Changing Perceptions About the Dermatology Residency Application Process Among Applicants and Program Directors: 2020-2022.

Importance Over the last two years, dermatology has undergone significant reforms in the residency application process in efforts to reduce applicant stress, increase equity, and due to the COVID-19 pandemic.  Objective We aimed to determine applicant and program director (PD) perspectives in implementing these changes over the last two application cycles.  Design, setting, and participants Anonymous online surveys were administered by the Association of American Medical Colleges (AAMC) to PDs and applicants from the 2021-2022 dermatology residency application cycle. These results were compared with similar online surveys distributed after the 2020-2021 cycle. Results Coordinated interview release was introduced in the 2020-2021 dermatology application cycle. At that time, 57% of PDs and 84% of applicants wished that more programs participated in the release, compared to 53% and 84%, respectively, in the 2021-2022 cycle. In 2021, 28% of PDs reported matching applicants from their home institution higher on their list compared to 14% in 2022. In 2021 and 2022, 94% of PDs reported that diversity was an explicit goal in their application process. However, in 2021, 33% of PDs reported that they matched no UIMs (underrepresented in medicine) in their cohort, which grew to 39% in 2022. Conclusions This study identifies key trends in applicant and PD perspectives associated with changes in the application process such as coordinated interview release, virtual interviews, and emphasis on diversity. Additional data is needed from subsequent cycles in order to determine the efficacy of these reforms.

Perspectives on Full-Body Skin Examinations Among Sexual and Gender Minority Patients.

This survey study assesses full-body skin examination rates among sexual and gender minority patients and investigates their comfort with and reasons for discomfort during these examinations.

Impact of Preference Signals on Interview Selection Across Multiple Residency Specialties and Programs.

Background Program signaling is an innovation that allows applicants to express interest in specific programs while providing programs the opportunity to review genuinely interested applicants during the interview selection process. Objective To examine the influence of program signaling on "selected to interview" status across specialties in the 2022 Electronic Residency Application Service (ERAS) application cycle. Methods Dermatology, general surgery-categorical (GS), and internal medicine-categorical (IM-C) programs that participated in the signaling section of the 2022 supplemental ERAS application (SuppApp) were included. Applicant signal data was collected from SuppApp, applicant self-reported characteristics collected from the MyERAS Application for Residency Applicants, and 2020 program characteristics collected from the 2020 GME Track Survey. Applicant probability of being selected for interview was analyzed using logistic regression, determined by the selected to interview status in the ERAS Program Director's WorkStation. Results Dermatology had a 62% participation rate (73 of 117 programs), GS a 75% participation rate (174 of 232 programs), and IM-C an 86% participation rate (309 of 361 programs). In all 3 specialties examined, on average, signaling increased the likelihood of being selected to interview compared to applicants who did not signal. This finding held across gender and underrepresented in medicine (UIM) groups in all 3 specialties, across applicant types (MDs, DOs, international medical graduates) for GS and IM-C, and after controlling for United States Medical Licensing Examination Step 1 scores. Conclusions Although there was variability by program, signaling increased likelihood of being selected for interview without negatively affecting any specific gender or UIM group.

Guidelines on Away Rotations in Dermatology Programs.

The Association of Professors of Dermatology (APD) recently announced recommendations for away rotations for medical students. In this column, we provide an overview of the importance of away rotations, discuss the Organization of Program Director Associations (OPDA) recommendations for away rotations, and outline the guidelines set forth by the APD. This work on providing guidelines and transparency is ongoing and collaborative among specialties in line with the reforms to the application process to create a more sustainable and equitable system.

Mood changes and clinical decision making in adolescent patients on isotretinoin therapy for acne vulgaris.

Although numerous studies have demonstrated no causal relationship between isotretinoin and depression or suicide, subtle mood changes and idiosyncratic mood symptoms have been reported in patients on isotretinoin treatment for acne vulgaris, and few studies have described the full range of mood symptoms and clinical course after a mood change arises. We reviewed 247 patients, ages 10-25 years, with acne vulgaris on isotretinoin and found that 26/247 (10.5%) patients experienced mood changes, the most common being depressive symptoms, anxiety, aggression, and emotional lability. Regardless of treatment management, 22/25 (88%) patients experienced improvement of mood symptoms to baseline, and 22/25 (88%) were able to complete their isotretinoin course without symptom recurrence. Our findings highlight the importance of monitoring for a broad range of mood changes in patients on isotretinoin, especially those related to a pre-existing mood disorder and including those which do not meet formal criteria for a psychiatric disorder.

Impact of considering United States Medical Licensing Examination Step 1 pass/fail on diversity in dermatology residency recruitment.

The University of Chicago dermatology residency program considered the United States Medical Licensing Examination (USMLE) Step 1 pass/fail during the 2020-2021 application cycle with the goal of recruiting diverse dermatology residency candidates. We conducted a retrospective multiyear cross-sectional study among applicants to the dermatology residency program during the 2018-2019 and 2020-2021 application cycles, the latter excluding use of USMLE Step 1 cutoff scores as a screening tool. Of the applicants, 69.8% (n = 419) and 94.5% (n = 605) had their residency applications reviewed by our program during the 2018-2019 and 2020-2021 application cycles, respectively. There was a statistically significant upward trend in the number of underrepresented in medicine (URiM) applicants offered an interview from 10.4% (n = 5) to 37.7% (n = 20) across the application cycles. Multiple linear regression demonstrated there was a statistically significant decrease in the mean USMLE Step 1 score among applicants reviewed across application cycle and URiM status independently, and as a factor of their interaction (P = .016 and P = .001). By de-emphasizing the USMLE Step 1 score and using the test as originally intended, a marker for licensure, our program significantly increased the number of URiM applicants who were offered an interview and implemented a holistic review process focused on individual attributes and cultural competence.

Alopecia and hyperpigmentation in a neonatal patient with lanosterol synthase gene deficiency and Spectrin alpha, non-erythrocytic 1 mutation.

Lanosterol synthase is required for cholesterol synthesis, and deficiencies have been associated with hypotrichosis as well as neuroectodermal syndromes including intellectual delay and epilepsy. Here, we report a case of lanosterol synthase deficiency in a 4-day-old patient who presented with alopecia and a previously unreported dermatologic manifestation of congenital localized hyperpigmentation.

The Residency Application Process: Current and Future Landscape.

The residency application process has been the subject of increased scrutiny, accelerated by pandemic-associated effects on undergraduate and graduate medical education. Within dermatology, several reforms have been implemented since the 2020-2021 application cycle, with ongoing work to improve the process for both programs and applicants. Multiple other specialties also have implemented changes, and there is ongoing collaboration across specialties to reform the residency application and selection process to ultimately create a more equitable and sustainable system.

Disparities in telemedicine use during the COVID-19 pandemic among pediatric dermatology patients.

BACKGROUND/OBJECTIVES: The COVID-19 pandemic necessitated rapid implementation of telemedicine at medical centers across the United States. As telemedicine is expected to persist beyond the pandemic in subspecialties like pediatric dermatology, there is growing concern that socioeconomic factors may contribute to inequitable telemedicine access. This study aims to identify factors associated with disparities in telemedicine use among pediatric dermatology patients during the pandemic. METHODS: In this single-center cross-sectional study, patients less than 18 years old who completed a visit with a pediatric dermatologist via a video telemedicine call or in-person office visit during the specified time periods were included. Univariate and multivariable analyses were performed to compare demographic factors for (1) patients who had a telemedicine visit versus office visit during June 1, 2020, to January 22, 2021, and (2) patients who had either visit type during June 1, 2020, to January 22, 2021, versus June 1, 2019, to January 2020. RESULTS: The independent factors associated with lower odds of telemedicine include identifying as Black/African American, having a non-English preferred language, and having public insurance, whereas the independent factors reducing overall access to pediatric dermatology care during the pandemic include identifying as Hispanic/Latino and having public insurance. CONCLUSIONS: Differential telemedicine use in vulnerable communities may be attributed to disparities in technology access and digital literacy and should be addressed at a structural level. If such disparities are identified and adequately remedied, telemedicine can serve as an important tool for expanding access in the field of pediatric dermatology.

Follicular keratosis of the face in pediatric patients of color.

BACKGROUND/OBJECTIVES: Follicular keratosis (FK) is a poorly understood disorder presenting with multiple, grouped hyperkeratotic follicular papules typically affecting the chin or jawline. This study describes the clinical presentation, histopathology, management, and outcomes of a series of pediatric patients of color with FK of the face, thought to be related to rubbing or friction on the skin. METHODS: Retrospective review of 20 pediatric patients with FK of the face who presented to our pediatric dermatology practice between April 2019 and October 2021. RESULTS: Twenty patients (mean age 12.1 years, 13 females), all self-identified as Black/African American, were included. All presented with an initially asymptomatic, hyperpigmented patch containing multiple hyperkeratotic follicular papules, located on the cheek, chin, upper lip, and/or jawline. Five patients endorsed a history of rubbing the site. Nine patients had onset of the lesions during the COVID-19 pandemic. Treatments included topical vitamin D analogs, corticosteroids, and/or retinoids. Topical vitamin D analogs and retinoids improved the texture and hyperpigmentation of the follicular lesions in only four patients, while topical corticosteroids had no effect. Histopathological examination of two patients revealed multiple dilated follicles containing keratinized material and associated with a sparse dermal inflammatory infiltrate in one patient and granulomatous inflammation within the dermis in the other. CONCLUSIONS: In our cohort of pediatric patients with FK, patients of color were preferentially affected, and all cases were associated with hyperpigmentation. Some patients presented during the COVID-19 pandemic suggesting that friction from facial mask wearing may have induced or exacerbated this uncommon condition.

Virtual group visits to reduce psychosocial distress and racial disparities in pediatric vitiligo and alopecia areata patients.

We examined the potential for virtual, pediatric group visits to reduce racial disparities in psychosocial isolation and access to care among children of color with pediatric vitiligo and alopecia areata as well as their caregivers. We have conducted 10 visits with 30 pediatric skin of color patients between 5 and 16 years old: 18 patients with alopecia areata, 12 with vitiligo, 59% female, 64% Black, and 23% Latinx, and 33 parents. After the visits, children and parents felt they had more people they knew and could reach out to about their dermatologic condition, the visits exceeded both children's and parents' expectations, and both children and parents reported that they would continue attending future group visits if offered. Group visits in the virtual format may present an opportunity for reducing racial disparities in psychosocial isolation and access to care across geographic locations in pediatric dermatology.

Prevention of racialized medicine in pediatric dermatology: A call to re-examine skin tone typing.

The Fitzpatrick skin phototype (FSPT), a biologic concept originally constructed in light-skinned patients to measure UVA sensitivity, is widely used today across pediatric dermatology as a proxy for race, a social and political construct. We outline why this is problematic and could contribute to racially inequitable care and discuss the broader question of whether skin tone is relevant to measure in all cases. We propose that, instead of indiscriminately measuring skin tone in all clinical cases, pediatric dermatologists choose the skin characterization variable most relevant to their patient's condition. This both avoids conflating skin tone with race and more broadly quells the myth of racial essentialism and the resultant practice of racialized medicine, which history has shown is used as justification for discriminatory and harmful practices toward racially marginalized groups.

Vitiligoid variant of lichen sclerosus in young girls with darker skin types.

BACKGROUND/OBJECTIVES: Vitiligo and lichen sclerosus are autoimmune disorders characterized by white discoloration, and both frequently affect the anogenital region. Vitiligoid lichen sclerosus refers to a superficial variant of lichen sclerosus in which the lesion appears clinically to be vitiligo based on the predominant presentation of depigmentation and minimal inflammation and sclerosis but histologically is consistent with lichen sclerosus. A limited number of reports have described vitiligoid lichen sclerosus, and from these reports, it appears to primarily affect darker-skinned people. METHODS: We retrospectively reviewed the records of 7 girls with darker skin types seen in our pediatric dermatology clinic who presented with a clinical overlap of vitiligo and lichen sclerosus. All had primarily well-demarcated, depigmented patches characteristic of vitiligo, but the lesions were symptomatic (pruritus, pain, bleeding, constipation), a presentation more consistent with lichen sclerosus. RESULTS: The girls were all treated with high-potency topical steroids, calcineurin inhibitors, or both. The associated symptoms improved or resolved, but most had minimal improvement of the depigmentation. CONCLUSIONS: The girls presented in this series appear to have had vitiligoid lichen sclerosus, given the clinical overlap of lichen sclerosus and vitiligo affecting the anogenital region, particularly given that they did not have depigmented patches elsewhere on their body. Previous cases of vitiligoid lichen sclerosus have been reported in darker skin types, and our findings support this possible predisposition. It is important for clinicians to assess patients presenting with genital depigmentation for overlapping features of vitiligo and lichen sclerosus and determine appropriate management.

Cutaneous reactions to vaccinations.

Vaccinations are important for infectious disease prevention; however, there are adverse effects of vaccines, many of which are cutaneous. Some of these reactions are due to nonspecific inflammation and irritation at the injection site, whereas other reactions are directly related to the live attenuated virus. Rarely, vaccinations have been associated with generalized hypersensitivity reactions, such as erythema multiforme, Stevens-Johnson syndrome, urticaria, acute generalized exanthematous pustulosis, and drug hypersensitivity syndrome. The onset of certain inflammatory dermatologic conditions, such as lichen planus, granuloma annulare, and pemphigoid, were reported to occur shortly after vaccine administration. Allergic contact dermatitis can develop at the injection site, typically due to adjuvant ingredients in the vaccine, such as thimerosal and aluminum. Vaccinations are important to promote development of both individual and herd immunity. Although most vaccinations are considered relatively safe, there may be adverse effects associated with any vaccine. Cutaneous manifestations make up a large portion of the types of reactions associated with vaccines. There are many different reasons for the development of a cutaneous reaction to a vaccination. Some are directly related to the injection of a live attenuated virus, such as varicella or vaccinia (for immunity to smallpox), whereas others cause more nonspecific erythema and swelling at the injection site, as a result of local inflammation or irritation. Vaccinations have also been associated in rare reports with generalized hypersensitivity reactions, such as erythema multiforme, Stevens-Johnson syndrome, urticaria, acute generalized exanthematous pustulosis, and drug hypersensitivity syndrome. There have been case reports associating the administration of a vaccine with the new onset of a dermatologic condition, such as lichen planus, granuloma annulare, and Sweet syndrome. Finally, allergic contact dermatitis can develop at the injection site, typically due to adjuvant ingredients in the vaccine, such as thimerosal and aluminum.

A 22-month-old girl with lesions on the face and extremities.

CME EDUCATIONAL OBJECTIVES: 1.Diagnose Gianotti-Crosti syndrome (GCS) based on the clinical presentation.2.Understand the various etiologies (viral, immunizations, bacterial) associated with GCS.3.Know the natural course of GCS. A 22-month-old black girl presented to the emergency department with a 5-day history of an itchy rash. Her family reported that the rash started as itchy bumps on the extremities and spread to the face and buttocks and was associated with a runny nose and cough. There was no history of fevers, abdominal pain, vomiting or diarrhea. The patient had a medical history significant for pyleonephritis, pneumonia, and meningitis. She did not have any allergies to medications and was not taking any medications.

Inhibition of the Rho GTPase, Rac1, decreases estrogen receptor levels and is a novel therapeutic strategy in breast cancer.

Rac1, a Rho GTPase, modulates diverse cellular processes and is hyperactive in some cancers. Estrogen receptor-alpha (ERα) in concert with intracellular signaling pathways regulates genes associated with cell proliferation, tumor development, and breast cancer cell survival. Therefore, we examined the possibility of Rac1 and ERα crosstalk in breast cancer cells. We found that Rac1 enhanced ERα transcriptional activity in breast cancer cells. Vav3, a Rho guanine nucleotide exchange factor that activates Rac1, was an upstream mediator, and P21/Cdc42/Rac1 activating kinase-1 (Pak-1) was a downstream effector of Rac1 enhancement of ERα activity. These results suggest that Rac1 may prove to be a therapeutic target. To test this hypothesis, we used a small molecule Rac inhibitor, EHT 1864, and found that EHT 1864 inhibited ERα transcriptional activity. Furthermore, EHT 1864 inhibited estrogen-induced cell proliferation in breast cancer cells and decreased tamoxifen-resistant breast cancer cell growth. EHT 1864 decreased activity of the promoter of the ERα gene resulting in down-regulation of ERα mRNA and protein levels. Therefore, ERα down-regulation by EHT 1864 is the likely mechanism of EHT 1864-mediated inhibition of ERα activity and estrogen-stimulated breast cancer cell proliferation. Since ERα plays a critical role in the pathogenesis of breast cancer and the Rac inhibitor EHT 1864 down-regulates ERα expression and breast cancer cell proliferation, further investigation of the therapeutic potential of Rac1 targeting in the treatment of breast cancer is warranted.

Inhibition of androgen receptor transcriptional activity as a novel mechanism of action of arsenic.

Environmental sodium arsenite is a toxin that is associated with male infertility due to decreased and abnormal sperm production. Arsenic trioxide (ATO), another inorganic trivalent semimetal, is an effective therapy for acute promyelocytic leukemia, and there is investigation of its possible efficacy in prostate cancer. However, the mechanism of arsenic action in male urogenital tract tissues is not clear. Because the androgen receptor (AR) plays an important role in spermatogenesis and prostate cancer, we explored the possibility that trivalent arsenic regulates AR function. We found that arsenic inhibited AR transcriptional activity in prostate cancer and Sertoli cells using reporter gene assays testing several androgen response element-containing regions and by assessing native target gene expression. Arsenic inhibition of AR activity was not due to down-regulation of AR protein levels, decreased hormone binding to AR, disruption of AR nuclear translocation, or interference with AR-DNA binding in vitro. However, chromatin immunoprecipitation studies revealed that arsenic inhibited AR recruitment to an AR target gene enhancer in vivo. Consistent with a deficiency in AR-chromatin binding, arsenic disrupted AR amino and carboxyl termini interaction. Furthermore, ATO caused a significant decrease in prostate cancer cell proliferation that was more pronounced in cells expressing AR compared with cells depleted of AR. In addition, inhibition of AR activity by ATO and by the AR antagonist, bicalutamide, was additive. Thus, arsenic-induced male infertility may be due to inhibition of AR activity. Further, because AR is an important target in prostate cancer therapy, arsenic may serve as an effective therapeutic option.