-to-10 year mark in their careers, as by that point they have achieved their maximum salary potential, mastered the diagnostic and technical skills in their specialty, and find themselves asking, “What else?” A side hustle can help you learn new skills in areas such as marketing, networking, and leadership. Proficiency in these areas will not only propel your new endeavor, it will also improve your clinical career by bringing new skills and understanding to your NP or PA role.  Once you make the decision to launch a side hustle, you must determine which side hustle meets your needs and goals. A side hustle can provide you with flexibility, creative challenges, and increased income, but it will also require time and, in some circumstances, money to start. It is important to define which category of side hustle will fit into your lifestyle without negatively impacting your work/life balance. Reflecting on your skills, interests, passions, and personality can lead you to the perfect side hustle that will recharge your energy and excitement about work in general. To determine which side hustle to pursue, the first step is self-reflection. The side hustle opportunities are endless! You want to choose one that will match your personality, lifestyle, and desired outcomes so that this endeavor is fulfilling and sustainable. For example, reflect on if you consider yourself introverted or extroverted, creative or analytical, or adventurous or cautious. Also, reflect on what unique skills you can bring to your side hustle experience. Consider your artistic talents, social skills, marketing skills, writing skills, and financial literacy. Finally, determine the amount of time you are willing to devote to this side hustle, as some side hustles mandate a certain time obligation. This side hustle should be complementary to your clinical career and personal goals and should not negatively impact your clinical career or personal life.  After you perform self-reflection to determine what you are passionate about, next you should reflect on the skills you wish to develop. For example, if you want to develop marketing skills, consider taking on a role in affiliate marketing, direct sales, or pharmaceuticals. If you want to improve your legal literacy, take on a role as an expert witness. If you want to improve your communication and education skills, become an adjunct professor or conference speaker. An incredible part of medicine is that these skills can all be utilized in our profession. Medicine is a business, and we can contribute more to our business entity by improving our skills in areas outside of clinical medicine.  Once you have an idea of what side hustle matches your personality, skills, and desires, you should connect with others that have walked a similar path. Just as you would network and seek advice when looking for a clinical role, you should do the same when starting a side hustle. Finding a mentor that does a similar hustle can provide you with great information on the potential benefits and pitfalls, including financial expense versus income, time investment, and opportunities for growth. By networking with others with similar interests, you can also generate leads and collaborate, which can be invaluable to your venture.  Having a side hustle should provide growth, progress, excitement, and added fulfillment to your clinical career, and should not serve as an escape from an undesirable work situation. If your clinical role is truly miserable, you will need to address that and make some changes because a side hustle will not change a toxic clinical work environment. Before making a career change, you might want to consider a side hustle to help reignite the learning part of your brain! Having helped thousands of PAs and NPs pursue a side hustle or make a career transition to a different practice, specialty, or even a nonclinical role over the past decade, we have found that PAs and NPs who find the right side hustle for their situation and personality can lead to much longer career fulfillment and much less burnout.  If you find a side hustle that you are passionate about and cannot determine how to integrate with your current clinical role, you might want to consider a different clinical role that can support your side hustle. It is important to be sensitive about conflicts of interest and know how to foster a side hustle that is sustainable and enjoyable without causing any conflict with your

Dermatological Conditions in Skin of Color— Clinical Considerations When Treating Acne Vulgaris in Skin of Color

J Clin Aesthet Dermatol. 2023;16(9 Suppl 2):S20–S21 by Archana M. Sangha, MMS, PA-C  Ms. Sangha is a medical science liaison for Incyte in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also Immediate Past President of the Society of Dermatology Physician Assistants. FUNDING: No funding was provided for this article. DISCLOSURES: Ms. Sangha is an employee of Incyte in Wilmington, Delaware.  Acne vulgaris affects nearly 10 percent of the world-wide population.1 In a study by Perkins et al, acne was found to be more prevalent in African Americans (37%) and Hispanics (32%), followed by Asians (30%), Caucasians (24%), and Continental Indians (23%).2 This article highlights five considerations when treating acne in patients with skin of color.  Evaluate topical retinoid regimen Topical retinoids are the mainstay of acne treatment and exert their effects by minimizing active lesions and inhibiting microcomedone formation.3 Higher doses of retinoids can cause skin irritation, thus increasing the risk of postinflammatory hyperpigmentation (PIH). Common side effects of topical retinoids include erythema, dryness, peeling, and irritation. These side effects are most common during the first few weeks of treatment initiation.4 To improve tolerability and patient adherence, consider the following:  Retinoid concentration and vehicle formulation. Lower concentrations of topical retinoids have been shown to minimize the risk of PIH.5 Studies have shown that creams, microsphere, crystalline formulations, and aqueous gels are better tolerated in patients with skin of color.6 Short contact therapy. This method minimizes the length of exposure to the retinoid. Patients apply the topical retinoid for a specified amount of time (e.g., 30–60 minutes once daily) and then rinse it off their skin. In a study assessing tretinoin 0.05% cream applied in this manner for up to 32 weeks, results showed similar efficacy to its once-daily leave-on regimen, but with improved tolerability.7 Nondaily application. This method minimizes the frequency of exposure to the retinoid. Patients should apply the retinoid every other day. In a study comparing every other day tazarotene 0.1% gel to once-daily adapalene 0.1% gel, results showed that both formulations had similar efficacy and tolerability.8 Take a history of skincare regimen  It is important to take a thorough history of a patient’s current skincare regimen. By doing so, you can learn if they are using products that may exacerbate potential side effects of a treatment regimen. Counsel patients to avoid toners and astringents, as they can excessively dry the skin and increase irritation.9 Recommend lipid-free cleansers, as they gently clean the skin and maintain epidermal integrity.10 Recommend noncomedogenic moisturizers as well. One study showed that adapalene used in combination with an anti-inflammatory moisturizer had greater efficacy and tolerability versus adapalene alone.11 Lastly, emphasize the importance of daily sunscreen use. Darker skin is naturally protected from ultraviolet B (UVB) light but susceptible to UVA and visible light. UVA has been shown to induce PIH in patients with acne.12 One study found that one of the most common reasons for sunscreen avoidance in skin of color populations was “dislike of greasiness;” thus, it is important to address this concern with patients and counsel them on the wide variety of sunscreen formulations available.13 Initiate isotretinoin gradually For patients who require isotretinoin, they should be started on a low dosage, which is then increased gradually, as isotretinoin initiation can cause an initial acne flare. This initial flare can lead to subsequent PIH. Patients may also experience ashen or grayish facial skin secondary to the drug’s xerotic effects.14  Inquire about haircare practices Individuals of different ethnicities have varying haircare practices, and many frequently apply comedogenic oils to the hair and scalp. For example, a study by Nayak et al15 showed that Asian Indian male and female individuals applied coconut oil to the hair for moisturization. This practice often leads to pomade acne, which is characterized by numerous closed comedones over the forehead and temples.14 It is important to be aware of what products are being used on the hair so you can counsel patients appropriately.  Discuss PIH  Patients with skin of color are often equally or more bothered by PIH than active acne. Therefore, it is important to discuss how active acne leads to PIH and how a customized treatment plan treats both (e.g., consider treatment regimens that include topical retinoids and/or azelaic acid). Discuss with patients the anticipated timeline for improvement of both acne and PIH. Also, ask patients if they have treated their PIH in the past, and if so, with what products (e.g., hydroquinone, etc.).  By understanding some of the unique challenges that impact patients with skin of color who have acne, you will be better equipped to achieve shared treatment goals.  References Heng AHS, Chew FT. Systematic review of the epidemiology of acne vulgaris. Sci Rep. 2020;10(1):5754. Perkins AC, Cheng CE, Hillebrand GG, et al. Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African American women. J Eur Acad Dermatol Venereol. 2011;25(9):1054–1060  Thielitz A, Abdel-Naser MB, Fluhr JW, et al. Topical retinoids in acne—an evidence-based overview. J Dtsch Dermatol Ges. 2008;6(12):1023–1031. Culp L, Moradi Tuchayi S, Alinia H, Feldman SR. Tolerability of topical retinoids: are there clinically meaningful differences among topical retinoids? J Cutan Med Surg. 2015;19(6):530–538. Alexis AF, Woolery-Lloyd H, Williams K, et al. Racial/ethnic variations in acne: implications for treatment and skin care recommendations for acne patients with skin of color. J Drugs Dermatol. 2021;20(7):716–725. Alexis AF, Barbosa VH. Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment. Springer; 2012. Veraldi S, Barbareschi M, Benardon S, Schianchi R. Short contact therapy of acne with tretinoin. J Dermatolog Treat. 2013;24(5):374–376. Leyden J, Lowe N, Kakita L, Draelos Z. Comparison of treatment of acne vulgaris with alternate-day applications of tazarotene 0.1% gel and once-daily applications of adapalene 0.1% gel: a randomized trial. Cutis. 2001;67(6 Suppl):10–16. Callender VD, Baldwin H, Cook-Bolden FE, et al. Effects of topical retinoids on acne

Potential effects, diagnosis, and management of De Quervain Tenosynovitis in the aesthetics community: A Brief Review, Case Example, and Illustrative Exercises

J Clin Aestet Dermatol 2023;16(9 Suppl 2):S28–S31 by Michele Rutkowski, APrN, FNP-C, and Kristy Rutkowski, OTR/L Ms. M. Rutkowski is with Face Forward Aesthetics in Wexford, Pennsylvania. Ms. K. Rutkowski is with Positive Steps Therapy, LLC in Rochester, Pennsylvania. FUNDING: The authors received no funding for this article. DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.  ABSTRACT: Background. Aesthetics is a demanding and growing specialty. More providers are injecting daily at a high volume. De Quervain’s tenosynovitis (DQT) is a well-known syndrome involving the hand in the orthopedic and rehabilitation space. The prediction is that DQT will soon become well known to aesthetic injectors. DQT presents with swollen tendons that run along the thumb side of the wrist and attach to the base of the thumb. This is a result of repetitive motion or overuse of the thumb, most often of the dominant hand. This causes pain to the thumb and wrist area, making it difficult to complete daily tasks and perform injections on patients. Objective. This article’s goal is to increase awareness among providers of the signs and symptoms of DQT and to be proactive in preventing this condition. A home exercise program has been created to focus on strengthening and conditioning the hand of injectors. Methods. A systematic literature search of the PubMed database was completed. Results. There is a positive correlation between industry demand, increased daily injecting, and the probability of injectors developing DQT. The pain caused by this syndrome can affect the daily lives and work performance of injectors. Proper body ergonomics, including stretching and strengthening the thumb, can be used to reduce pain caused by DQT. Limitations. There was no case study or testing done on groups of people, which limits the results of this review.  Keywords: De Quervain tenosynovitis (DQT), Finklestein test, first dorsal compartment (FDC), abductor pollicis longus (APL), extensor pollicis brevis (EPB), nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), occupational therapy (OT), nurse practitioner (NP) De Quervain’s tenosynovitis (DQT) is a well-known syndrome involving the hand in the orthopedic and rehabilitation space. As the field of aesthetics grows, this syndrome has become more prevalent among injectors, thus coining the phrase, “injector’s thumb.” Injectors should be aware of the signs and symptoms of DQT to address this condition as early as possible to prevent long-term pain and discomfort and other serious complications, which may require surgery. A table of exercises has been created to help injectors strengthen their dominant thumb to help avoid the pain of DQT.  Etiology DQT is characterized by thickening and myxoid degeneration of the tendon sheath in the first dorsal compartment (FDC) of the wrist. The FDC is formed by fibrous bands of the extensor retinaculum and contains the tendons of the abductor pollicis longus (APL) and the more dorsal extensor pollicis brevis (EPB).1 DQT presents as swollen tendons that run along the thumb side of the wrist and attach to the base of the thumb (Figure 1). This occurs when the tendons are constricted by the sheath through which they run from the wrist to the hand.2 This is a result of repetitive motion or overuse of the thumb, most often of the dominant hand. The correct diagnosis of this debilitating tendon condition and the seeking of early treatment yields excellent outcomes for patients.3 Epidemiology  The estimated prevalence of DQT is about 0.5 percent in men and 1.3 percent in women, with peak prevalence occurring around age 40 to 50 years. The current most widely affected population are new mothers and daycare workers. Often referred to as “mommy’s thumb,” DQT in this patient population is the result of the strain placed on the thumb in the cylindrical position due to picking and carrying infants and toddlers.5 Another cause of DQT that has recently become more prevalent is the strain on the thumb from texting and scrolling on smart phones.6  As medical spas become more popular in the aesthetics market, injectors may be practicing 40 hours a week, putting them at risk for repetitive motion and stabilization of the injecting thumb. It is important for injectors to recognize the early signs and symptoms of DQT so that intervention can occur as quickly as possible. Early intervention may help prevent severe inflammation of the tendons in the injecting thumb and avoid the use of short-term disability. Assessment A history and physical are needed for a DQT diagnosis. The provider may examine and palpate along the affected area to assess for pain and swelling. It is important to review daily life and work activities that could be contributing to inflammation of the thumb area. A gold standard to test for DQT in the United States is the Finkelstein’s Test (Figure 2).2,7 Occasionally, an ultrasound or x-ray may be needed to confirm the diagnosis.8  Management  Nonoperative management is the first line of defense against DQT. To avoid surgery, an early onset diagnosis is important for a full recovery from this injury. Conservative treatment methods are primarily used as a starting point when managing DQT. The first step is rest and immobilization. This is often paired with nonsteroidal anti-inflammatory drugs (NSAIDs) to help reduce inflammation.1 Use of a thumb spica splint (Figure 3) can assist with immobilization.  The thumb is vital to humans in that it allows us to be able to grab and manipulate items of a variety of sizes and shapes. The thumb is unique, compared to the other fingers of the hand, due to its large amount of muscle mass and range of motion from the saddle joint.  After a diagnosis of DQT, the affected area needs rest from the mechanism of consistent injecting as well as other activities of daily living (ADLs), such as holding a coffee mug, opening a jar, or grasping a sponge to clean. Modifying activities for the affected thumb allows the inflamed tendon to rest and repair.  Once the brace is discontinued, physical therapy (PT) and occupational therapy (OT) will be ordered to help regain strength and proper function to the injured

Spotlight Interview: A Deeper Dive into Dermatopathology An Interview with Dr. Maria Robinson

J Clin Aesthet Dermatol. 2023;16(9 Suppl 2):S41 by Margaret A. Bobonich, DNP, FNP-C, DCNP, FAANP Dr. Bobonich is Assistant Professor at Case Western Reserve University in Cleveland, Ohio, and Founder of Center for Dermatology Nursing Practice in Silver Lake, Ohio.  I wish to congratulate the Journal of Clinical and Aesthetic Dermatology (JCAD)’s NP+PA Perspectives in Dermatology in stepping up to provide NP and PA education and practice with a new journal section dedicated to dermatopathology. I am so very excited that dermatology NPs and PAs will now have an opportunity to not only learn dermatopathology, but to address some of the hurdles that we face in daily practice.   Dermatology NPs and PAs acquire requisite knowledge and skills for the diagnosis and management of dermatologic conditions. Skin biopsies are an essential diagnostic procedure that dermatology clinicians perform to diagnose skin cancers, skin eruptions, and sometimes underlying systemic disease.  However, one of the gaps in the education and training of advance practice providers is in dermatopathology. The clinicopathologic correlation of any biopsy is dependent on the clinician’s ability to interpret the dermatopathology report from the biopsy specimen.  It was a privilege to talk with Dr. Maria Robinson, a dermatopathologist who has worked extensively with NPs and PAs. I worked with Dr. Robinson during her dermatology residency. Working shoulder to shoulder, you quickly realize when colleagues not only understand HOW to teach us, but also CARE about teaching us. When I saw the time and effort she dedicated to her online learning program (www.dermpathforapc.com), I realized the extent of her commitment to teaching dermatopathology to NPs and PAs. I share our recent conversation together here. Dr. Bobonich: Welcome Dr. Robinson. Tell us about the new dermatopathology column in JCAD NP+PA Perspectives and what prompted you to present this education.  Dr. Robinson: I’m thrilled to partner with JCAD’s NP+PA Perspectives on their new column “Pearls from the Scope—What Your Dermatopathologist Wants You to Know.”  Throughout my dermatology and dermatopathology career, I’ve had the opportunity to work with excellent dermatology NPs and PAs. But there is a bit of a knowledge gap when it comes to dermatopathology, largely due to the varying degrees of dermatopathology education. In helping to fill this gap, my hope is that clinicians will get the most out of their biopsies and enhance their patient care.   Dr. Bobonich: Can you tell us what information about the patient would be helpful for the dermatopathologist to help me narrow my differential diagnosis? Dr. Robinson: This is a really important topic, and it’s actually the focus of our first column in the journal. In addition to the detailed information there, it’s important to clarify a frequent misconception about the clinical information on the biopsy requisition form. Some clinicians may believe that supplying clinical information will “bias” the dermatopathologist. This is not the case at all. Clinical information is critical to the clinicopathological correlation, especially with inflammatory processes. Some completely different clinical diagnoses (such as an epidermal nevus and confluent and reticulated papillomatosis) can have identical histologic findings. Accurate and thorough clinical information helps us give you a more specific diagnosis and can help you narrow your differential diagnosis. Dr. Bobonich: What should I do if I receive a dermatopathology report that I don’t understand? Dr. Robinson: First, make sure it’s the correct patient. In addition to looking at the name and date of birth, check the gross description in the report to make sure the tissue type and size match what you submitted. For example, if you submitted a 4mm punch, the gross description should reflect this same information. Switched cases are uncommon, but they do happen. If this checks out and you want clarification on a case, you can always reach out to your dermatopathologist to review the case and discuss the findings. Sometimes a conversation can help clarify the report findings or provide important additional information for the case. Remember, the dermatopathologist’s goal is to work with the clinician to correctly diagnose the condition.  Dr. Bobonich: When a clinician performs a biopsy of a rash that is a suspected allergic contact dermatitis, often the patient wants to know what is causing the rash. What should we consider in the clinicopathologic correlation? Dr. Robinson: When a clinician does a biopsy of a suspected allergic contact dermatitis (ACD), the histologic findings can support a diagnosis of ACD. However, the biopsy can’t identify the causative agent. A thorough history, clinical exam, and patch testing are needed to do this. It’s also important to understand that the findings in ACD (a spongiotic dermatitis) are not specific to ACD. Other spongiotic processes, such as nummular eczema, can have identical histologic findings. This is another example of why clinical information and clinical correlation are so important.  Dr. Bobonich: Thank you, Dr. Robinson, for your enthusiasm and commitment to teach dermatopathology to NPs and PAs. We look forward to the many clinical pearls in dermatopathology you’ll be sharing in each issue of the journal.   

Pearls from the Scope— What Your Dermatopathologist Wants You to Know

J Clin Aesthet Dermatol. 2023;16(9 Suppl 2):S42–S44 by Maria R. Robinson, MD, MBA, FAAD Dr. Robinson is a board-certified dermatologist and dermatopathologist with over 15 years of experience across the academic, private practice, and telehealth sectors. She has a passion for education, and is the founder of www.dermpathforapc.com, an innovative online dermatopathology CME course for advanced practice clinicians.   FUNDING: No funding was provided for this article. DISCLOSURES: Dr. Robinson reports no conflicts of interest relevant to the content of this article.  ABSTRACT: The skin biopsy and histologic examination are an important part of providing dermatologic care. Effective communication with your dermatopathologist on the biopsy requisition form helps provide clinicopathological correlation and facilitates accurate and timely histopathologic diagnosis of the biopsy. Welcome to Pearls from the Scope, where clinical pearls are shared from the perspective of your dermatopathologist to help enhance the provision of effective dermatologic care.   Communication with your dermatopathologist is an important part of providing comprehensive dermatologic care. Effective communication primarily happens through the information provided on the biopsy requisition form (RF), which is a crucial link between the submitting clinician and the dermatopathologist. When the clinical information on the RF is comprehensive and accurate, it provides clinicopathological correlation and facilitates accurate and timely histopathologic diagnosis in dermatopathology.1 In many situations, however, the RF contains clinical information that is incomplete, inaccurate, or sometimes missing altogether.2,3 Additionally, when descriptions are present, they may consist of vague and nonspecific terms, such as “lesion,” “NUB,” (i.e., neoplasm of uncertain behavior), “rash,” or “recent changes.” These terms do not convey helpful clinical information to the dermatopathologist, nor do they contribute to clinicopathological correlation.4 Clinicians may also write rule out on the RF, a term which prevents the dermatopathologist from understanding the true clinical suspicion of a lesion. For example, “rule out basal cell carcinoma (BCC)” may mean the clinician thinks it’s a BCC. Or it may mean the opposite—the clinical suspicion for a BCC is low.4 A survey of the membership of the American Society of Dermatopathology (ASPD) highlighted some of these concerns, including discontent associated with the quality of RF clinical information and the added time spent gathering accurate information.2 The lack of accurate and comprehensive information on the RF can have significant consequences in the quality and safety of patient care.1–5 Providing less information on the RF for inflammatory disorders has been shown to lead to additional stains, additional tissue sections, and a prolonged turnaround time for histopathologic diagnosis.1 In many situations, relevant clinical information is captured in the Electronic Medical Record (EMR) Encounter Note, but it is not transferred to the RF provided to the dermatopathologist.1  Clinical Case Review Reviewing the following clinical cases will highlight the importance of clinical information on the RF.  Patients 1 and 2 both had erythematous, annular plaques with similar underlying etiologies. The dermatitis in Patient 1 was located in a nonhair-bearing area (Figure 1). In Patient 2, however, the dermatitis extended into a hair-bearing area on the scalp (Figure 2).  Punch biopsies from Patients 1 and 2 showed similar findings—mild inflammation and subtle epidermal changes suggestive of a dermatophyte; a Periodic acid-Schiff stain (PAS) stain confirmed the diagnosis of tinea in both cases (Figures 3 and 4 show biopsies from Patient 2; Patient 1 biopsies not shown). At this point, a diagnosis of tinea corporis could have been made for both Patients, but this would have only been a partial diagnosis for Patient 2. The clinician for Patient 2 provided thorough clinical information and a photograph, which showed the possibility of follicular involvement by the rash. Because of this, deeper sections were performed, which showed dermatophyte involvement of a hair follicle (Figure 5), which potentially changed the management of the patient.6  When indicated by the clinical situation, deeper sections of a biopsy specimen can be done, which may show additional findings (Figure 6). In the absence of accurate and thorough clinical information, the clinicopathological correlation is limited, and this may hinder the histopathologic evaluation. Optimizing communication with your dermatopathologist Improving the communication with your dermatopathologist can result in a faster and more accurate histopathologic diagnosis. There are significant time-demands in a busy dermatology clinic. Fortunately, optimizing the clinician-pathologist communication doesn’t have to require a significant time commitment, and it can save time in the long run while improving patient care.  Clinicians should include accurate and thorough clinical information on the RF when submitting a biopsy specimen. Vague terminology (such as “lesion” and “rash”) should be avoided, and clinical suspicion should be accurately reflected (e.g., “favor sebaceous hyperplasia, doubt BCC” or “confirm BCC”).  When completing the RF, the 5 D’s, as listed below, can be used as a guide for providing accurate and complete clinical information:  Demographics: Ensure age, sex, and race are included (these are often automatically included on the RF). Description: Descriptors, such as appearance, location, distribution, prior treatment, and a clinical photo if possible should be used/included.8 The default EMR description is often not an accurate reflection of the clinical findings. Duration: Describe how long the process has been present and if it’s changing.  Diameter: For lesions, include an accurate size and whether it’s a partial biopsy. Differential diagnosis: The clinician’s thoughts on the diagnosis, which also helps the dermatopathologist understand the clinical findings, should be clearly described.    Pearl 1. Including accurate and thorough clinical information on the biopsy requisition provides clinicopathological correlation and enables accurate and timely histopathologic diagnosis.  Pearl 2. When tinea occurs on hair-bearing skin, consider follicular involvement (such as tinea capitis or Majocchi granuloma). The RF is an essential connection between the submitting clinician and the dermatopathologist, and it contains information vital for clinicopathological correlation and effective patient care. If questions ever arise about a clinical case or histopathologic diagnosis, the submitting clinician should not hesitate to call the dermatopathologist for discussion and further clarification.   References Romano RC, Novotny PJ, Sloan JA, et al. Measure of completeness and accuracy of clinical information in skin requisition forms: an analysis of 249 cases. Am J Clin

Association Between Atopic Dermatitis, Anxiety, and Symptoms of Panic Among United States Adults in the 2001–2004 National Health and Nutrition Examination Survey

J Clin Aesthet Dermatol. 2023;16(6 Suppl 1):S10–S12 by Shivali Devjani, MS; Brandon Smith, BA; George Han, MD, PhD; and Jashin J. Wu, MD Mr. Devjani is with SUNY Downstate College of Medicine in Brooklyn, New York. Mr. Smith is with Drexel University’s College of Medicine in Philadelphia, Pennsylvania. Dr. Han is with the Zucker School of Medicine at Hofstra/Northwell in Uniondale, New York. Dr. Wu is with the University of Miami Miller School of Medicine in Miami, Florida. FUNDING: No funding was provided for this article. DISCLOSURES: Dr. Wu is or has been an investigator, consultant, or speaker for AbbVie, Almirall, Amgen, Arcutis, Aristea Therapeutics, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, DermTech, Dr. Reddy’s Laboratories, Eli Lilly, EPI Health, Galderma, Janssen, LEO Pharma, Mindera, Novartis, Pfizer, Regeneron, Samsung Bioepis, Sanofi Genzyme, Solius, Sun Pharmaceutical, UCB, and Zerigo Health. Dr. Han is or has been an investigator, consultant/advisor, or speaker for AbbVie, Athenex, Boehringer Ingelheim, Bond Avillion, Bristol-Myers Squibb, Celgene Corporation, Dermavant, Eli Lilly, Janssen, LEO Pharma, MC2, Novartis, Ortho Dermatologics, PellePharm, Pfizer, Regeneron, Sanofi/Genzyme, SUN Pharmaceutical, and UCB. Authors Devjani and Smith have no conflicts of interest to declare. ABSTRACT: Atopic dermatitis (AD) is a common, chronic inflammatory dermatologic condition that can cause discomfort and thus negatively influence the mental health of patients. Research directly exploring the relationship between AD, anxiety, and symptoms of panic in a large United States (US) adult population is limited. We studied the relationship between AD and anxiety versus panic in US adults aged 20 to 39 years. The association between AD and anxiety was significant, but not between AD and panic. This association between AD and anxiety was significantly increased in adults aged 30 to 39 years and female adults. Our study may demonstrate that a focus on the wellbeing of patients might be helpful in clinical practice. Further longitudinal studies can help to elucidate these relationships. Keywords: Atopic dermatitis; anxiety; panic; general dermatology; statistics; mental healths. Atopic dermatitis (AD) is a common, chronic inflammatory dermatological condition characterized by the presence of pruritic, erythematous lesions on the skin. Given its uncomfortable symptoms, AD can often be debilitating and negatively influence the mental health of patients in a variety of ways. Links between AD, depression, and suicidality have been established in observational studies, with the degree of depression correlated with the severity of cutaneous manifestations.1 The link between AD and anxiety has also been documented in the literature and may be bidirectional in nature.2,3 While the chronic and debilitating nature of AD has been found to have a sizable impact on the mental health of those affected by the disease, acute psychological stress can lead to elevated immunoglobulin E (IgE) levels and eosinophils in the blood of patients with AD.4 However, there is limited research directly exploring the relationship between AD, anxiety, and symptoms of panic in a large United States (US) adult population. We studied the relationship between AD and anxiety versus panic in adults aged 20 to 39 years from the US using the 2001 to 2004 National Health and Nutrition Examination Survey (NHANES).  AD status and symptoms of anxiety and/or panic were assessed by various survey questions. There were 472 patients included in our analysis that responded to such questions. Multivariate logistic regressions were performed using STATA/MP 17.0 to explore the relationship between AD and anxiety. We controlled for age, income, education, sex, race, and body mass index (BMI) in our models (Table 1). The prevalence of AD in our analysis was 15.5 percent. Approximately 49.1 percent of individuals with AD reported a history of anxiety, and 57 percent reported a history of panic. On the other hand, 31 percent of patients without AD reported a history of anxiety, significantly lower (p<0.01) than in patients with AD, while 47.4 percent of patients without AD reported a history of panic; this difference, while numerically lower, was not significant. After adjustment for potential confounders, there remained a significant association between AD and anxiety among participants aged 20 to 39 years of age (adjusted odds ratio [aOR]: 2.78, 95% confidence interval [CI]: 1.35–5.75, p=0.007). Subgroup analyses revealed that the odds of anxiety among subjects with AD was significantly more likely in females (aOR: 2.38, 95% CI: 1.23–4.64, p=0.012) and adults aged 30 to 39 years (aOR: 2.48, 95% CI: 1.46–4.19, p=0.001) than other participants. There was no significant association between AD and panic among these same participants after adjusting for potential confounders (aOR: 1.69, 95% CI: 0.85–3.38, p=0.130; Table 2). Our results indicate that there is a significant association between AD and anxiety, but not panic, among adults in the US. Apprehension and worry, characteristics of anxiety, might be triggered by the chronic nature of the condition, whereas the intense fear and emotion of panic might be less relevant. Our study is limited by lack of temporality, sample size, and subjective interpretation of questions. Further longitudinal studies might be helpful to better understand the causality between AD, anxiety, and panic. If the relationship between AD and anxiety is truly bidirectional, a focus on the wellbeing of patients might improve outcomes in clinical practice. References Patel KR, Immaneni S, Singam V, et al. Association between atopic dermatitis, depression, and suicidal ideation: a systematic review and meta-analysis. J Am Acad Dermatol. 2019;80(2):402–410. Long Q, Jin H, You X, et al. Eczema is a shared risk factor for anxiety and depression: a meta-analysis and systematic review. PLoS One. 2022;17(2):e0263334. Silverberg JI, Gelfand JM, Margolis DJ, et al. Symptoms and diagnosis of anxiety and depression in atopic dermatitis in US adults. Br J Dermatol. 2019;181(3):554–565. Hashizume H, Horibe T, Ohshima A, et al. Anxiety accelerates T-helper 2-tilted immune responses in patients with atopic dermatitis. Br J Dermatol. 2005;152(6):1161–1164. 

A Practical Approach to Centrifugal Cicatricial Alopecia

J Clin Aesthet Dermatol. 2023;16(6 Suppl 1):S22–S24 by Archana M. Sangha, MMS, PA-C  Ms. Sangha is a medical science liaison for Incyte in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also Immediate Past President of the Society of Dermatology Physician Assistants. FUNDING: No funding was provided for this article. DISCLOSURES: Ms. Sangha is an employee of Incyte in Wilmington, Delaware. Centrifugal cicatricial alopecia (CCCA) is the most common cause of scarring alopecia in African American women. As the name indicates, it is hair loss that begins at the vertex or midscalp and spreads centrifugally.1  Several studies have reported varying prevalence rates of CCCA in the United States (US). One study with 529 African American women reported a prevalence rate of 5.6 percent.2 Another study with 326 African American women reported a prevalence rate of approximately 28 percent.3 Both of these studies were conducted in 2011. There is need for more recent and larger scale studies to determine the true prevalence of CCCA.  When the condition was first described in 1968 and named “hot comb alopecia,” it was thought to be due to common haircare practices of African American women. Indeed, some haircare practices, such as traction styles, cause an inflammatory reaction of the scalp and lead to scarring.4 However, recent research has shown that, while hair care practices may contribute to the development of CCCA, they are not the cause. CCCA is thought to be multifactorial, with genetics also playing a role. For example, a study by Dlova et al5 looked at 14 Black South African families and found there to be an autosomal dominance inheritance pattern with partial penetrance. There was a positive correlation between traction styles and severity of CCCA. However, six patients with CCCA did not have a history of traction styling.5 This demonstrates that while haircare practices may contribute to the development and progression of CCCA, they should not be assumed to be the sole culprit.  As with many dermatological diseases, there is more to CCCA than meets the eye. Recently, a small study of five patients by Aguh et al6 found that those with CCCA have an upregulation in genes that are found in other fibroproliferative disorders (i.e., keloids). New research has also demonstrated a possible association between CCCA and several systemic diseases, such as Type 2 diabetes mellitus3 and uterine leiomyomas.7 More research is needed to understand the implications of these findings.  Patient History  A comprehensive patient history is important for diagnosis. See Box 14,8 for a list of questions that are helpful in aiding a diagnosis of CCCA.  Clinical Presentation   Early diagnosis and prompt treatment of CCCA leads to the best possible treatment outcome. Early in the disease, the crown of the scalp has subtle hair thinning. As the disease progresses, central scarring begins to occur with an increase in hair thinning. In late stages of CCCA, there is widespread hair loss with scarring. In addition to hair thinning and loss, patients may also experience scalp symptoms, such as burning, pruritis, erythema, tenderness, flaking/scaling, and/or pustules.9 Differential diagnosis   Early in its presentation, CCCA can often be mistaken for other alopecic disorders, the most common of which are traction alopecia, androgenetic alopecia, discoid lupus erythematosus, and lichen planopilaris (Table 1).10–15 Diagnosis   A 4mm punch biopsy from an active area of inflammation is often performed to confirm the diagnosis. If in doubt, the border of an alopecic patch is a good place to biopsy. The sample needs to include subcutaneous fat, as this is where the anagen follicles are found. Common dermoscopic findings include perifollicular gray-white halo, loss of follicular ostia, and one or two hairs emerging together.8  Treatment The goals of treatment are to halt disease progression and establish hair regrowth. The first step in treatment is to minimize inflammation. Recall that chronic and persistent inflammation leads to hair follicle destruction and subsequent scarring. Treatment during this inflammatory stage is multipronged and often involves a combination of high-potency topical corticosteroids daily or every other day, intralesional triamcinolone (TAC) 5 to 10mg/mL every 4 to 6 weeks for 3 to 6 months, doxycycline 100mg twice daily for three months, and an antiseborrheic shampoo every 1 to 2 weeks.16 The next stage in treatment is to encourage hair regrowth. Topical minoxidil daily (2% or 5%) is incorporated into the regimen to support hair growth. A maintenance regimen for patients often includes a midpotency topical corticosteroid three nights per week, daily topical minoxidil, an antiseborrheic shampoo weekly, with intralesional TAC as needed.16  In addition to medical treatments, recently, literature has been published on the positive impact of cosmetic procedures, such as platelet-rich-plasma (PRP) in the treatment of CCCA.17 More research needs to be conducted before PRP can be widely recommended.  Pearls See patients early and often. It is prudent during the first six months of diagnosis to see patients monthly for TAC injections and follow-up. After that, you can decrease follow-ups to every 2 to 3 months. Once patients are seeing significant regrowth and are comfortable with the treatment maintenance regimen, you can decrease visit frequency as appropriate.  When examining the patient, actually touch their scalp. This might seem obvious, but you would be surprised at how many patients cried in my exam room because I not only looked at their scalp, but touched it. This helps you become a more astute diagnostician and at the same time builds rapport with the patient.   Seek cultural competency training. There is widespread belief among patients that if a provider does not share the same racial or ethnic background as them, they are ill-equipped to treat them. Unfortunately, this belief often becomes a self-fulling prophecy for the patient when they see a provider who does not know how to care for their hair. Take the time to learn about cultural practices across races and ethnicities.

Anthralin’s Applicability in the Treatment of Pediatric Alopecia Areata

J Clin Aesthet Dermatol. 2023;16(3 Suppl 1):S29–S33 by Rohan R. Shah, BA; Zaeem Nazar, MD; Alyssa Swearingen, BS; Nadia Waqas, MD; Shawana Sharif, MD; and Babar Rao, MD Mr. Shah and Ms. Swearingen are with the Department of Dermatology at Rutgers New Jersey Medical School in Newark, New Jersey. Drs. Nazar, Waqas, and Sharif are with the Department of Dermatology at Benazir Bhutto Hospital in Rawalpindi, Pakistan. Dr. Rao is with  the Department of Dermatology at Weil Cornell School of Medicine in New York, New York, and Rutgers Robert Wood Johnson Medical School of Medicine in Piscataway, New Jersey.  FUNDING: No funding was received for this study or article. DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article. ABSTRACT: Background. Alopecia areata is an autoimmune-induced hair loss disorder affecting nearly two percent of the global population and is the third most common cause of dermatology visits among children. The prevalence and incidence of pediatric alopecia areata have increased significantly in certain regions of the world, including south Asia. Pediatric alopecia areata not only can affect patients psychosocially and emotionally, but also lacks proper therapeutic options as most treatments are beneficial only to adults. Topical anthralin is a commonly used ingredient in psoriasis treatment with potential application for pediatric alopecia areata.  Objective. We sought to assess the effectiveness of topical anthralin 1% for the treatment of alopecia areata in a pediatric population. Methods. Our quasi-experimental study evaluated 190 patients ages 3 to14 years with alopecia areata. Each patient received daily application of topical anthralin 1% ointment to the area of scalp with hair loss and was observed at one, four, eight, and 12 weeks of treatment. Percentage of regrowth on the scalp was measured. Results. Sixty-seven (35.3%) of the patients demonstrated complete response with anthralin therapy, 80 (42.1%) had partial response, and 43 (22.6%) had no response. There was no significant association between treatment response and age group, but treatment response was significantly associated with hair loss patch size. Conclusion. We suggest that anthralin may be beneficial for pediatric patients with alopecia areata, including younger patients in which steroids are not indicated or as a second-line option in patients with minimal response to glucocorticoids. We recommend the routine use of anthralin for pediatric alopecia areata management to improve patient satisfaction and disease outcome.  Key words: Alopecia areata, pediatric, anthralin, topical Alopecia areata (AA) is an autoimmune type of nonscarring hair loss that affects up to two percent of the global population.1 It  is characterized by relapsing and remitting patches of hair loss that may progress to more severe types, including alopecia universalis, alopecia ophiasis, or alopecia totalis.1 While AA is commonly considered an adult condition, approximately 40 percent of patients with AA have their first episode of hair loss by 20 years of age and one in five cases of AA occur during infancy.2 As such, AA is the third most common cause of dermatology visits among children.2 The annual prevalence of pediatric AA in the United States has increased steadily from 2009 to 2019 (0.057% to 0.11%), nearly doubling in that timespan.3 Additionally, US rates during this timespan were highest among Hispanic and Asian children, followed by Black and White children.3 Similarly, pediatric AA has increased significantly in prevalence and incidence in South Asia—an epidemiological study from Eastern India and Kuwait recorded a prevalence rate of up to 20.4 percent in certain populations of pediatric patients.4 This was higher when compared to previous studies from China, Singapore, and Saudi Arabia.5–7 Although AA is a physioloigically harmless condition without any systemic findings, it can affect the patient emotionally and psychosocially.2 Furthermore, AA occurring before puberty has been associated with a poorer prognosis than AA in adults.2 Other negative prognostic factors include a positive family history, seen in 20 percent of pediatric AA cases, atopy, and nail involvement.1 Because the pediatric population is more susceptible to the psychosocial consequences of AA, adequate treatment is critical to prevent further morbidity associated with this condition.1 While various therapies, including topical and systemic modalities, are available for AA treatment, they are focused on the adult population. Thus, therapeutic options for children and adolescents are limited. One reason for this is the lack of studies on pediatric AA. The second reason stems from incongruent guidelines among physicians regarding the definition and management of pediatric AA. For instance, according to the British Association of Dermatologists, pediatric patients with AA should be treated with a similar regimen as adults.8 However, the Italian Association of Dermatologists suggest children below the age of 10 years receive a different therapeutic regimen from their adult counterparts.9 Finally, many currently available treatments have potential adverse side effects, which are less manageable and less desirable in children.10  Anthralin, also known as dithranol, is a commonly used active ingredient in psoriasis treatments. The free radicals generated by anthralin induce an anti-inflammatory response localized to the site of application in contrast to systemically active glucocorticoids10 This lack of systemic toxicity makes anthralin a promising candidate for pediatric AA.10 In this single-institution study, we assessed the effectiveness of topical anthralin 1% therapy on the scalp area in pediatric patients with AA.  Methods Our quasi-experimental study was performed within the inpatient dermatology department of a Pakistani hospital. A total of 190 male and female pediatric patients were included in the study, based on the World Health Organization (WHO) sample size calculator11 using a consecutive sampling method. Patients 3 to 14 years of age with a diagnosis of AA of the scalp, regardless of previous treatment, were included in the study. Patients with a prior history of skin disease that can cause hair loss, other chronic medical conditions (e.g., diabetes mellitus, nephritic syndrome, connective tissue disease), history of skin cancer, or known allergy to anthralin compounds were excluded from the study.   The study was approved by the hospital’s ethics committee, and the guardians of each patient provided informed consent. Patients and their parents were asked about any underlying medical conditions or drug allergies. All

Lymphatic Vessel Morphometry: Is It a Predictor for Aggressive Basal Cell Carcinoma?

J Clin Aesthet Dermatol. 2023;16(3 Suppl 1):S41–S46. by Nourhan Anis, MD; Nagwa Diab, MD; Magda Assaf, MD; Ahmed Soliman, MD; and Eman Salah, MD  Drs. Anis, Diabi, and Salah are with the Dermatology Department and Dr. Assaf is with the Pathology Department, Faculty of Medicine, at Zagazig University in Zagazig, Egypt. Dr. Soliman is with the Pathology Department, Medical Division, at the National Research Center in Cairo, Egypt. FUNDING: No funding was received for this study or article. DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article. ABSTRACT: Background. Basal cell carcinoma (BCC) is a locally aggressive skin tumor in which metastatic spread occurs infrequently, with a predominance of lymphatic involvement. Objective. We sought to evaluate podoplanin-stained lymphatic vessels in different histological growth patterns of basal cell carcinoma, a well as the proliferative activity of tumor tissue, to determine if podoplanin provides any additional prognostic information. Methods. The number of lymphatic vessels and total lymphatic vessel area was morphometrically analyzed in podoplanin-stained sections using anti-D2-40. The immunohistochemical study of epidermal Ki-67 in BCC and control skin specimens was also performed. Results. The number of lymphatic vessels was higher in BCC cases compared to normal skin (P=0.03). In infiltrating growth pattern, the number of lymphatic vessels, total lymphatic vessel area, and Ki-67 immunoreactivity were higher than those in nodular lesions (P=0.03, P=0.001, P=0.001, respectively). Ki-67 immunoreactivity was correlated with the number of lymph vessels (r=0.6) (P=0.004) and total lymphatic vessel area (r= 0.6) (P=0.002). Conclusion. Podoplanin expression in lymphatic vessels may be implicated in BCC carcinogenesis and is associated with cancer aggressiveness. Podoplanin expression can be further utilized as a marker reflecting tumoral local behavior.  Keywords: Basal cell carcinoma, growth pattern, lymphangiogenesis, morphometry, podoplanin Lymphatic vessels (LVs) have been largely investigated in health and disease. LVs transport interstitial fluid from tissue into the blood circulatory system.1 They also serve as channels for trafficking immune cells, cytokines, and foreign antigens from the periphery to the regional lymph nodes.2  Lymphangiogenesis is a term to describe the formation of new LVs from an existing lymphatic network in response to regional stimuli, a process that primarily occurs during the developmental phase of human growth.3,4 LV remodeling in which existing LVs become enlarged can also occur.4 Lymphangiognesis typically does not occur in healthy adults, an exception being during the female reproductive cycle in the breasts and ovaries.4 However, englargement of existing LVs and creation of new LVs in adults can be triggered by acute and chronic inflammatory conditions and diseases, such as the wound healing process and cancers.4  Lymphangiogenesis in primary tumors facilitates tumor dissemination to regional lymph nodes. It is well-known that enlarged lymphatic vessel density (LVD) correlates with a higher incidence of metastasis and poorer survival in multiple cancers. In tumors, lymphangiogenesis may occur both within the primary tumor mass (intratumoral LVs) and/or in the tumor periphery (peritumoral LVs).4 Basal cell carcinoma (BCC), the most prevalent skin cancer, is associated with the induction of the proliferative activity of basal cells.5 While BCC can be aggressive locally, metastatic spread rarely occurs, with a predominance of lymphatic involvement.6,7 Metastatic BCC occurs more frequently in male patients, and characterizations include largely neglected lesions, predominance in the head and neck regions, resistance to multiple local treatments, and being of basosquamous or morphoeic subtype.7 The study of lymphangiogensesis and tumor proliferation is considered an essential tool in predicting lesional growth.8 Podoplanin is a LV-specific marker. It is a 38-kDa mucin-type transmembrane protein that is expressed exclusively on lymphatic endothelial cells (LECs), but not in blood endothelial blood cells.9  We assessed podoplanin-stained LVs to determine the extent of lymphangiogenesis in different histological growth patterns of BCC. We sought to correlate the extent of lymphangiogenesis with the proliferative activity of tumor tissue to determine whether podoplanin levels have prognostic value in BCC management. Methods Patients. This study was approved by the ethics committe of the authors’ institution, and all participants gave informed consent before enrollment.  Patients were recruited from the outpatient clinic of the dermatology department of an Egyptian hospital. Adult male and female patients under the age of 60 years (to avoid the age-dependent variability of skin microcirculation10) with a clinically and pathologically confirmed diagnosis of BCC were included in the study. Patients under 18 years of age or over 59 years of age, who were pregnant or lactating, who had previously received treatment for BCC, and/or who had other skin or systemic disorders were excluded.    Histopathological evaluation. A skin biopsy using a 5mm disposable punch was taken from the edge of the lesions. Biopsy specimens from both BCC and control groups were exposed to fixation using a 10% buffered formalin solution. The specimens were then stored in paraffin-embedded blocks. Serial sections of 4μm thickness were taken from each block and stained with routine hematoxylin and eosin (H&E) to confirm the diagnosis. BCC samples were histologically classified according to growth pattern—a nodular growth pattern (i.e., well-circumscribed, round, dermal islands) was categorized as low risk and an infiltrating pattern (i.e., thin infiltrative strands in the dermis, particularly at the deeper advancing edge of the tumor) was categorized as high risk.11 Immunohistochemical staining. Cutaneous podoplanin detection was achieved via a primary antipodoplanin antibody (monoclonal mouse anti-human D2-40 IgG1, clone D2-40, code: IR072, ready-to-use; Dako Denmark, Glostrup, Denmark). A primary antibody against Ki-67 (monoclonal mouse anti-human Ki-67 IgG1, clone MIB-1, code: IR626, ready-to-use; Dako Denmark) was used to evaluate epidermal hyperproliferation. The processing was handled according to manufacturer instructions using a labeled streptavidin-biotin visualization system (BenchMark Ultra Automated IHC/ISH staining instrument; Roche Tissue Diagnostics, Oro Valley, Arizona, USA). Immunostaining interpretation. A slide was considered positive if it showed a brown cytoplasmic and/or membranous precipitate for D2-40.  All D2-40-stained sections were morphometrically analyzed using Leica Qwin plus Image Analyzer Computer System (Leica Microsystems Inc. Deerfield Park, Illinois, USA). All solitary-stained endothelial cells and endothelial cell groups separate from another microvasculature were considered a vessel.12 Three lymphangiogenesis hotspots were identified at x100 magnification. Three intratumoral and three peritumoral hotspots were identified for

Dermatological Conditions in Skin of Color— Physiological Nuances in Skin of Color and Their Clinical Implications

 J Clin Aesthet Dermatol. 2023;16(2 Suppl 1):S12–S13 by Archana M. Sangha, MMS, PA-C  Ms. Sangha is a medical science liaison for Incyte in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also Immediate Past President of the Society of Dermatology Physician Assistants. FUNDING: No funding was provided for this article. DISCLOSURES: Ms. Sangha is an employee of Incyte in Wilmington, Delaware.  Numerous studies have suggested that there are subtle physiological variances in the skin depending on a patient’s ethnic background. While larger studies need to be performed, there are certain trends of differences observed among the varying skin types. This article will look at five nuances seen in skin of color (SOC).  Vitamin D levels  SOC patients are at higher risk of vitamin D deficiency. Vitamin D plays an important role in calcium homeostasis and bone metabolism.1 In the skin, it regulates numerous processes ranging from cellular proliferation and differentiation to barrier maintenance and immune functions. Vitamin D deficiency has been associated with increased risk of psoriasis and atopic dermatitis.2 The skin is the site of vitamin D synthesis. When exposed to ultraviolet radiation, provitamin D3 is pholysed to previtamin D3.3 This photolysation happens at a lower rate in SOC patients due to their increased levels of melanin, compared to lighter skin types, thus placing this population at increased risk of vitamin D deficiency.1  Ceramide Levels  Ceramides are the major lipid constituent found within the lamellar sheets in the stratum corneum. Ceramides play an important role in the barrier function of the skin.4 A study by Sugino et al5 found that Asian skin has the highest ceramide levels, followed by Caucasian skin and then Black skin. Ceramide levels are inversely correlated with transepidermal water loss (TEWL), and skin disorders with a compromised barrier function, such as atopic dermatitis and psoriasis, have lower total ceramide content.4 Skin reactivity  Erythema has been commonly used as a marker for skin sensitivity. In SOC populations, erythema is more difficult to detect. To be more objective, studies now employ the use of Doppler velocimetry. This device noninvasively measures the number of red blood cells times their velocity, thus conveying information regarding blood flow changes.6 A vasodilator, such as methyl nicotinate, is applied to the skin and then blood flow is measured and compared to baseline.7 Skin that vasodilates the fastest is found to be the most reactive. Several studies have found Asian skin to be the most reactive, followed by Caucasian skin and then Black skin.8,9 TEWL  TEWL is a measure of the water vapor evaporating from the skin surface. It is an important indicator of skin barrier function. Several studies have been done comparing TEWL in different ethnic groups. One study by Muizzuddin et al10 looked at TEWL on the face and found that African Americans had lower TEWL values compared too East Asians. In a study by Wilson et al,11 investigators compared TEWL at different body locations in African American women and White women. TEWL was similar among both groups when measured on the forearm; however, African American women had lower TEWL in cheeks and legs.11 Several other studies have been performed comparing TEWL in Black and White skin and the results have been contradictory; thus, no definitive conclusions can be made at this time. More robust and diverse research is needed. Sebum content   In a study by Rawlings,12 Black patients were found to have 60 to 70 percent more lipid content in their hair than Caucasian patients. Another study looking at pores and sebum in multi-ethnic female populations found that despite ethnicity, the number of pores increased with age.13 African American patients had the highest sebum production, followed by East Asians, Caucasians, and then Hispanics. These findings may influence your choices of vehicle bases, choosing more emollient based vehicles for those with less sebum production and vice versa. In Closing Being aware of these physiological variances in SOC can help inform some of your treatment recommendations. For example, if performing a chemical peel on a patient, it would be prudent to not only take into account their medical history but also their ethnicity. Based on studies by Gean et al8 and Kompore et al,9 you can anticipate that Asian skin will be more reactive than Black skin. There is a need for larger and more robust multi-ethnic studies to more comprehensively understand the physiological variances in SOC and how these variances may impact patient care. References Sizar O, Khare S, Goyal A, Givler A. Vitamin D deficiency. 2022 Jul 27. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30335299. Umar M, Sastry KS, Al Ali F, et al. Vitamin D and the pathophysiology of inflammatory skin diseases. Skin Pharmacol Physiol. 2018;31(2):74-86. doi: 10.1159/000485132. Epub 2018 Jan 6.  Holick MF, Smith E, Pincus S. Skin as the site of vitamin D synthesis and target tissue for 1,25-dihydroxyvitamin D3: use of calcitriol (1,25-dihydroxyvitamin D3) for treatment of psoriasis. Arch Dermatol. 1987 Dec;123(12):1677-1683a. Coderch L, López O, de la Maza A, Parra JL. Ceramides and skin function. Am J Clin Dermatol. 2003;4(2):107-29. doi: 10.2165/00128071-200304020-00004.  Sugino K, Imokawa G, Maibach HI. Ethnic difference of stratum corneum lipid in relation to stratum corneum function. J Invest Dermatol. 1993;100(4):587. Ewald U, Huch A, Huch R, Rooth G. Skin reactive hyperemia recorded by a combined TcPO2 and laser Doppler sensor. Adv Exp Med Biol. 1987;220:231-4. doi: 10.1007/978-1-4613-1927-6_42.  Berardesca E, Maibach HI. Racial differences in sodium lauryl sulphate induced cutaneous irritation: black and white. Contact Dermatitis. 1988;18(2):65–70. Gean CJ, Tur E, Maibach HI, Guy RH. Cutaneous responses to topical methyl nicotinate in black, oriental, and caucasian subjects. Arch Dermatol Res. 1989;281(2):95–98. Kompaore F, Marty JP, Dupont C. In-vivo evaluation of the stratum corneum barrier function in Blacks, Caucasians, and Asians with two noninvasive methods. Skin Pharmacol. 1993;6(3):200–207. Muizzuddin N, et al. Structural and functional differences in

Incorporating JAK Inhibitors into Clinical Practice for the Treatment of Atopic Dermatitis—Safety Considerations

J Clin Aesthet Dermatol 2023;16(2 Suppl 1):14 An interview with Nicole Keeter Ms. Keeter is a certified physician assistant in dermatology who practices in Fort Mill, South Carolina. It’s an exciting time in the atopic dermatitis field. We have new topical and systemic options for treatment—Janus kinase inhibitors or JAK inhibitors. Topical and oral JAK inhibitor formulations have been FDA–approved, and we are beginning to incorporate these therapeutic options into clinical practice for the treatment of atopic dermatitis, as well as other inflammatory conditions, such as psoriasis and alopecia areata, in patients 12 years of age and older. Here, I review safety considerations and offer suggestions on patient counseling when prescribing JAK inhibitors for the treatment of atopic dermatitis.  For patients who have atopic dermatitis on a body surface area greater than 20 percent or have moderate-to-severe atopic dermatitis, RINVOQ® (upadacitinib, Abbvie,  North Chicago, Illinois) and CIBINQO™ (abrocitinib, Pfizer, Inc., Mission, Kansas), which were FDA-approved for atopic dermatitis in 2022,  are oral JAK inhibitors that have both demonstrated effectiveness in improving pruritus, similar to topical corticosteroids, without the concern of atrophy or stria. RINVOQ is approved for use in patients 12 years of age or older, while CIBINQO is approved for patients 18 years of age or older. Both therapies are efficacious and provide a rapid decrease in symptoms, particularly pruritus, which is one of the most significant symptoms for our patients with atopic dermatitis.  Opzelura® (ruxolitinib, InCyte, Wilmington, Deleware) is a topical JAK inhibitor approved by the FDA in 2021 for the treatment of mild-to-moderate atopic dermatitis in patients who are 12 years of age and older whose disease is not adequately controlled with topical prescription therapies, or when those therapies are not advisable. Opzelura is safe for use on a body surface area of 20 percent or less, and on special sites, including eyelids and skin folds. Historically, we’ve treated these special sites with topical immunomodulators or cautiously with corticosteroids. Opzelura provides rapid improvement similar to that of steroids, with excellent tolerability and safety. No screening is required for Opzelura, and I look forward to Opzelura’s label extension in the future to include our younger patient population. Oral JAK inhibitors come with a black box warning due to association with thrombotic events, myocardial infarction, stroke, immunosuppression, skin cancer, and infections. Topical JAK inhibitors also carry a black box warning. These black box warnings are based on data extrapolated from studies evaluating tofacitinib, a systemic JAK inhibitor used to treat rheumatoid arthritis. It’s important to note that the patient population in the tofacitinib studies were considered to be at higher risk for adverse events due to being older than 50 years of age, having at least one cardiovascular risk factor, and having inflammatory arthritis. However, because of this black box warning and, with it, the potential for significant adverse events, some clinicians may not feel comfortable prescribing oral JAK inhibitors for a disease process historically treated with topical agents. However, keep in mind that as dermatology clinicians, we frequently counsel and manage patients on other systemic agents that have significant safety concerns, such as isotretinoin, methotrexate, cyclosporine, and prednisone. We have experience in evaluating and screening patients for candidacy for these medications, including taking a thorough history of patient risk factors and monitoring patients with serology. The same approach is used when prescribing JAK inhibitors. After familiarizing yourself with the clinical data on JAK inhibitors, formulate your patient education conversation. This discussion with the patient should include the black box warning for the potential of the thrombotic events, malignancy, and infection that was observed in tofacitinib studies. However, increased risk of major adverse cardiovascular and thrombotic events have not been observed in RINVOQ or CIBINQO thus far, and the class effect association found in the oral therapies has not been observed in the topical formulations—this should also be discussed with your patients. All the same, these risks should be thoroughly reviewed with your patients, who should be involved in the treatment decision-making process, similar to your clinician-patient discussions regarding other systemic medications routinely prescribed in dermatology.  When prescribing oral or topical JAK inhibitors, rely on your experience counseling patients on similar safety signals we’ve seen with TNF inhibitors. As derm clinicians, we have experience with this; we’ve counseled our patients on black box warnings before with the use of other topical immunomodulators. Let your experience guide you through the process of prescribing JAK inhibitors to your patients with atopic dermatitis.   

Dermatology NP & PA Workforce Survey—Practice Characteristics and Compensation

J Clin Aesthet Dermatol. 2023;16(2 Suppl 1):S16–24. by Margaret A. Bobonich, DNP, FNP-C, DCNP, FAANP; Veronica Richardson, MSN, ANP-C, DCNP; and Sotero Alvarado, MA Dr. Bobonich is Assistant Professor at Case Western Reserve University in Cleveland, Ohio, and Founder of Center for Dermatology Nursing Practice in Silver Lake, Ohio. Ms. Richardson is with Penn Dermatology, Perelman Center for Advanced Medicine, at the University of Pennsylvania in Philadelphia, Pennsylvania. Mr. Alvarado is Professor of Mathematics at Arizona Western College in Yuma, Arizona. FUNDING: No funding was provided for this article. DISCLOSURES: Dr. Bobonich has served on the advisory boards and/or speakers bureaus of Boehringer Ingelheim, Bristol Myers Squibb, Dermavant, Eli Lilly, and AbbVie. Ms. Richardson has served on the advisory boards of Boehringer Ingelheim, Bristol Myers Squibb, Dermavant, Eli Lilly, and Leo Pharmaceuticals. Mr. Alvarado has no conflicts of interest relevant to the content of this article.  Introduction The dermatology landscape has been rapidly changing to meet the rising demand for dermatology care in the United States (US). According to the Dermatology Workforce Supply Model: 2015-2030, keeping pace with the demand for dermatologic care will require the adoption of a team-based approach and greater reliance on nurse practitioners (NPs) and physician assistants (PAs).1 But there is a dearth of detailed information about the workforce characteristics of NPs and PAs specializing in dermatology. The aim of this survey was to identify workforce characteristics and compensation for dermatology NP and PA clinicians. Survey Design Dermatology NPs and PAs were invited to participate in a brief 10-minute survey emailed to 7,132 subscribers of the Journal of Clinical and Aesthetic Dermatology’s supplement journal series, NP+PA Perspectives in Dermatology. The survey was conducted between December 28, 2022, and February 3, 2023. Participants who completed the survey could be entered into a drawing to win one of two gift cards. The survey consisted of 22 questions, including demographics, gender, educational degree, clinical experience, hours worked, type of dermatology services provided, practice setting, and staffing. Respondents were also asked to provide information about their productivity, billing, compensation, and benefits. There was a range of possible answers to questions involving quantitative data, with the exception of the continuing education budgeted amount variable. Several graphs illustrate how different observed variables may relate to each other, but the etiology of these variations were not assessed. The reported median salary range includes all respondents and does not differentiate between part-time and full-time. Since only salary categories were reported, repeated values for each class midpoint were used to find the confidence interval (CI). Survey results Demographics. There were 180 respondents who completed the survey. Of the respondents, 55 percent were PAs and 45 percent were NPs; 38 states across the US were represented by respondents. Further analysis shows the percentage of gender by profession (Figures 1A–1B). Clinical experience is an important attribute for all healthcare professionals and can impact hiring and terms of employment. The survey showed 43 percent of dermatology NPs and PAs had 11 or more years of experience, 25 percent had 6 to 10 years of experience, 18 percent had 4 to 6 years of experience, and 14 percent had 1 to 3 years of experience. Although educational preparation, licensure, and regulations are unique for each profession, 86 percent of the respondents held a master’s degree. There were 14 percent of NPs and seven percent of PAs who reported having doctoral degrees (Figures 2A–2B).  Practice setting and staffing. As dermatology care continues to transform, practice setting and staffing can vary considerably. The majority of respondents (44%) reported working in large practices with a group of 3 to 6 dermatologists (Table 1). This is consistent with trends that show dermatology group practices were likely to hire advanced practice clinicians.2 Similarly, dermatology practices often employ more than one NP or PA and include multiple practice locations. Forty-six percent of the survey respondents reported working with 2 to 4 other NP and/or PA colleagues, 23 percent reported working with 5 to 9 NP and/or PA colleagues, and 14 percent reported working with more than 10 other NP and/or PA colleagues. Only 17 percent of the respondents reported being the only advanced practice provider in their practice.  Numerous changes in the dermatology workforce have impacted the scheduled hours of patient care among providers. Given the variable definition of “part-time” and “full-time” employment, survey participants were asked to select from different categories of scheduled patient care hours in an average week. Most dermatology NPs and PAs (44%) reported they worked an average of at least 33 hours a week, which could be considered full-time practice. Thirty-eight percent of respondents reported working an average of 25 to 32 hours a week, and 17 percent reported working an average of 10 to 24 patient care hours a week (Figure 3).  Clinical staff support is variable in dermatology practices and can have a direct impact on quality of care, efficiency, and productivity. In this survey, respondents were asked to identify the number of clinical staff they were provided for support, including medical assistants or scribes. Of the NPs and PAs who reported seeing 100 to 200 patients a week, 31 percent reported they had one clinical staff, 51 percent had two staff, and 15 percent had three staff for support. Table 2 presents further details about staffing trends based on the weekly number of patients seen by the providers. Consideration was also given to the unique administrative burden of preauthorizations that dermatology NPs and PAs who prescribe therapies such as biologics often encounter. While 69 percent of respondents had a clinical staff member to assist with these responsibilities, 23 percent had a biologic coordinator or pharmacist to assist in the process. Only eight percent of the respondents reported they were required to complete preauthorizations, including insurance denials, without any staff support.   Type of dermatology services. Dermatology NPs and PAs are engaged in a wide spectrum of clinical dermatology services and administrative responsibilities. Moreover, the type and frequency of these services may impact generated revenue, reimbursement rates,

Editorial Message: Matthew T. Reynolds, MS, MPAS, PA-C

J Clin Aesthetic Dermatol 2022;15(12 Suppl 1):S8 Dear Colleagues: This year, we have seen many advances in the field of dermatology. In the realm of therapeutics, we have seen fundamental game-changing therapies introduced to the market for our patients. Specifically, we have seen three new oral JAK inhibitors gain approval earlier this year; two for atopic dermatitis and one for alopecia areata. These therapies are proving to be exactly what we expected—rapid itch reduction scores, incredible skin clearance rates, and more incredibly, life-changing results. Additionally, we have seen a new oral TYK-2 therapy come to market for patients with psoriasis, further enhancing our ability to better manage these patients. These new treatment options not only allow us in the NP/PA community to treat our patients more effectively, but more importantly, provide a more personalized approach in providing more options to our patients. I believe that when patients are satisfied with their treatment choices, they are more adherent , thus leading to greater success in treatment.  For our specialty as a whole, we have seen our community of NP/PAs grow tremendously. As we have returned to in-person events, such as conferences, local or state meetings, and dinner programs, it has been great to see so many new faces and a continued interest in dermatology as a whole. Our NP/PA community has not only grown in numbers but has grown in its share of responsibility in patient management. There is continued interest among our community in taking on more complex medical and surgical dermatology cases. This drive for continued challenges and professional growth has inspired me greatly. I am personally very humbled to be among so many great NP/PAs across all fields of medicine.   As we transition from this year to the next, I want to express my continued support for dermatology education in our community. It is paramount that we all commit to lifelong learning and continued education, increased credentials, and the continued pursuit to be specialists in our field. In this regard, do not forget to utilize the tools easily at your disposal. Your pharmaceutical field representatives and medical science liaisons are great resources. Use them! Make connections with members of industry at conferences, schedule meetings with them, and learn what’s in the therapeutic pipeline. Use these incredibly important relationships to help your own knowledge but also your individual practices. I cannot begin to count the number of times I’ve met with a member of industry and learned something game-changing or new that I was able to bring by to my practice in Arkansas and use to help our organization. Don’t pass on these opportunities when given the chance. Lastly, as a PA and clinical trials investigator, I understand the importance of our community being involved in clinical trials. For me, my introduction to research began with a real world, Phase IV study. This initial study sparked my interest to take on higher level clinical trials, to cofound a research center, to find talented staff to help lay the foundation, and the rest is history. Not only can being involved in clinical trials be very rewarding, you have access to countless therapeutics first before anyone else and can follow these therapeutics all the way to FDA approval, but you can also become a direct partner with industry beyond just the clinical side. Remember—your role as an NP/PA goes far beyond just seeing patients; use your knowledge, degrees, and credentials to continue to grow your career professionally. I’m here to tell you that you can do this by being involved in clinical trials.  I look forward to seeing you all in 2023! Warm regards, Guest Editor, NP+PA Perspectives in Dermatology Matthew T. Reynolds, MS, MPAS, PA-C is a physician assistant with Arkansas Dermatology in Little Rock, Arkansas. He is also the cofounder of the Arkansas Research Trials Center in North Little Rock, Arkansas

Spotlight Interview: Matthew T. Reynolds, MS, MPAS, PA-C

J Clin Aesthetic Dermatol 2022;15(12 Suppl 1):S13–S15 Matthew T. Reynolds, MS, MPAS, PA-C, a native of Arkansas, received his physician assistant training at the University of Arkansas for Medical Sciences (UAMS) in Little Rock. In 2015, after completing his Master of Science degree in Physician Assistant Studies, he joined Arkansas Dermatology, where he completed a one-year physician assistant fellowship in dermatology and where he continues to practice dermatology to this day. Matt enjoys treating a wide variety of general and surgical dermatologic conditions—from psoriasis and acne to atopic dermatitis and skin cancer.  In addition to his clinical practice, Matt serves as a guest lecturer for the UAMS Physician Assistant Program, as well as a national speaker and educator for nurse practitioners and physician assistants. Over the last seven years, Matt has authored several published articles on a variety of dermatological topics, including atopic dermatitis, melanoma and nonmelanoma skin cancers, and psoriasis, and has coauthored book chapters on squamous cell skin cancer.  Matt is also the cofounder of the Arkansas Research Trials Center in North Little Rock, Arkansas, where he currently serves as a subinvestigator for many ongoing clinical studies.  What inspired you to pursue a career in dermatology?  Matt: I was initially inspired to pursue a career in dermatology when I came to the realization that nearly every systemic disease has some sort of skin manifestation, whether it is heart failure, diabetes, an autoimmune disorder, or other chronic condition. This impressed me most, and as I continue to expand my own knowledge, I often find I am humbled by the ever-expanding wealth of knowledge the dermatology field gains year after year on the many diseases we treat in the specialty. I now, more than ever, am most intrigued by the number of discoveries continually being made in immune pathway research. The number of biologic compounds that have been or are being developed that can target these pathways and disrupt the pathogenesis of these skin diseases has greatly expanded our treatment options for our patients. I continue to be inspired by not only how far we’ve come in recent years in our knowledge of skin diseases, but also by where we are heading in the future. What clinical areas in dermatology interest you the most? Matt: I am passionate about preventing and managing nonmelanoma and melanoma skin cancer. In our beautiful state of Arkansas, we have a high incidence of these types of cancers, and at Arkansas Dermatology, where I practice dermatology, we prioritize these patients so they can access high-quality care as quickly as possible for optimal outcomes.  I also enjoy treating inflammatory skin disorders, such as atopic dermatitis, plaque psoriasis, and urticaria. The ever-expanding landscape of therapies for these diseases is very promising, and I am thankful to have such a wide variety of tools available to effectively treat these patients. For example, when I initially began practicing dermatology, there were only two biologics available for the treatment of plaque psoriasis— alefacept and efalizumab; now, there are numerous therapeutic options available to patients. For atopic dermatitis, I’ve seen the launch of dupilumab, and now JAK inhibitors have made their debut, creating more therapeutic options for all patient types. In 2019, my colleagues and I founded a dedicated research facility for patients with inflammatory skin conditions; we are currently investigating several agents that will eventually be on the market.  Being involved in several clinical trials, you’ve got your finger on the pulse of new and emerging therapies in dermatology. What emerging therapies or areas of research are you most excited about?  Matt: One area of research/drug discovery that I’m very excited about is the use of oral IL-17 and-23 agents as therapeutic options for plaque psoriasis. I believe if we can get a handle on the potency and safety of these agents, we could potentially move completely away from the injectables. I’m also interested in the next generation of medication delivery systems; currently, there are several companies working on highly effective, continuous drug delivery systems that go beyond the patient having to self-inject or remember to take a daily pill. I’m very excited to see what happens over the next 10 years in this area of research. Targeted therapy, or precision medicine, has definitely become an important aspect of drug develpment for the treatment of skin cancer, psoriasis, and other chronic skin conditions. What types of targeted therapy do you utilize in skin cancer management? How do you integrate these treatments into clinical practice?   Matt: One of the greatest gifts to derm practitioners is the number targeted therapies that are availble for many skin diseases. Specifically, for nonmelanoma skin cancer, I believe the Hedgehog inhibitors have been the biggest game changer. The ability to give your patients another option for treatment besides surgery or radiation is very rewarding to me as a provider. We have patients with too many lesions to treat or who have lesion recurrence following surgery or radiation that do really well on a Hedgehog inhibitor. We manage these patients with a specialized pulse dosing regimen and L-Carnitine 1500mg daily for muscle cramps, and they typically do very well. In addition to Hedgehog inhibitors, we also heavily utilize PD-1  blockers in our practice to treat patients with advanced squamous cell carcinoma. When it comes to optimal outcomes, the more advanced the disease, the more you need to have advanced tools in your armamentarium. I can’t encourage the advanced practice provider (APP) community enough to become educated and proficient in prescribing these types of therapies. How do you keep your patients engaged in and adherent to their treatment plans?   Matt: Certainly, I try to give my patients a lot of extra attention. I will follow up with them every week or two when they are first starting an injectable for their psoriasis or eczema. I will often give away more samples than I’m probably supposed to (and without my clinic manager knowing) just so my patients can start treatment sooner. I firmly believe that if

Dermatological Conditions in Skin of Color— Debunking Vitiligo Myths

J Clin Aesthet Dermatol. 2022;15(9 Suppl 1):S10–11 by Archana M. Sangha, MMS, PA-C  Ms. Sangha is a medical science liaison for Incyte in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also Immediate Past President of the Society of Dermatology Physician Assistants. FUNDING: No funding was provided for this article. DISCLOSURES: Ms. Sangha is an employee of Incyte in Wilmington, Delaware.  Vitiligo has been a skin condition near and dear to my heart since I began practicing dermatology. The disease caught my attention because I saw the devastating and far-reaching repercussions it had on a patient’s self-esteem. I’ve seen, in my own clinical practice, how having vitiligo impacted the smallest to largest of life decisions. Patients shared with me how they chose their clothes painstakingly so they could conceal their patches of vitiligo. Other patients disclosed that vitiligo was the reason they didn’t take the promotion for fear of having to be “the face of their company” or chose not to have children for fear of passing along the disease. For so many patients, vitiligo seemed to be their rate-limiting step. It hindered their ability to reach their fullest potential because of how others perceived their disease and therefore them.  As a clinician, vitiligo has been a frustrating disease to treat. Until recently, we had no United States Food and Drug Administration (FDA)-approved drugs for repigmentation. But now, the future looks bright for patients with vitiligo as decades of research has led to a better understanding of its pathophysiology and more therapeutics are under development.  In this article, I debunk some of the widely held myths about vitiligo within the dermatology community.  Myth 1: Vitiligo prevalence is greater among skin of color (SOC) populations.  While the appearance of vitiligo in SOC populations is more apparent due to the sharp contrast against darker skin phototypes, vitiligo does not have a predilection for SOC populations.1  Myth 2: Vitiligo mainly impacts adults.  Nearly 50 percent of patients with vitiligo develop it before the age of 20.2 Myth 3: Depression and anxiety prevalence is the same in patients with vitiligo as the general population. Patients with vitiligo are disproportionately affected by anxiety and depression compared to those without vitiligo. In a study looking at 100 vitiligo patients and 100 healthy controls, depression and anxiety disorders affected patients with vitiligo disproportionately (62% vs 25%).3 A recent meta-analysis found the prevalence of anxiety to be 35.8 percent among patients with vitiligo. In a subgroup analysis, it was found there were slight differences in prevalence based on the patient’s continent of residence. The highest prevalence rates of anxiety were seen in Africa.4 Another study found that out of 308 patients with vitiligo, nearly 55 percent suffered from depression. Single women in their first few years of disease were found to have greater prevalence of depression.5 Myth 4: The psychosocial disease burden of vitiligo is only seen in SOC populations.  The psychosocial impact of vitiligo affects all patients, regardless of their skin phototype. A recent article by Ezzedine et al6 showed that while the psychosocial burden of disease is similar across all patients, there are a few differences in what most concerned patients based on their skin color. In particular, fair-skinned patients were more concerned about skin cancer development, whereas darker-skinned patients were more concerned about the appearance.6 Myth 5: The hair color in a depigmented patch doesn’t mean anything.  The presence of leukotrichia (white hairs) within a patch of vitiligo is often a poor prognostic sign for repigmentation. One study looked at UVB response rates among vitiligo patients who had leukotrichia within their vitiligo patches and those who did not. Those without leukotrichia had a much higher response rate.7 This can be attributed to the reservoir of melanocyte stem cells located within the hair bulge of the hair follicle. If leukotrichia is present, there is a decreased likelihood that repigmentation will occur.  Myth 6: All areas of the body repigment at the same rate.  Two criteria help determine the rapidity of repigmentation within a vitiligo patch: 1) exposure to ultraviolet (UV) radiation and 2) density of hair follicles. One study by Otberg et al8 looked at hair follicle density on varying body regions (Table 1). Taking into account both UV exposure and hair follicle density, we can expect the forehead to repigment much faster than the back, which has significantly less hair follicle density and UV exposure.  Myth 7: Culture has no impact on a patient’s vitiligo.  In India, where the prevalence of vitiligo is estimated to be 0.25 to 2.5 percent,9 the social implications of the disease are often lifelong. There, it is believed that having vitiligo is a curse from God or a punishment for past sins.10 In a culture where arranged marriages are common practice, patients reported having vitiligo as a significant barrier to finding a life partner.11 Another study looking at vitiligo in the Arab population found that 84 percent believed their disease was due to fate. Additionally, 28 percent of patients in the same study believed evil eye was a cause of their illness.12 In Nigeria, vitiligo is commonly confused with leprosy and thus leads to a high level of social stigmatization.13 When evaluating patients with vitiligo, it’s important to understand how the disease has far reaching impacts on the patient’s quality of life.  Other considerations Skin color is often a way that patients identify with their respective ethnic group/race. When areas of deeply pigmented skin become depigmented, patients can feel as though they are losing their identity. Understanding this may help clinicians  better empathize with their patients. I should also mention that not all patients want to treat their vitiligo; some have embraced it while others have given up out of frustration. Don’t make assumptions on whether a patient is interested in treatment—just ask them.  References Alikhan A, Felsten LM, Daly

Editorial Message from Guest Editor Susan Mayne, DNP, FNP-C, DCNP

Dear Colleagues: The pharmaceutical floodgates have recently burst, and many of us struggle to keep up with the safety and efficacy of new medications along with emerging safety risks of familiar medications. I’m not complaining—this is a great problem to have. For some of the most common chronic conditions, we’ve had limited treatment options that merely calm flares or have a side effect profile the length of a CVS receipt. So how does one stay current while balancing work and family demands?  There are a vast number of resources, a few of the most credible being journal articles and the United States (US) Food and Drug Administration (FDA) drug database. UpToDate is another great resource, provided you hand over half of your annual income every year. Larger health systems typically provide access to this database through the core library. Yet sifting through the vast amount of information these resources provide is both daunting and time consuming. Dermatology podcasts are always a part of my work commute. Most provide the latest information, and I always learn something new with each episode. As an added benefit, I no longer suffer through the misery of daily news or my futile attempts to decipher popular music lyrics. Trust me…you’re better off not knowing the words.      At home, I love to read specialty-specific news magazines. They’re an easy read full of firsthand information. To some extent, they’re the dermatology equivalent of Vogue or GQ: Drugs of the Year—the Best, the Brightest, the Most Swaggerific; Sexy Summer-bod Ready Makeovers with Energy-based Treatments; Trendy Off-Label Therapeutics the FDA approved for Every Other Specialty but Ours, etc., etc. Dermatology conferences provide a nice escape from the daily grind and are a great way to stay current. Most are jam packed with updates and interesting case studies that bring to life exhausted synapses. Many of the best conferences are held in destination cities. Bring the family and ease the guilt of being absentee spouses and parents—a win-win! Do not take your pharmaceutical field reps for granted. They come well-equipped with compliments, and wow us with beautifully designed charts and jaw-dropping graphics while we stuff our faces full of caloric gifts. More importantly, they put us in touch with Medical Science Liaisons (MSLs) who are easily accessible and provide a wealth of knowledge. Familiarizing yourself with new therapeutics is only half the battle. Now we must get them approved by the third-party payers and into the hands of our patients. The insurance companies and their Pharmacy Benefits Managers (PBMs) have gifted us the contemporary version of Dante’s Inferno by forcing us to endure all nine circles of hell to get most medications covered for our patients. Fortunately, there is a growing trend to incorporate specialty pharmacies into hospital systems. Advantages of doing so include increased revenue, faster initiation of medications, and improved consumer support and collaboration, and they shift the administrative burden of the prior authorization process from us to them.  I have a deep respect for pharmacists; they must balance their higher-than-average intelligence with the purposefully incomprehensible process of medication distribution. It’s difficult enough for those of us who have a deep knowledge of dermatology to explain concepts in layman’s terms to our patients. Now imagine it being a constant requirement for nearly every conversation. Shower  pharmacists with love…they’ve earned it.   And my final word of advice—Do not underestimate the knowledge and power of those responsible for prior authorizations. Unfortunately, this absurd amount of administrative work is now a normal part of our day. You can cut costs and calm tempers by simply asking what is easiest to get approved. Ridiculously enough, it may be as simple as prescribing a capsule instead of a tablet.  Warm regards, Susan Mayne Guest Editor, NP+PA Perspectives in Dermatology

Spotlight Interview: Susan Mayne, DNP, FNP-C, DCNP

J Clin Aesthetic Dermatol 2022;15(6 Suppl 1):S11–S12 Susan Mayne, DNP, FNP-C, DCNP, is a Family Nurse Practitioner who practices dermatology at University Hospitals Cleveland Medical Centers (UHCMC) in Cleveland, Ohio. She received her Master of Science in Nursing with a family focus from Ohio University and her Doctor of Nursing Practice from Kent State University. Dr. Mayne is one of very few in the nation to complete a two-year interdisciplinary post-master’s dermatology NP training program at UHCMC. She is a Clinical Instructor at Case Western School of Medicine and lectures nationally and locally. Her clinical focus is complex skin conditions in pediatric and adult patients.  What inspired you to pursue a career in dermatology?  Susan: I’m professionally fickle— dermatology is my third career. Thankfully, it’s the perfect fit since I don’t have the lifespan for another.    What clinical areas in dermatology interest you the most? Susan: I find artificial intelligence (AI) and advances in genetic technologies fascinating. On more of the day-to-day stuff, dermoscopy is it. When determining if it is necessary to biopsy a lesion, there are many variables to consider, and it can be tough to make sure lesions are not missed versus leaving the patient with unnecessary scars.  I’ve tried all of the most common diagnostic algorithms but have found the “gut” algorithm to be best. That is, with experience you gain a gut instinct for spotting lesions that are better suited for formalin than on the body. The variety of melanoma presentation is stunning. Most of us are familiar with colors and structures common to melanoma, but I’ve biopsied many melanomas that mimic inflamed or benign lesions. Even scarier are featureless melanomas  How do you keep patients engaged in and adherent to their treatment plans?  Susan: With our own deep understanding of dermatologic conditions, it’s easy to mistakenly assume our patients understand the basics of skin function. I take a few extra minutes to educate my patients about their disease, the chronicity of the many conditions we manage, how to control flares, and the medications we use to do so. Many studies show that over half of what we tell our patients does not make it from working memory to long-term memory; for this reason, I keep a binder of printed hand-outs for common conditions in each treatment room. We are seeing greater use of AI in medical research and practice. What do you see as its benefits and limitations? How does it impact the care you provide your patients? How can we coexist with it in clinical dermatology while still building and maintaining positive clinician-patient relationships?  Susan: I’ve been around long enough to have survived previous technological revolutions that brought as much innovation as they have obsolescence, and I have no doubt the trend will continue as such. I don’t worry about humanity becoming obsolete in the age of AI. As excited as I am about the power of this technology, I try my best to keep an open mind and balance that with a healthy dose of skepticism. The possibilities are endless, from individual- to population-based medicine. We can utilize AI not only to help with risk stratification, but also determine those patients who are likely to respond to outreach programs. AI can drive marketing efforts by predicting which patients will likely need future intervention.  We have also, for obvious reasons, been experiencing a huge surge in the use of telemedicine. Is there an art to teledermatology? How do you incorporate it into your daily practice?   Susan: Telemedicine has been around for quite some time but its use was catapulted into our daily reality at the onset of COVID-19. At the beginning of the pandemic, I would start each day with a double-dose of “Dramamine,” in expectation of the numerous technical glitches I was sure to encounter throughout the day—which at the time seemed on scale with the massive technical disasters only seen in sci-fi movies. But telemedicine technology has come a long way over the past two years and has become an important part of dermatology practice. Telederm provides us with a convenient and efficient way to triage new patients, perform follow-up visits, and touch base with patients who have fallen off the adherence wagon. It also improves access for those who would otherwise be required to wait 6 to 8 months for a specialty visit. As a provider, what gives you the greatest sense of fulfillment in what you do? Susan: A patient’s thankful hug and a clinic full of laughter and comradery.  How do you find balance between your personal life and your career? How do you avoid burnout? Susan: Burnout doesn’t have to be a bad thing—it gives me yet another reason to defer personal responsibility for my irritability, fatigue, and forgetfulness. But seriously, in my humble opinion, burnout is a common side effect of work, and it doesn’t discriminate based on profession. My recipe to combat burnout includes a good sense of humor and supportive colleagues…and the occasional post-clinic “Hungry Man” serving of red, pink, or white wine. This can save your soul from people and situations that raise cortisol levels to brain-pulverizing heights. You’re welcome. What advice would you give NPs and PAs just beginning their dermatology careers?  Susan: Go ahead and cry! We’ve all been there, and no one will judge. You will also personally understand hyperhidrosis and its quality-of-life impact for your first 2 to 3 years of practice. Whether you’re an NP or a PA, I implore you join associations like the Society of Dermatology Nurse Practitioners (SDNP) or the Society of Dermatology Physician Assistants (SDPA). Outside of collaborating with your physician colleagues, consider using programs such as VisualDX, a succinct diagnostic clinical support program, which I still use daily for its great patient hand-outs. There are also great educational apps like Top Derm and Figure 1 that are engaging and entertaining. Many of these resources also provide free educational webinars given by experts in the field.  

Dermatological Conditions in Skin of Color — A Look at Skin Cancer in Skin of Color

J Clin Aesthet Dermatol. 2022;15(6 Suppl 1):S17–S18 by Archana M. Sangha, MMS, PA-C Ms. Sangha is a medical science liaison for Incyte in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also Immediate Past President of the Society of Dermatology Physician Assistants. FUNDING: No funding was provided for this article. DISCLOSURES: Ms. Sangha is an employee of Incyte in Wilmington, Delaware. It’s no surprise that non-Hispanic White patients have a much higher risk of developing non-melanoma and melanoma skin cancers compared to skin of color (SOC) populations. Melanin has long been attributed to the lower incidence rates of skin cancer in SOC populations. Melanin functions as a broadband ultraviolet (UV) light absorbent and has antioxidant and radical scavenging properties.1 However, melanin does not decrease the risk of developing skin cancer to zero in SOC populations. Let’s take a closer look at skin cancer affecting SOC populations.  Incidence Skin cancer represents 1 to 2 percent of all cancers seen in Black people, 2 to 4 percent total in Asian people, and 4 to 5 percent total in Hispanic people.2  Squamous cell carcinoma (SCC). SCC is the most common type of skin cancer seen in Black and Asian-Indian populations and is the second most common skin cancer seen in Hispanic, Chinese, and Japanese populations. SCC accounts for 30 to 65 percent of all skin cancers seen in SOC populations, compared to 15 to 25 percent seen in White populations.3  Basal cell carcinoma (BCC). BCC is the most common skin cancer in White patients, accounting for 65 to 75 percent of total skin cancers in this population. It is the second most common skin cancer (following SCC) in Black patients and the most common skin cancer seen in Hispanic, Chinese, and Japanese populations. Development of BCC has been closely correlated to a history of UV light exposure. Thus, patients living closer to the equator have a higher risk of developing BCC.3 An estimated 90 percent of BCCs are found on the head/neck region in SOC populations.4 Melanoma. SOC populations have a 20-to 30- fold lower incidence of melanoma than non-Hispanic Whites. The lifetime prevalence of melanoma is 1 in 1,000 for Blacks, 1 in 167 for Hispanics, and 1 in 38 for Whites.5 Black (52%) and Hispanic (26%) patients are more likely to be diagnosed with advanced-stage melanoma than White (16%) patients. Black patients also have a lower five-year melanoma survival rate than White patients: 71 percent versus 93 percent, respectively.2 Clinical Nuances in SOC  SCC. SCC is often seen on the buttocks, hips, legs, knees, and feet in Black patients. Chronic scarring and areas of chronic inflammation are associated with SCC.3 BCC. BCC most commonly presents in its pigmented variant—a dark brown to black, pearly, translucent growth—in SOC patients. SOC populations have 50-percent higher incidence of pigmented BCC than White populations.3  Melanoma. In SOC populations, melanoma is more commonly found on non-sun-exposed areas, such as the palms, soles, mucosal surfaces and under nails. Risk factors include genetics, burn scars, radiation, immunosuppression, and cutaneous trauma.3 The plantar foot is the most common site of melanoma in SOC patients, accounting for 30 to 40 percent of all cases.6,7 Tables 1 to 3 describe helpful diagnostic characteristics of melanoma: the ABCDEs of Melanoma, the Alphabet of Nail Melanoma, and the CUBED acronym (which is useful for detecting plantar melanoma; the presence of any two criteria should prompt referral or excision).8,9  Increasing Awareness and Patient Counseling  There are several steps clinicians can take to help increase awareness of skin cancer in SOC populations. Clinicians should educate SOC patients on skin cancer prevention and management, including the following: 1. Importance of annual skin exams. A thorough yearly skin exam should include subungual, acral, mucosal, and genital areas.  2. Identifying skin changes and when to seek care. Educate patients on the signs and symptoms of different skin cancers and when it is appropriate to seek care. Review ABCDEs of Melanoma (Table 1),  Alphabet of Nail Melanoma (Table 2), and CUBED acronym (Table 3). 3. Using sun protection. Counsel patients on the importance of applying daily broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or higher and its proper use (i.e., apply 30 minutes before going outdoors and reapplied every 2 hours while outdoors).  4. Performing skin self-examinations. Encourage patients to perform monthly self examinations, paying close attention to subungual, acral, mucosal, and genital areas.  References Brenner M, Hearing VJ. The protective role of melanin against UV damage in human skin. Photochem Photobiol. 2008;84(3):539–549.  American Cancer Society. Cancer facts and figures. 2022. American Cancer Society website. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2022.html. Accessed 16 May 2022. Gupta AK, Bharadwaj M, Mehrotra R. skin cancer concerns in people of color: risk factors and prevention. Asian Pac J Cancer Prev. 2016;17(12):5257–5264.  Almahroos M, and Kurban AK. Ultraviolet carcinogenesis in nonmelanoma skin cancer. part I: incidence rates in relation to geographic locations and in migrant populations. Skinmed. 2004;3(1):29–35. National Cancer Institute. SEER*Explorer: an interactive website for SEER cancer statistics. Recent trends in SEER age-adjusted incidence rates, 2000-2019. Surveillance Research Program. https://seer.cancer.gov/explorer/. Accessed 18 Apr 2022.  Bradford PT, Goldstein AM, McMaster ML, Tucker MA. Acral lentiginous melanoma: incidence and survival patterns in the United States, 1986–2005. Arch Dermatol. 2009;145(4):427–434.  Ward-Peterson M, Acuña JM, Alkhalifah MK, et al. Association between race/ethnicity and survival of melanoma patients in the united states over 3 decades: a secondary analysis of SEER data. Medicine. 2016;95(17):e3315.  United States Centers for Disease Control and Prevention. What are the symptoms of skin cancer? 18 Apr 2022. 2022. https://www.cdc.gov/cancer/skin/basic_info/symptoms.htm. Accessed 29 Apr 2022. Levit EK, Kagen MH, Scher RK, et al. The ABC rule for clinical detection of subungal melanoma. J Am Acad Dermatol. 2000;42(Pt 1):269–274.