Strategies to maximize clinical efficiency while maintaining patient safety during the COVID-19 pandemic: an interview-based study from private practice dermatologists.

BACKGROUND: Many dermatologists have experienced significant changes to their practices due to the COVID-19 pandemic. OBJECTIVE: It is vital to recognize how the pandemic has affected dermatology practices and identify methods to maximize clinical efficiency while maintaining patient safety. METHODS: Private practice dermatologists in metropolitan areas were interviewed regarding various issues, including patient volume, types of visits or procedures being performed, screening for COVID-19, and operational modifications. RESULTS: On average, there was a 65.2% decrease in patient volume during the initial surge of the COVID-19 outbreak, which was improved to a 15.5% decrease in July 2020. Despite this reduction in patient volume, the proportion of acute dermatologic issues, biopsies performed, and skin cancer concerns were all increased compared to pre-COVID. All of the dermatologists reported notable changes in regards to scheduling, staff, operations, and workplaces. LIMITATIONS: Interview participants were limited to metropolitan dermatologists mainly within the California region. CONCLUSION: Improving patient communication, implementing protocols to facilitate social distancing, and utilizing teledermatology were reported to be essential to optimizing efficiency and safety. As the COVID-19 pandemic continues to evolve, it is important that dermatologists identify specific ways to practice efficiently and effectively, while mitigating the spread of the virus.

Epithelioid and clear-cell variant of Kaposi sarcoma: A rare histopathologic subtype.

Kaposi sarcoma is a malignant vascular tumor consisting of multiple clinical subtypes and varying histopathologic patterns. We report a case of a 53-year-old African-American male with HIV/AIDS who presented multiple times with skin nodules, pain, and edema in his lower extremities, secondary to recurrent Kaposi sarcoma. The patient was treated with two courses of liposomal doxorubicin with improvement, but his symptoms recurred a third time. A biopsy specimen of one of the nodules showed prominent neoplastic cells of epithelioid morphology, some with clear-cell change, appearing to form rudimentary vessels in the superficial dermis. Further inspection of the deeper dermis revealed more classic findings of Kaposi sarcoma, including admixed spindle cells, poorly defined vessels, scattered apoptotic bodies, entrapped collagen bundles, and extravasated erythrocytes. Both the epithelioid and classic portions of the neoplasm stained positive for CD31 and human herpesvirus 8, supporting a diagnosis of Kaposi sarcoma. Prior to this case, the epithelioid variant of Kaposi sarcoma has been reported only twice in the literature. Recognizing this rare histopathologic variant of Kaposi sarcoma among its other histopathologic patterns may assist in accurate and expedient diagnosis of this well-recognized disease.

Characterization of mutant type VII collagens underlying the inversa subtype of recessive dystrophic epidermolysis bullosa.

BACKGROUND: Patients with recessive dystrophic epidermolysis bullosa (RDEB) lack functional type VII collagen (C7) leading to skin fragility, bullae, and erosive wounds. RDEB-Inversa (RDEB-I), a subset of RDEB, is characterized by lesions localized to body areas with higher skin temperatures such as flexures and skin folds. OBJECTIVE: We aimed to determine if C7 derived from RDEB-I mutations had structural and functional aberrancies that were temperature sensitive and could be reversed by lowering the temperature. METHODS: In this study, we generated 12 substitution mutations associated with RDEB-I via site-directed mutagenesis and purified recombinant C7 protein. These C7 mutants were evaluated for structural parameters (trimer formation and protease sensitivity) and the ability to promote keratinocyte migration at 37 °C (the temperature of skin folds) and 30 °C (the maximum skin temperature of arms and legs). Fibroblasts derived from RDEB-I patients were evaluated for C7 secretion and cellular migration at both temperatures. RESULTS: C7s from RDEB-I mutations exhibited decreased thermal stability, increased sensitivity to protease digestion, diminished formation of collagen trimers, and reduced ability to promote keratinocyte migration compared with wild-type C7. In addition, fibroblasts derived from RDEB-I patients demonstrated intracellular accumulation of C7 and abnormal cell migration at 37 °C. All of these aberrancies were corrected by reducing the temperature to 30 °C. C7s generated from severe-RDEB mutations (non-Inversa) did not display temperature-dependent perturbations. CONCLUSION: These data demonstrate that RDEB-I mutations generate C7 aberrancies that are temperature dependent. This may explain why RDEB-I patients develop clinical lesions in areas where their skin is considerably warmer.

Teledermatology in the United States: An Update in a Dynamic Era.

BACKGROUND: Teledermatology is rapidly advancing in the United States. The last comprehensive survey of U.S. teledermatology programs was conducted in 2011. INTRODUCTION: This article provides an update regarding the state of teledermatology programs in the United States. MATERIALS AND METHODS: Active programs were identified and surveyed from November 2014 to January 2017. Findings regarding practice settings, consult volumes, payment methods, and delivery modalities were compared to those from the 2011 survey. Findings from the Veterans Affairs (VA) were reported as an aggregate. RESULTS: There were 40 active nongovernmental programs, amounting to a 48% increase and 30% discontinuation rate over five years. Academia remained the most common practice setting (50%). Median annual consultation volume was comparable with 263 consultations, but maximum annual consultation volume increased (range: 20-20,000). The most frequent payment method was self-pay (53%). Store-and-forward continued to be the most common delivery modality. In Fiscal Year 2016, the VA System consisted of 62 consultation sites and performed a total of 101,507 consultations. DISCUSSION: The limitations of this study were that consult volume and payment methods were not available from all programs. CONCLUSION: U.S. teledermatology programs have increased in number and annual consultation volume. Academia is the most prevalent practice setting, and self-pay is the dominant accepted payment method. Innovative platforms and the provision of direct-to-patient care are changing the practice of teledermatology.

Updates on cardiovascular comorbidities associated with psoriatic diseases: epidemiology and mechanisms.

Psoriasis and psoriatic arthritis are associated with a significantly increased risk of cardiovascular risk factors and major adverse cardiovascular events (MACE). Active research is ongoing to elucidate this relationship between psoriatic diseases and cardiovascular comorbidities, as well as their shared pathogenic mechanisms. This review focuses on (1) the epidemiologic association between psoriasis and cardiovascular risk factors, (2) the epidemiologic association between psoriasis and MACE, (3) the epidemiologic association between psoriatic arthritis, cardiovascular risk factors, and MACE, and (4) proposed mechanisms for the contribution of psoriatic diseases to cardiovascular diseases. The proposed mechanisms for shared pathogenesis between psoriatic diseases and cardiovascular diseases are inflammation, insulin resistance, dyslipidemia, angiogenesis, oxidative stress, and endothelial dysfunction. There is complex interplay and overlap among these mechanisms and their contributions to shared pathogenesis. Future translational research is necessary to elucidate the link between psoriatic diseases and cardiovascular diseases. Such findings may be applied clinically to improve the lives of psoriasis patients.