The utility of augmented teledermatology to improve dermatologist diagnosis of cellulitis: a cross-sectional study.

Dermatology consultation for cases of presumed cellulitis improves diagnostic accuracy and management. However, access to in-person consultation remains limited, a gap that could be filled with teledermatology. Augmented teledermatology may improve outcomes. In this cross-sectional study, 20 dermatologists (60% of whom reported conducting inpatient consults > 1 month per year) reviewed 10 real-life cases representing either cellulitis or pseudocellulitis as diagnosed by in-person dermatology consultation. For each case, respondents recorded their diagnosis, confidence, and management decisions after viewing the history and standard teledermatology photos, the responses to a physician-reported cellulitis questionnaire, and finally thermal images. Overall mean diagnostic accuracy increased from 84 ± 4% with the history and physical to 89 ± 3% when adding a cellulitis questionnaire and thermal images (p = 0.23). Accuracy for cellulitis cases specifically significantly increased from 76 ± 6% to 88 ± 4% when adding a cellulitis questionnaire and thermal images (p = 0.049). Accuracy for pseudocellulitis was consistently ≥ 94%. Augmented teledermatology with a standardized questionnaire and thermal images improved diagnostic accuracy for cases of cellulitis and may increase physician confidence. Dermatologists were able to accurately diagnose regardless of experience with inpatient consults, increasing the pool of potential dermatologists who could diagnose cellulitis remotely.

Development and Validation of a Simple Model to Predict the Risk of Nonmelanoma Skin Cancer on Screening Total Body Skin Examination.

Objective: There is insufficient evidence to generate skin cancer screening guidelines at the population level, resulting in arbitrary variation in patient selection for screening skin examinations. This study was aimed at developing an easy-to-use predictive model of nonmelanoma skin cancer (NMSC) risk on screening total body skin examination (TBSE). Methods: This epidemiologic assessment utilized data from a prospective, multicenter international study from primarily academic outpatient dermatology clinics. Potential predictors of NMSC on screening TBSE were identified and used to generate a multivariable model that was converted into a point-based scoring system. The performance characteristics of the model were validated in a second data set from two healthcare institutions in the United States. Results: 8,501 patients were included. Statistically significant predictors of NMSC on screening TBSE included age, skin phototype, and history of NMSC. A multivariable model and point-based scoring system using these predictors exhibited high discrimination (AUC = 0.82). Conclusion: A simple three-variable model, abbreviated as CAP (cancer history, age, phototype) can accurately predict the risk of NMSC on screening TBSE by dermatology. This tool may be used in clinical decision making to enhance the yield of screening TBSE.

Microtubule motor transport in the delivery of melanosomes to the actin-rich apical domain of the retinal pigment epithelium.

Melanosomes are motile, light-absorbing organelles that are present in pigment cells of the skin and eye. It has been proposed that melanosome localization, in both skin melanocytes and the retinal pigment epithelium (RPE), involves melanosome capture from microtubule motors by an unconventional myosin, which dynamically tethers the melanosomes to actin filaments. Recent studies with melanocytes have questioned this cooperative capture model. Here, we test the model in RPE cells by imaging melanosomes associated with labeled actin filaments and microtubules, and by investigating the roles of different motor proteins. We found that a deficiency in cytoplasmic dynein phenocopies the lack of myosin-7a, in that melanosomes undergo fewer of the slow myosin-7a-dependent movements and are absent from the RPE apical domain. These results indicate that microtubule-based motility is required for the delivery of melanosomes to the actin-rich apical domain and support a capture mechanism that involves both microtubule and actin motors.

Evaluation of Point-of-Care Decision Support for Adult Acne Treatment by Primary Care Clinicians.

Importance: Acne is a common reason for referral to dermatologists from primary care clinicians. We previously modeled the impact of algorithm-based acne care in reducing dermatology referrals, missed appointments, and treatment delays. Objective: To prospectively evaluate the downstream outcomes following a real-time, algorithm-based electronic decision-support tool on the treatment of patients referred for acne. Design, Setting, and Participants: This prospective cohort study included 260 treatment-naive patients referred to a dermatologist for the chief concern of acne, as well as the referring primary care clinicians, at 33 primary care sites affiliated with Brigham and Women's Hospital from March 2017 to March 2018. Interventions: We developed and implemented a decision-support tool into the electronic medical record system at an academic medical center. The algorithm identified patients referred to a dermatologist who had not previously been treated for acne and offered guideline-based recommendations for treatment via a real-time notification. Main Outcomes and Measures: Treatment modification by referring clinicians. Results: Of 260 patients referred for acne, 209 (80.4%) were women, 146 (56.1%) were non-Hispanic white, and 236 (90.8%) listed English as the preferred language. Patients had a median (quartile 1-quartile 3) age of 28.8 years (24.4-35.1 years) and 185 of 260 had private insurance (71.1%). In total, the algorithm was associated with cancellation of the initial referral in 35 of 260 (13.5%) instances and treatment initiation by the referring clinician in 51 of 260 (19.6%) instances. Conclusions and Relevance: This decision-support algorithm was associated with a modest reduction in rates of acne-related referrals to dermatologists, and an increased likelihood of treatment initiation by the referring clinician.

Spending on World Health Organization essential medicines in Medicare Part D, 2011-15: retrospective cost analysis.

OBJECTIVES: To characterize the trends, drivers, and potential modifiers of increased spending by US Medicare beneficiaries on medicines deemed essential by the World Health Organization. DESIGN: Retrospective cost analysis of Medicare Part D Prescriber Public Use File, detailing annual generic and brand name drug prescribing and spending from 2011 through 2015 by Medicare Part D participants who filled prescriptions for WHO essential medicines. SETTING: US Medicare System. MAIN OUTCOME MEASURES: Total and per beneficiary Medicare spending, total and per beneficiary out-of-pocket patient spending, cumulative beneficiary count, claim count, and per unit drug cost. All spending measures were adjusted for inflation and reported in 2015 US dollars. RESULTS: Medicare Part D expenditures on 265 WHO essential medicines between 2011 and 2015 was $87.2bn (£68.4bn; €76.5bn), with annual spending increasing from $11.9bn in 2011 to $25.8bn in 2015 (116%). Patients' out-of-pocket spending for essential medicines over the same period was $12.1bn. Total annual out-of-pocket spending increased from $2.0bn to $2.9bn (47%), and annual per beneficiary out-of-pocket spending on these drugs increased from $20.42 to $21.17 (4%). Total prescription count increased from 376.1m to 498.9m (33%), and cumulative beneficiary count grew from 95.9m to 135.8m (42%). Of the essential medicines included in the study, the per unit cost of 133 (50%) agents increased faster than the average inflation rate during this period. Overall, approximately 58% of the increase in total spending during this period can be attributed to the introduction of novel agents. CONCLUSIONS: Spending associated with essential medicines grew substantially from 2011 to 2015, driven largely by the increased use of two expensive novel drugs used in treating hepatitis C. Approximately 22% of increased total spending during this period can be attributed to increases in per unit cost of existing drugs. These trends may limit patients' access to essential drugs while also increasing healthcare system costs.

The ALT-70 cellulitis model maintains predictive value at 24 and 48 hours after presentation.

BACKGROUND: Cellulitis has many potential mimickers, and its misdiagnosis often leads to unnecessary hospitalizations and higher health care costs. The ALT-70 predictive model offers an objective tool to help differentiate between cellulitis and other clinically similar conditions at the time of initial emergency department (ED) presentation. OBJECTIVE: To evaluate the performance of the ALT-70 predictive model at 24 and 48 hours following ED presentation. METHODS: We performed a retrospective review of our prior cohort and expanded our data collection to include data at 24 and 48 hours after initial ED presentation. We compared classification measures for the ALT-70 at the time of initial ED presentation, 24 hours after presentation, and 48 hours after presentation. RESULTS: There was a statistically significant difference in median ALT-70 score between patients with true cellulitis and those with mimickers of cellulitis at all time points. Sensitivity, specificity, positive predictive value, and negative predictive value of the ALT-70 score was similar across all 3 time points. LIMITATIONS: Single-center design may reduce generalizability. CONCLUSION: At 24 and 48 hours, the ALT-70 performed similarly to the way it performed at the time of initial ED presentation, allowing for its use in a wider array of clinical settings.

Prevalence and Disclosure of Potential Conflicts of Interest in Dermatology Patient Advocacy Organizations.

Importance: Patient advocacy organizations are nonprofit organizations that represent patients with medical conditions. Although these organizations may increase disease awareness and influence health care policy, reports have suggested financial relationships between organizations and drug, device, and biotechnology companies, which may lead to potential conflicts of interest. The extent of these conflicts has not been explored among patient advocacy organizations in dermatology. Objective: To examine potential financial conflicts of interest and characterize disclosure practices among dermatology patient advocacy organizations. Design, Setting, and Participants: This cross-sectional study of the largest dermatology patient advocacy organizations using the Kaiser Health News database acquired data on total revenue from each organization's Form 990 for the year 2015. Tax forms and annual reports from 2017 were used for 2 organizations that were missing donor information for 2015. Annual reports, websites, and LinkedIn profiles were manually examined to ascertain donations and determine disclosure practices pertaining to financial support and board membership. Main Outcomes and Measures: The amount and minimum proportion of donations attributable to industry sponsorship among organizations as well as the proportion of organizations disclosing (1) industry-sponsored financial support, (2) the amount of industry-derived donations, and (3) current and past relationships between governing board members and industry sponsors. Results: This study identified 24 dermatology patient advocacy organizations with annual revenues that exceeded $500 000. Of these, 5 (21%) had total donations that exceeded $5 million and 4 (17%) reported industry donations that exceeded $500 000. Two organizations (8%) reported having at least 40% of total donations from industry sponsorship. Overall, 17 organizations (71%) reported receiving donations from industry on the annual report or the website and 12 (50%) reported the amount of donations in ranges. None of the organizations reported the exact amount or use of donations. On the basis of annual reports and websites, 3 organizations (13%) reported having a current or former industry executive on the organization's governing board. When this search was replicated using LinkedIn, this figure was at least 54%. Conclusions and Relevance: These findings suggest inconsistent disclosure of industry-derived financial support and board membership that may represent conflicts of interest. Policies that support the transparency and consistency of disclosure practices between industry and patient advocacy organizations appear to be needed to fully characterize the extent of conflicts of interest among patient advocacy organizations in dermatology and maintain trust in these important institutions.

Association Between Market Competition and Prices of Generic Topical Dermatology Drugs.

Importance: During the last decade, increases in drug prices for commonly prescribed dermatologic medications have outpaced the rate of inflation, national health care growth, and reimbursements. Among nondermatologic medications, studies have shown a role for robust generic market competition in reducing drug prices. The association between competition and the costs of topical dermatologic generic drugs has not been evaluated. Objective: To characterize the association between changes in drug price and the number of US Food and Drug Administration (FDA)-approved manufacturers among the most commonly used topical dermatologic generic products. Design, Setting, and Participants: This retrospective cost analysis of the most commonly prescribed topical dermatologic generic drugs used cumulative annual claims data from the Medicare Part D Prescriber Public User File to identify 597 dermatologist-prescribed drugs with more than 10 claims. The number of manufacturers and the price per unit were identified from the FDA Orange Book and the National Average Drug Acquisition Cost (NADAC) database, respectively, for 2013 through 2016. Drugs that were nondermatologic, were not topically administered, were missing NADAC data, were lacking a generic formulation, or had fewer than 400 claims were excluded. Main Outcomes and Measures: Primary outcomes included per-unit drug price and number of FDA-approved manufacturers. Pricing measures were adjusted for inflation and are reported in 2016 dollars. Results: The present analysis included 116 topical dermatologic generic formulations, representing 70.5% of the total Medicare Part D dermatologist-coded claims from 2015. Drug formulations with 1 to 2 manufacturers during the study period sustained a median percentage increase in price of 12.7%, whereas those with more than 6 manufacturers had a median percentage decrease in price of 20.5%. Formulations with 1 to 2 manufacturers had a 20.6%, 19.5%, and 33.2% higher percentage increase in price than those with 3 to 4 manufacturers, 5 to 6 manufacturers, and more than 6 manufacturers, respectively. There was a statistically significant inverse association between the percentage change in drug price and median number of manufacturers (Spearman correlation coefficient, -0.26; P = .005). Conclusions and Relevance: The negative association between the change in drug price and the median number of manufacturers of generic topical dermatologic drugs indicates a role for market competition in controlling the costs of generic drug prices within dermatology. These findings support policies that facilitate robust market competition among topical dermatologic generic drugs produced by a limited number of manufacturers.

Efficacy of Systemic Dapsone Treatment for Pyoderma Gangrenosum: A Retrospective Review.

INTRODUCTION: Pyoderma gangrenosum (PG) is a neutrophilic dermatosis commonly treated with steroid immunosuppression. The utility of dapsone as a non-immunosuppressive treatment for PG has been reported in case reports and series. We sought to evaluate the response and tolerability of concurrent systemic dapsone therapy for treating PG. METHODS: We reviewed PG patients treated with systemic dapsone at Massachusetts General Hospital and Brigham and Women's Hospital from 2000-2015. A treatment episode was defined as a minimum of 4 weeks of dapsone therapy with a documented response of complete, partial, or no improvement in wound healing. RESULTS: 27 patients treated with systemic dapsone met inclusion criteria. 15.6% of treatment episodes demonstrated a response of complete healing, 81.3% of treatment episodes demonstrated a response of partial improvement, and 1 patient (3.1%) demonstrated no response. 9 patients (33.3%) had documented side effects of varying severity, with one (3.7%) requiring cessation of dapsone therapy. DISCUSSION: Systemic dapsone therapy may represent an effective and tolerable non-immunosuppressive adjuvant treatment for PG wound healing. J Drugs Dermatol. 2018;17(10):1058-1060.

Clinical Diagnostic Accuracy of Onychomycosis: A Multispecialty Comparison Study.

Although onychomycosis can be diagnosed clinically, many guidelines still recommend pathologic confirmation of the diagnosis prior to initiation of systemic treatment. We retrospectively reviewed results from 541 toenail clippings (160 by dermatologists, 198 by podiatrists, and 183 by other provider types) sent to the Brigham and Women's Department of Dermatopathology between January 2000 and December 2013 for confirmatory periodic acid-Schiff (PAS) testing of clinically diagnosed onychomycosis. Of these, 93 (58.1%), 125 (63.1%), and 71 (38.8%) were sent for confirmation of onychomycosis (as opposed to diagnosis of onychodystrophy) by dermatologists, podiatrists, and other provider types, respectively. Confirmatory PAS stains were positive in 70 (75.3%), 101 (80.8%), and 47 (66.2%) of samples ordered by dermatologists, podiatrists, and other providers, respectively. Our study demonstrates that clinical diagnosis of onychomycosis in the appropriate clinical setting is accurate across specialties. Further prospective investigation on the accuracy of clinical diagnosis of onychomycosis may be beneficial.

Factors Influencing Patient Decisions Regarding Treatments for Skin Growths: A Cross-Sectional Study.

Variations in treatment modalities for skin growths contribute substantially to overall healthcare spending within dermatology. However, little is known regarding factors impacting patient decision-making when choosing a treatment modality. In this survey-based, cross-sectional study (n = 375, 81.9% response rate), we asked patients to rate the importance of different treatment parameters for a nonfacial skin growth, further classified into five domains: efficacy, appearance, financial impact, visit duration, and productivity. Although patients generally prioritized treatment efficacy when selecting a treatment modality, they emphasized different aspects of the treatment experience as a function of age, gender, race, insurance status, and history of malignancy. Patients over age 50 were less likely to consider treatment impact on finances as being "important", but more so efficacy and visit duration. Women were more likely to value efficacy and appearance. Patients without private insurance were more likely to cite efficacy and impact on productivity as being "important". While the underlying reasons for these variations differ across patients, these findings help explain variations in treatment selection among patients choosing between treatments for skin growths and may ultimately lead to improved shared decision-making.

The ALT-70 predictive model outperforms thermal imaging for the diagnosis of lower extremity cellulitis: A prospective evaluation.

BACKGROUND: We previously demonstrated that dermatology consultation substantially reduces the rates of misdiagnosis of cellulitis; however, broad implementation of dermatology consultation is impractical on account of existing practice patterns and reimbursement systems. Meanwhile, efforts to improve diagnostic accuracy have culminated in point-of-care tools, including the ALT-70 predictive model for lower extremity cellulitis and thermal imaging. OBJECTIVE: To prospectively evaluate the performance of the ALT-70 predictive model and thermal imaging in diagnosing lower extremity cellulitis in a head-to-head comparison. METHODS: We collected ALT-70 and thermal imaging data from patients with presumed lower extremity cellulitis and compared classification measures and accuracy for the ALT-70 predictive model, thermal imaging, and combination testing (ALT-70 predictive model plus thermal imaging). RESULTS: We enrolled 67 patients with ALT-70 and thermal imaging data. The ALT-70 predictive model conferred the highest sensitivity (97.8%) and negative predictive value (90.9%), whereas combination testing had the highest specificity (71.4%) and positive predictive value (86.6%). The ALT-70 predictive model had improved classification measures compared with thermal imaging. Combination testing conferred a marginal benefit compared with the ALT-70 predictive model alone. LIMITATIONS: Single-center design may limit generalizability. CONCLUSION: The ALT-70 predictive model outperformed thermal imaging in diagnosing lower extremity cellulitis. The accuracy of the ALT-70 predictive model was high and consistent with its performance in previously published literature. Broad implementation of the ALT-70 predictive model in clinical practice may decrease the rates of misdiagnosis of lower extremity cellulitis.

Mass Compression from Recurrent Lymphoma Mimicking Lower Extremity Cellulitis.

Cellulitis is a common skin and soft tissue infection with substantial misdiagnosis rates due to its nonspecific clinical characteristics. In this report, we present a patient with recurrent metastatic diffuse large B-cell lymphoma (DLBCL) masquerading as a unilateral lower extremity cellulitis. A 62-year-old man with a history of DLBCL, in remission for two years, presented with a two-week history of swelling and erythema of the right thigh and leg. Despite treatment with clindamycin and cephalexin, the redness and swelling continued to progress. On presentation to the emergency department, vitals were within normal limits, laboratory workup was significant only for borderline anemia and thrombocytopenia, and bilateral lower extremity ultrasound was negative for a clot. The patient was evaluated by a dermatologist who recommended further imaging workup for proximal vascular compression given the uniformity of inflammation and edema in the absence of fever or systemic symptoms. Imaging revealed retroperitoneal lymphadenopathy, right pelvic side wall and right inguinal lymphadenopathy, an intramuscular lymphomatous involvement of the right iliopsoas muscle, and mass compression of the right external iliac vein. Bone marrow and soft-tissue biopsies confirmed recurrent and metastatic DLBCL. In this patient, the atypical cellulitis-like features are likely due to venous and lymphatic obstruction secondary to mass effect from metastasis. Going forward, clinicians should consider compression-induced edema as a sign of primary or recurrent malignancy in patients with refractory or atypical cellulitis.