Restrictions on blood donations relevant to dermatology.

Over 36,000 units of blood are transfused every day in the US. With nearly 40% of the population eligible to donate, we may frequently treat potential blood donors. We reviewed the American Red Cross and World Health Organization's restrictions on blood donation. Multiple drugs used, and diseases treated in dermatology, are associated with blood donation restrictions. Understanding these restrictions may help us better educate our patients.

Rosacea in skin of color: not a rare diagnosis.

BACKGROUND: The prevalence of rosacea in skin of color is not well characterized and may be underestimated. Physicians may not recognize and diagnose rosacea correctly in skin of color. PURPOSE: To assess the prevalence of rosacea in skin of color and determine if patients of color with rosacea symptoms are receiving a diagnosis of rosaceaMethods: We analyzed the National Ambulatory Medical Care Survey (NAMCS) for 1993-2010 for racial and ethnic distribution of patients with rosacea. Common reasons for visit in rosacea patients were tabulated and frequency of rosacea diagnosis was compared in patients of each race with the relevant reasons for visit. RESULTS: Of all patients diagnosed with rosacea, 2.0% were black, 2.3% were Asian or Pacific Islander, and 3.9% were Hispanic or Latino of any race. Leading reasons for visit associated with rosacea included "other diseases of the skin", skin rash, and discoloration or abnormal pigmentation. Rosacea was the primary diagnosis for 8.3% of whites and 2.2% of blacks complaining of "other diseases of the skin", for 2.0% of whites and 0.6% of blacks complaining of skin rash, and for 3.0% of whites and 0.0% of blacks complaining of discoloration or abnormal pigmentation. The percentage of rosacea patients who were black or Asian/Pacific Islander did not change significantly over time. LIMITATIONS: No specific reason-for-visit code indicating rosacea exists in the NAMCS. Prevalence may be underestimated if some patients do not visit a physician for treatment. CONCLUSIONS: Patients of color rarely receive a diagnosis of rosacea, even when they have symptoms suggesting it. Rosacea has not become more commonly diagnosed in skin of color in recent years.

Systemic corticosteroids are frequently prescribed for psoriasis.

BACKGROUND: The use of systemic corticosteroids is discouraged in major psoriasis treatment guidelines. PURPOSE: Our objective was to assess how often systemic corticosteroids are prescribed for psoriasis and trends in their use over time. METHODS: We used National Ambulatory Medical Care Survey (NAMCS) data to determine the systemic medications prescribed for psoriasis from 1989 to 2010. We confirmed the findings by analysis of 2003-2007 MarketScan Medicaid data. RESULTS: Systemic corticosteroids were prescribed at 650,000 (95% CI 380,000-920,000) of 21,000,000 psoriasis visits; 93% of these visits were to dermatologists. Of the top nine systemic medications listed at psoriasis visits, three of them were corticosteroids. Corticosteroids were the second most commonly prescribed systemic medication for psoriasis. No significant change in the use of systemic corticosteroids for psoriasis over time was observed (p  =  .27). In the MarketScan data, prednisone was prescribed more commonly than either methotrexate or etanercept. LIMITATIONS: Corticosteroid doses and the length of treatment were not recorded in the NAMCS data. CONCLUSIONS: Systemic corticosteroids are among the most common systemic treatments used for psoriasis despite current guidelines. Data are acutely needed on the risks and benefits so that physicians and patients can make evidence-based decisions about their use.

Common reasons why acne patients call the office.

BACKGROUND: Communication between physicians and patients is essential to providing proper medical care. At times, patients leave visits with insufficiently addressed questions. These questions prompt patients to call the clinic for additional information, which disrupts the flow of care, delays proper treatment, and reduces patient satisfaction. PURPOSE: We aim to examine acne patients' post-visit questions to develop interventions to improve patient education and reduce call backs. METHODS: A retrospective electronic medical record chart review was performed involving Wake Forest Baptist Health Dermatology clinic visits between October 1, 2012 and October 31, 2012. We identified acne patients using clinic visit notes and recorded their telephone calls to the clinic between October 1, 2012 and March 29, 2013. RESULTS: Of 315 acne patients, 31 (9.8%) called the clinic. Isotretinoin was the subject of 66.7% of the calls, half of which involved questions about potential side effects. Other calls addressed topical medications, acne symptoms, and pharmacy requests. LIMITATIONS: The study involved one center and email and fax correspondence was not captured. CONCLUSIONS: We found gaps in communication sufficient to require patients to call in for support, specifically regarding oral isotretinoin treatment. Interventions to address these questions have the potential to improve quality of care.

Are corticosteroids effective for prevention of scar formation after second-degree skin burn?

BACKGROUND: Superficial second-degree skin burns only need re-epithelialization to heal without a scar. After re-epithelialization, inflammation in the dermis contributes to changes in skin architecture and scarring. Suppression of inflammation and fibroblast activation immediately after re-epithelialization may prevent scar formation. Corticosteroids are the mainstay of treatment for keloids and hypertrophic scars. OBJECTIVE: To assess the available data on use of corticosteroids for prevention of scars. METHODS: A review of literature was performed seeking clinical trials using corticosteroids for prevention of scars. RESULTS: Corticosteroids have been used to prevent recurrence after keloid or hypertrophic scar excision with variable success. We did not find any report involving the clinical use of corticosteroids for the prevention of scar formation in other settings, including after skin burns. CONCLUSION: Theoretically, topical corticosteroids can suppress inflammation and fibroblast activation after skin burn, decreasing the incidence of scar formation. However, there is no study evaluating this hypothesis.

Verruciform xanthoma of the earlobe in an immunosuppressed patient.

Verruciform xanthoma (VX) is an uncommon mucocutaneous lesion of uncertain etiology. Originally thought to be limited to the oral mucosa, its occurrence in other mucosal and nonmucosal sites also has been documented. Histologically, VX is characterized by subepithelial foamy histiocytes associated with papillomatosis, parakeratosis, and dyskeratosis. Subepithelial foamy cells are lipid-containing, non-Langerhans cell histiocytes. A variety of etiologies have been proposed without much consensus, including infectious (bacterial, viral, and fungal), degenerative, reactive/ reparative, inflammatory, metabolic, reactive/ multifactorial, and immunosuppressive factors. Verruciform xanthoma of the external ear is exceedingly rare. Herein, we report a rare case of VX occurring on the earlobe at a piercing site in an immunosuppressed patient and provide a discussion of the possible pathogenetic mechanism(s).

Medication adherence, healthcare costs and utilization associated with acne drugs in Medicaid enrollees with acne vulgaris.

BACKGROUND: Acne vulgaris is a common chronic disease that may require long-term treatment. Medication adherence is critical to acne management; non-adherence is a common reason for treatment failure and can lead to poor quality of life. OBJECTIVE: The aim of the study was to examine medication adherence, healthcare costs, and utilization associated with acne drugs among acne patients in the USA. METHODS: This was a retrospective cohort study from January 2004 to December 2007 using the Marketscan Medicaid Database, a national healthcare claims database. The study followed acne patients aged 0-64 years for 90 days after the first acne drug prescription to measure acne medication adherence, acne-related outpatient visits, and total acne-related healthcare costs. Adherence was measured among different acne drug classes using medication possession ratio (MPR). Multivariate regression analyses were conducted to assess the outcomes. RESULTS: The study included 24,438 eligible patients, of whom 89.39 % were under 18 years old. The average adherence rate to acne drugs (MPR) was 0.34, and only 11.74 % of the patients were adherent (MPR ≥0.80). Patients with drug refills had a higher adherence rate (MPR = 0.74) than who those without refills (MPR = 0.27). Factors significantly associated with adherence were age, comorbidity, gender, number of drug refills and number of drug classes used. Patients were more adherent to oral retinoids than any other acne drug classes (MPR = 0.78, 57 % adherent). Patients were less adherent to oral antibiotics (MPR = 0.21) and topical retinoids (MPR = 0.31). After controlling for medication use behavior, the use of oral antibiotics decreased the number of acne-related outpatient visits by 50.9 % (p < 0.001) and lowered acne-related total costs by 51.7 % (p < 0.001). CONCLUSION: Medication non-adherence is generally prevalent among young acne patients enrolled in Medicaid. The combination of a topical retinoid and an antibiotic agent may be a good choice given their associated healthcare outcomes and costs. However, adherence to these agents is not satisfactory. Therefore, developing specific strategies to improve adherence to these drugs among teenage acne patients is warranted.

The effect of folate supplementation on methotrexate efficacy and toxicity in psoriasis patients and folic acid use by dermatologists in the USA.

BACKGROUND: Methotrexate (MTX) is an effective treatment for psoriasis but its use is limited by its toxicity. Folate supplementation can be used to reduce the adverse effects of MTX, though this may impact efficacy. The frequency of folic acid supplementation is not well characterized. PURPOSE: The objective of this study was to review the literature involving the use of folate in patients (in particular those with psoriasis) treated with MTX and analyze trends in folic acid use. METHODS: We searched PubMed from 1 May 1989 through 1 April 2012 using the terms 'folic acid,' 'folinic acid,' 'folate,' 'supplementation,' and 'methotrexate.' We also used the National Ambulatory Medical Care Survey (NAMCS) database to collect data regarding trends in MTX use and folic acid supplementation by physicians in the USA from 1993 through 2009. We assessed data including the number of MTX visits, rate of folic acid use, diagnoses, physician specialty, and demographics of patients. We used linear regression to analyze the change in folic acid use over time. RESULTS: Twenty-six published trials were included addressing folic acid supplementation with MTX. The majority found a benefit to folic acid supplementation, but there were only seven studies in psoriasis. Dermatologists were among the highest prescribers of MTX, and psoriasis was commonly treated with MTX. Folic acid supplementation significantly increased over this time period (p < 0.0001). However, dermatologists ranked lowest for their folate use, co-prescribing folate to only 9.1 % of MTX-treated patients. LIMITATIONS: In contrast to rheumatoid arthritis, there is a scarcity of literature describing the effect of folate on MTX toxicity and efficacy in psoriasis patients. NAMCS data only included outpatient visits to non-federally employed physicians, and there is the possibility of healthcare providers not documenting over-the-counter folic acid usage. Lastly, doses of MTX and folic acid were not recorded in the database. CONCLUSION: Dermatologists were the least likely specialists to supplement MTX with folic acid. The evidence for supplementation of folic acid is mixed. The literature confirms a reduction in the adverse effects of MTX but less strongly that there may be a reduction in efficacy too. Keeping in mind the potential for folate to reduce MTX efficacy, folic acid supplementation should be considered in MTX-treated patients.

Risk of cardiovascular disorders in psoriasis patients: current and future.

Psoriasis is an inflammatory autoimmune disease that affects the skin. Recently, psoriasis and its consequential lifestyle and dietary habits have been associated with increased risks for cardiovascular diseases. This article discusses the connection between cardiovascular disorders and psoriasis and the effects of available treatment options on cardiovascular risk. A PubMed search revealed 11 articles that were analyzed for information regarding this association, its effects, and potential courses of treatment. Both the presence and severity of psoriasis increases the risk for cardiovascular disorders and co-morbidities. Forty percent of psoriasis patients met metabolic syndrome criteria as compared with 23 % of non-psoriasis control subjects. Rate ratios for atrial fibrillation are correlated with the severity of psoriasis; patients with severe and mild psoriasis produced rate ratios of 1.63 and 1.31, respectively. Studies also show an increase in the risks for myocardial infarction, atherosclerosis, ischemic stroke, and other cardiovascular disorders. The exact mechanisms behind this affiliation are still uncertain; however, the psychological and physiological effects of psoriasis and the overlapping pathogenesis behind atherosclerosis and psoriasis may play a role. Since the risk for cardiovascular disorders increases with the presence and severity of psoriasis, psoriasis treatment should not only address the disease and its symptoms, but also its co-morbidities. Recent National Psoriasis Foundation (NPF) guidelines have provided recommendations for psoriasis patient care. Histories of co-morbidities, screenings for potential diseases, increased exercise, decreased alcohol consumption, and smoking cessation should be implemented. Unfortunately, while there are data for the increased risk for cardiovascular diseases within psoriasis patients, there are presently no data stating that increasing cardiovascular screening rates in patients produces a significant difference.