Breast Density Notification Letters and Websites: Are They Too "Dense"?

PURPOSE: To evaluate grade-level readability of dense breast notification letters (DBNs) and popular websites. METHODS: HIPAA-compliant, institutional review board-exempt study. As of April 2018, letter characteristics and grade-level readability were evaluated from states with mandated text using five readability metrics, one of which was the Flesch-Kincaid Grade Level. For states that had mandated DBNs in 2016, the 2016 data were compared with 2018. Readability was also assessed for common websites about dense breasts. RESULTS: Thirty states had mandated text for DBNs. All were written above a Flesch-Kincaid sixth-grade level. Eight state DBNs were around or below a Flesch-Kincaid eighth-grade level. Connecticut was the highest (19.4) and Alabama and New York lowest (both at 7.2). For all states, the mean readability score using the five metrics exceeded an eighth-grade level. Of states that had updated DBNs since 2016, only one state significantly improved readability (Missouri 13.1 to 8.5). All DBNs discussed that breast density may mask cancer on a mammogram, 20 discussed the association with increased risk of breast cancer, and 23 discussed supplemental screening. For websites, the range of Flesch-Kincaid grade-level readability was 6 to 11.3. The lowest was the American Cancer Society dense breast website (6.0) followed by ACR dense breast patient pamphlet (7.2). CONCLUSION: As of 2018, the mean readability score using five metrics for all state-mandated DBNs exceeded an eighth-grade reading level. Compared with 2016, only one state significantly decreased DBN grade-level readability. Publicly available websites performed relatively better.

Treatment of vitiligo with the topical Janus kinase inhibitor ruxolitinib.

BACKGROUND: Existing therapies for vitiligo are limited in efficacy and can be associated with undesirable side effects. Topical Janus kinase inhibitors may offer a new therapeutic option for vitiligo. OBJECTIVE: We sought to assess the role of topical ruxolitinib 1.5% cream, a Janus kinase inhibitor, in vitiligo treatment. METHODS: This 20-week, open-label, proof-of-concept trial of twice-daily topical ruxolitinib 1.5% cream was conducted in 12 patients with a minimum of 1% affected body surface area of vitiligo. The primary outcome was percent improvement in Vitiligo Area Scoring Index from baseline to week 20. RESULTS: Of 12 patients screened, 11 were enrolled and 9 completed the study (54.5% men; mean age, 52 years). Four patients with significant facial involvement at baseline had a 76% improvement in facial Vitiligo Area Scoring Index scores at week 20 (95% confidence interval, 53-99%; P = .001). A 23% improvement in overall Vitiligo Area Scoring Index scores was observed in all enrolled patients at week 20 (95% confidence interval, 4-43%; P = .02). Three of 8 patients responded on body surfaces and 1 of 8 patients responded on acral surfaces. Adverse events were minor, including erythema, hyperpigmentation, and transient acne. LIMITATIONS: Limitations of the study include the small sample size and open-label study design. CONCLUSIONS: Topical ruxolitinib 1.5% cream provided significant repigmentation in facial vitiligo and may offer a valuable new treatment for vitiligo.

Direct and indirect patient costs of dermatology clinic visits and their impact on access to care and provider preference.

The direct and indirect costs of dermatology clinic visits are infrequently quantified. Indirect costs, such as the time spent traveling to and from appointments and the value of lost earnings from time away from work, are substantial costs that often are not included in economic analyses but may pose barriers to receiving care. Due to the national shortage of dermatologists, patients may have to wait longer for appointments or travel further to see dermatologists outside of their local community, resulting in high time and travel costs for patients. Patients' lost time and earnings comprise the opportunity cost of obtaining care. A monetary value for this opportunity cost can be calculated by multiplying a patient's hourly wage by the number of hours that the patient dedicated to attending the dermatology appointment. Using a single institution survey, this study quantified the direct and indirect patient costs, including opportunity costs and time burden, associated with dermatology clinic visits to better appreciate the impact of these factors on health care access and dermatologic provider preference.

Hidradenitis Suppurativa: Review of the Pathogenesis and Treatment.

Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by significant morbidity. The clinical course of HS ranges from relatively mild cases characterized by recurrent tender, subcutaneous, inflammatory nodules to severe cases demonstrating painful, deep dermal abscesses, fibrosis, draining sinuses, and hypertrophic scars. Conventional treatment options for management of HS include topical and systemic antibiotics, antiandrogens, fumarates, biguanides, retinoids, immunosuppressive drugs, laser and phototherapy, and surgical excision. Given its association with pro-inflammatory cytokines, there has been interest in the use of novel biological agents. Recently, available treatment options have expanded to include tumor necrosis factor alpha inhibitors (TNF-ai), interleukin-1 inhibitors (IL-1i), and interleukin-12/23 inhibitors (IL-12/23i), but the management of HS is still very challenging. In this review, the authors will discuss new therapies for HS.

J Drugs Dermatol. 2016;15(8):1017-1022.

International Dermatology Outcome Measures Initiative as Applied to Psoriatic Disease Outcomes: An Update.

Previous publications have described the International Dermatology Outcome Measures (IDEOM) group, comprising patients, physicians, health economists, participating pharmaceutical industry partners, payers, and regulatory agencies. The goal of IDEOM is to create patient-centered, validated measures of dermatologic disease progression and treatment efficacy for use in both clinical trials and clinical practice. We provide an update of IDEOM activities as of our 2015 IDEOM meeting in Washington, DC, USA.

Wound-Related Allergic/Irritant Contact Dermatitis.

PURPOSE: To provide information from a literature review about the prevention, recognition, and treatment for contact dermatitis. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Identify signs and symptoms of and diagnostic measures for contact dermatitis.2. Identify causes and risks for contact dermatitis.3. Select appropriate treatment for contact dermatitis and its prevention. ABSTRACT: Contact dermatitis to wound care products is a common, often neglected problem. A review was conducted to identify articles relevant to contact dermatitis.A PubMed English-language literature review was conducted for appropriate articles published between January 2000 and December 2015.Contact dermatitis is both irritant (80% of cases) or allergic (20% of cases). Frequent use of potential contact allergens and impaired barrier function of the skin can lead to rising sensitization in patients with chronic wounds. Common known allergens to avoid in wound care patients include fragrances, colophony, lanolin, and topical antibiotics.Clinicians should be cognizant of the allergens in wound care products and the potential for sensitization. All medical devices, including wound dressings, adhesives, and bandages, should be labeled with their complete ingredients, and manufacturers should be encouraged to remove common allergens from wound care products, including topical creams, ointments, and dressings.

Angioinvasive opportunistic filamentous mycoses in immunocompromised patients.

Immunocompromised individuals are at greater risk for disseminated fungal infections. Immunocompromised individuals in the community have increased because of medical advances, thereby increasing the incidence and prevalence of opportunistic mycoses. The following case series illustrates the importance of having a high clinical suspicion for skin manifestations concerning for deep fungal infections.

Tumor Necrosis Factor Inhibitor Primary Failure Predicts Decreased Ustekinumab Efficacy in Psoriasis Patients.

BACKGROUND: Additional studies are needed to examine the efficacy of ustekinumab in psoriasis patients who have previously been exposed to tumor necrosis factor inhibitors (TNFi). OBJECTIVE: To examine the predictive effect of TNFi primary failure and the number of TNFi exposures on the efficacy of ustekinumab in psoriasis treatment. METHODS: This retrospective study examined 44 psoriasis patients treated at the Tufts Medical Center Department of Dermatology between January 2008 and July 2014. Patients were selected if they were treated with ustekinumab and had ≥ 1 previous TNFi exposure. The following subgroups were compared: patients with vs without a previous TNFi primary failure, and patients with one vs multiple previous TNFi exposures. The efficacy measure used was the previously validated Simple Measure for Assessing Psoriasis Activity (S-MAPA), which is calculated by the product of the body surface area and physician global assessment. The primary outcome was the percentage improvement S-MAPA from course baseline at week 12 of ustekinumab treatment. Secondary outcomes were the psoriasis clearance, primary failure, and secondary failure rates with ustekinumab treatment. RESULTS: Patients with a previous TNFi primary failure had a significantly lower percentage improvement in S-MAPA score at week 12 of ustekinumab treatment compared with patients without TNFi primary failure (36.2% vs 61.1%, P=.027). Multivariate analysis demonstrated that this relationship was independent of patient demographics and medical comorbidities. Patients with multiple TNFi exposures had a non-statistically significant lower percentage S-MAPA improvement at week 12 (40.5% vs 52.9%, P=.294) of ustekinumab treatment compared with patients with a single TNFi exposure. CONCLUSIONS: Among psoriasis patients previously exposed to TNFi, a history of a previous TNFi primary failure predicts a decreased response to ustekinumab independent of patient demographics and medical comorbidities.

Dermal eosinophilic infiltrate in junctional epidermolysis bullosa.

Junctional epidermolysis bullosa (JEB) is a rare genodermatosis characterized by a split in the lamina lucida usually because of mutations in LAMA3, LAMB3 and LAMC2 resulting in absence or reduction of laminin-332. Rare subtypes of JEB have mutations in COL17A1, ITGB4, ITGA6 and ITGA3 leading to reduction or dysfunction of collagen XVII, integrin α6ß4 and integrin α3. The classic finding under light microscopy is a paucicellular, subepidermal split. We describe the unusual presence of an eosinophilic infiltrate in the bullae and subjacent dermis in a neonate with JEB, generalized intermediate (formerly known as non-Herlitz-type JEB), discuss the histologic differential diagnosis for a subepidermal blister in a neonate, review the literature regarding cases of epidermolysis bullosa (EB) presenting with inflammatory infiltrates, and discuss mechanisms to explain these findings. This case highlights that eosinophils can rarely be seen in EB and should not mislead the dermatopathologist into diagnosing an autoimmune blistering disorder.

Clearance of psoriasis: the impact of private versus public insurance.

BACKGROUND: Psoriasis treatments and therapeutic response as they relate to private versus public patient insurance in the United States have not yet been reviewed. Improved understanding could clarify factors challenging optimal psoriasis management and offer insight for dermatologists treating psoriasis within our healthcare system. METHODS: 258 subjects were included from a database of psoriasis patients seen at Tufts Medical Center (Boston, MA) during 2008-2014. Insurance was classified as primarily private or public (Medicare or MassHealth/Medicaid). Patients required a minimum of two consecutive visits per treatment and at least 8 weeks within one of four treatment categories: biologics, oral systemics/ phototherapy, combined biologics and oral systemics/phototherapy, or topicals only. Primary endpoint was the Simple-Measure for Assessing Psoriasis Activity (S-MAPA) calculated by multiplying Physician Global Assessment by Body Surface Area. S-MAPA<3 constituted absolute clearance. Insurance type was evaluated as a predictor of prescribed treatment categories, maximum S-MAPA improvement from baseline, and total drugs used per treatment course ("drug-switching"). RESULTS: 80.2% (n=207) and 19.8% (n=51) had primarily private and public insurance, respectively. 69.6% with private insurance were prescribed biologics versus 66.7% (public insurance) (P=0.689). 54% (private) versus 49% (public) achieved clearance (P=0.514). However, S-MAPA decreased 78.35% from baseline in those with private insurance compared to 61.48% (public) (P=0.036). On average, privately insured patients used at least twice as many same-category treatments, most commonly biologics, than publicly insured individuals (P=0.003). Drug-switching was significantly associated with clearance (P=0.024). Multivariate analysis demonstrated no significant differences in prescribed treatment categories, drug efficacy, clearance, S-MAPA, or drugswitching with respect to patient age. CONCLUSIONS: Treatment categories were comparably prescribed between insurance subgroups. However, privately insured patients achieved significantly greater degrees of clearance and switched between more medications within biologic and systemic categories, potentially explaining their overall improved therapeutic response. Further studies including cost-analysis could clarify any difference in the effectiveness of prescribed therapy for these two patient populations.

Treatment of coexistent psoriasis and lupus erythematosus.

BACKGROUND: The coexistence of psoriasis and lupus erythematosus (LE) is rare. Anecdotal evidence suggests that anti-tumor necrosis factor alfa (TNF-α) agents may be efficacious in LE, although their use is commonly avoided in this disease because of concern for lupus flare. OBJECTIVE: We sought to describe the epidemiology, serologic findings, and therapeutic choices in patients with coexistent psoriasis/psoriatic arthritis and LE and to determine the risk of lupus flares with TNF-α inhibitors. METHODS: We performed a retrospective multicenter study of patients given the diagnoses of psoriasis (or psoriatic arthritis) and lupus erythematosus (systemic LE or cutaneous LE, including either subacute cutaneous LE or discoid LE) at 2 academic tertiary-care centers. RESULTS: A total of 96 patients with a mean age of 56 years was included. We report higher-than-expected rates of white race and psoriatic arthritis. One clinical lupus flare was observed in a patient receiving a TNF-α inhibitor, resulting in an incidence of 0.92% lupus flares per patient-year of TNF-α inhibitor use. LIMITATIONS: Retrospective chart review, small sample size, and limited documentation. CONCLUSION: Anti-TNF-α agents, ustekinumab, and abatacept may be valid treatment options for patients with concomitant LE and psoriasis. Clinical lupus flares in LE patients treated with TNF-α inhibitors were infrequent.

Hyperinsulinemia associated with acanthosis nigricans, finger pebbles, acrochordons, and the sign of Leser-Trélat.

OBJECTIVE: To review common skin manifestations associated with type 2 diabetes mellitus (DM), and to discuss a potential underlying mechanism for these manifestations. METHODS: A PubMed literature search was conducted for articles describing the skin manifestations associated with hyperinsulinemia and type 2 DM. A case presentation describes a morbidly obese patient with type 2 DM treated with metformin who developed acanthosis nigricans, finger pebbles, scores of skin tags (acrochordons), and the sign of Leser-Trélat (sudden onset shower of seborrheic keratoses) in the absence of internal malignancy. RESULTS: Acanthosis nigricans, acrochordons, and finger pebbles have been associated with type 2 DM and obesity. While the Leser-Trélat sign is classically associated with internal malignancy, it can also be idiopathic. To our knowledge, this the first report of the occurrence of the Leser-Trélat sign in a patient with DM absent internal malignancy. CONCLUSION: Several skin manifestations can be seen in this patient with DM because of underlying insulin resistance and subsequent stimulation of insulin-like growth factor receptors. Management strategies could include weight loss, diet, and insulin-sensitizing pharmacologic therapy.