Work-life balance among female dermatologists.

BACKGROUND: Female dermatologists often face the challenges of balancing a rewarding medical career with duties of home life and childrearing. Excessive responsibility at home or work can introduce barriers to balance and prove detrimental to the health and wellness of the physician. OBJECTIVE: We aim to perform a needs assessment through a series of survey questions with regard to home and work responsibilities and impacts on mental health. METHODS: Survey participants were selected from the Women's Dermatologic Society through an e-mail invitation with a link to an anonymous survey tool and a paper questionnaire at the Women's Dermatologic Society Forum in February 2019 in Dallas, Texas. The survey included 20 questions with regard to household responsibilities, child care, clinical responsibilities, specialty education, and impacts on personal time, sleep, and overall sense of well-being. There were a total of 127 respondents. RESULTS: Eighty-five percent of physicians in our cohort are currently married. A large percent of respondents utilized hired household help in the form of nannies to perform chores. Spousal contribution was emphasized in this cohort and often highlighted as an important factor in maintaining home life duties. CONCLUSION: The professional women in our cohort may be balancing work and life at the expense of personal physical and mental health with little time to exercise and fewer hours of sleep per night.

Association between type of reconstruction after Mohs micrographic surgery and surgeon-, patient-, and tumor-specific features: a cross-sectional study.

BACKGROUND: There are few data to indicate whether the type of final wound defect is associated with the type of post-Mohs repair. OBJECTIVE: To determine the methods of reconstruction that Mohs surgeons typically select and, secondarily, to assess the association between the method and the number of stages, tumor type, anatomic location, and patient and surgeon characteristics. METHODS: Statistical analysis of procedure logs of 20 representative young to mid-career Mohs surgeons. RESULTS: The number of stages associated with various repairs were different (analysis of variance, p < .001.). Linear repairs, associated with the fewest stages (1.5), were used most commonly (43-55% of defects). Primary repairs were used for 20.2% to 35.3% of defects of the nose, eyelids, ears, and lips. Local flaps were performed typically after two stages of Mohs surgery (range 1.98-2.06). Referral for repair and skin grafts were associated with cases with more stages (2.16 and 2.17 stages, respectively). Experienced surgeons were nominally more likely perform flaps than grafts. Regression analyses did not indicate any association between patient sex and closure type (p = .99) or practice location and closure type (p = .99). CONCLUSIONS: Most post-Mohs closures are linear repairs, with more bilayered linear repairs more likely at certain anatomic sites and after a larger number of stages.

Association between number of stages in Mohs micrographic surgery and surgeon-, patient-, and tumor-specific features: a cross-sectional study of practice patterns of 20 early- and mid-career Mohs surgeons.

OBJECTIVE: To determine the number of Mohs micrographic surgery (MMS) stages per tumor taken by early- to mid-career Mohs surgeons and to assess other factors affecting number of stages. METHODS: Statistical analysis of MMS logs of 20 representative early- to mid-career surgeons. RESULTS: There was no difference in stages when surgeons were divided into two categories based on whether they had more than 500 cases per year or more than 5 years of experience. Similarly, when surgeons were categorized according to geographic location, there was no difference in number of stages. Anatomic location was associated with the number of stages (analysis of variance, p<.001), with the greatest number of stages for nose (2.01) and ear (2.06) lesions and the fewest for neck (1.47), back and shoulder (1.47), and lower extremity (1.33) lesions. Basal cell carcinomas required 1.92 stages (median 2.00), compared with 1.66 (median 1.00) for squamous cell carcinoma (p<.001). CONCLUSIONS: Early- and mid-career Mohs surgeons appear to remove tumors with similar numbers of stages regardless of their experience, case volume, or geographic location. Number of stages varies with anatomic location and tumor type. The authors have indicated no significant interest with commercial supporters.

Ultrasound tightening of facial and neck skin: a rater-blinded prospective cohort study.

BACKGROUND: Nonablative skin tightening technologies offer the prospect of reduction of wrinkles and skin sagging with minimal downtime, discomfort, and risk of adverse events. The excellent safety profile is mitigated by the limited efficacy of such procedures. OBJECTIVE: We sought to assess the efficacy of ultrasound skin tightening for brow-lift in the context of a procedure treating the full face and neck. METHODS: This was a rater-blinded, prospective cohort study at a dermatology clinic in an urban academic medical center. Subjects were medicated with topical anesthetic and then treated with an investigational focused intense ultrasound tightening device to the forehead, temples, cheeks, submental region, and side of neck using the following probes: 4 MHz, 4.5-mm focal depth; 7 MHz, 4.5-mm focal depth; and 7 MHz, 3.0-mm focal depth. Standardized photographs of front and side views were obtained at 2, 7, 28, 60, and 90 days; rating scales of pain, adverse events, physical findings, and patient satisfaction were also completed. Primary outcome measure was detection of improvement in paired comparison of pretreatment and posttreatment (day 90) photographs by 3 masked expert physician assessors, cosmetic and laser dermatologists, and plastic surgeons who were not authors. Second primary outcome measure was objective brow elevation as quantitated by a standard procedure using fixed landmarks. Secondary outcomes measure was patient satisfaction as measured by a questionnaire. RESULTS: A total of 36 subjects (34 female) were enrolled, one subject dropped out, and 35 subjects were evaluated. Median age was 44 years (range 32-62). On the first primary outcome measure, 30 of 35 subjects (86%) were judged by the 3 masked experienced clinician raters to show clinically significant brow-lift 90 days after treatment (P = .00001). On the second primary outcome measure, mean value of average change in eyebrow height as assessed by measurement of photographs at 90 days was 1.7 mm. LIMITATIONS: Limitations of this study include the inability to quantitatively measure lower face tightening because of the lack of fixed anatomic landmarks in this area. CONCLUSION: Ultrasound appears to be a safe and effective modality for facial skin tightening. A single ultrasound treatment of the forehead produced on average brow height elevation of slightly less than 2 mm. Most treated individuals responded, commonly with accompanying transitory mild erythema and edema.

Comparison of treatment of cherry angiomata with pulsed-dye laser, potassium titanyl phosphate laser, and electrodesiccation: a randomized controlled trial.

OBJECTIVE: To assess the comparative efficacy of energy treatments in resolving cherry angiomata. DESIGN: Rater-blinded randomized controlled trial. SETTING: Outpatient dermatology clinic in an urban referral academic medical center. PARTICIPANTS: Fifteen healthy adults aged 21 to 65 years were enrolled. Two eligible individuals who were approached declined to participate, and no one enrolled was withdrawn for adverse effects. INTERVENTIONS: For each participant, 3 areas on the torso were demarcated such that each area contained 4 cherry angiomata. Each area was then randomly assigned to receive 1 of the 3 treatments: pulsed-dye laser (PDL) (595 nm), potassium titanyl phosphate (KTP) laser (532 nm), or electrodesiccation. Two treatments spaced 2 weeks apart were delivered to each area. MAIN OUTCOME MEASURES: Standardized photographs from before treatment and 3 months after the last treatment were evaluated for color and texture on visual analog scales. RESULTS: Mean change in color was a significant improvement of 7.77 (P<.001), but there was no significant difference across treatment arms (P=.19). Mean change in texture was a significant improvement of 6.23 (P<.001), and the degree of textural change also differed across treatments (P<.001). In pairwise comparisons, cherry angiomata treated with electrodesiccation were significantly less improved than were those receiving KTP laser (P=.003) and those treated with PDL (P=.001). The effects of KTP laser and PDL on texture were not different (P=.50). CONCLUSIONS: Cherry angiomata can be effectively treated with electrodesiccation and with laser. Laser, especially PDL, may minimize the likelihood of treatment-associated textural change. Trial Registration clinicaltrials.gov Identifier: NCT00509977.

Assay development and high-throughput antiviral drug screening against Bluetongue virus.

Bluetongue virus (BTV) infection is one of the most important diseases of domestic livestock. There are no antivirals available against BTV disease. In this paper, we present the development, optimization and validation of an in vitro cell-based high-throughput screening (HTS) assay using the luminescent-based CellTiter-Glo reagent to identify novel antivirals against BTV. Conditions of the cytopathic effect (CPE)-based assay were optimized at cell density of 5000 cells/well in medium containing 1% FBS and a multiplicity of infection at 0.01 in 384-well plate, with Z'-values > or = 0.70, Coefficient of Variations > or = 5.68 and signal-to-background ratio > or = 7.10. This assay was further validated using a 9532 compound library. The fully validated assay was then used to screen the 194,950 compound collection, which identified 693 compounds with >30% CPE inhibition. The 10-concentration dose response assay identified 185 structures with IC(50) < or =100 microM, out of which 42 compounds were grouped into six analog series corresponding to six scaffolds enriched within the active set compared to their distribution in the library. The CPE-based assay development demonstrated its robustness and reliability, and its application in the HTS campaign will make significant contribution to the antiviral drug discovery against BTV disease.

Comparison of electrodesiccation and potassium-titanyl-phosphate laser for treatment of dermatosis papulosa nigra.

BACKGROUND: There is a lack of randomized split-face studies investigating treatments for dermatosis papulosa nigra (DPN) in dark skin. OBJECTIVE: To compare the efficacy, safety, and tolerability of potassium-titanyl-phosphate (KTP) laser with efficacy, safety, and tolerability of electrodesiccation in the treatment of DPN in subjects with Fitzpatrick skin phototypes IV to VI. METHODS: Fourteen subjects with Fitzpatrick skin phototypes IV to VI were randomized to receive two KTP laser treatments 4 weeks apart to half of the face. The contralateral half received two electrodesiccation treatments 4 weeks apart. Response was evaluated by photography reviewed by blinded dermatologists at 4 weeks after the second treatment. A treatment quality questionnaire about side effects and cosmetic outcome was also administered. RESULTS: Difference in improvement of DPN between the KTP side and the electrodesiccation side per each rater (p=.99, p=.54) and per raters combined (p=.50) did not reach statistical significance. There was no treatment difference for subjective effectiveness (p=.06) or subjective confidence improvement (p=.99), although there was a significant treatment difference for subjective discomfort (p=.002) in favor of KTP. Both treatments were well tolerated without significant adverse effects. CONCLUSIONS: Although treatment of DPN with KTP laser and electrodesiccation are comparable in efficacy, KTP laser is preferable for patient comfort.

Effectiveness, safety, and effect on quality of life of topical salicylic acid peels for treatment of postinflammatory hyperpigmentation in dark skin.

BACKGROUND: There are no randomized split-face model studies investigating treatments for postinflammatory hyperpigmentation (PIH) in dark skin. OBJECTIVE: To assess the efficacy, safety, and effect on quality of life of salicylic acid peels for PIH in dark skin. METHODS: Ten subjects with Fitzpatrick skin phototypes IV to VI were randomized to receive two 20% salicylic acid peels followed by three 30% salicylic acid peels to half of the face. The contralateral half remained untreated. Response was evaluated by photography reviewed by three blinded dermatologists. The Visual Analog Scale, Dermatology Life Quality Index (DLQI), and treatment quality questionnaire were administered. RESULTS: Improvement of PIH on the treatment side according to each rater (p=.81, p=.81, p=.42) and according to the raters combined (p=.11) approached but did not reach statistical significance. Subjects' Visual Analog Scale scores indicated significantly greater improvement of PIH on the treatment side than in the control (p=.004). Quality of life measured according to the DLQI improved after treatment but not statistically significantly so (p=.13). Treatment had no significant adverse effects. CONCLUSIONS: Salicylic acid peels are safe in this population. Although patients rated them as clinically effective, blinded raters found a brief series of peels to have less efficacy. Measured quality of life improved nominally.

Barbed sutures: a review of the literature.

BACKGROUND: Despite substantial mention in the popular press, there is little in the plastic surgery or dermatology literature regarding the safety, efficacy, longevity, or complications of barbed suture suspension procedures. The authors review the literature to estimate several clinical parameters pertaining to barbed thread suspensions. METHODS: The authors performed a MEDLINE search using the keywords "barbed and suture," "thread and suspension," "Aptos," "Featherlift," and "Contour Thread." RESULTS: The authors identified six studies that met their criteria of addressing midface elevation with barbed thread suspension. These detected some adverse events, but most of these were minor, self-limited, and of short duration. Less clear are the data on the extent of the peak correction and the longevity of effect. Objective outcome measures and long-term follow-up data were not provided in a systematic manner in the few available studies. CONCLUSIONS: Suspension of the aging face with barbed sutures offers the promise of a minimally invasive technique with diminished adverse events. The technique is in its infancy, but it has potential to be a useful and effective clinical tool as further innovations are made in the clinic and laboratory.

Breaking strength of barbed polypropylene sutures: rater-blinded, controlled comparison with nonbarbed sutures of various calibers.

OBJECTIVES: To assess the strength of 2.0 barbed polypropylene suture, and, specifically, to determine the load required to break this suture, and to compare this with the strength of nonbarbed polypropylene suture. DESIGN: Rater-blinded, controlled trial. The individual responsible for setting up the experimental conditions was not blinded. SETTING: Biomechanics laboratory in an academic medical center. MATERIALS: This study did not include human subjects. Materials used included six 2.0 barbed polypropylene sutures and 3 each of 2.0, 3.0, 4.0, and 5.0 nonbarbed polypropylene sutures. Each suture was randomly selected from a different batch or box of similar sutures. INTERVENTION: Each suture was strung between 2 (top and bottom) cylinders and tied with a surgeon's knot. A tensile testing device was used to apply increasing force until the suture broke. Data were acquired through an analog-to-digital board on an IBM-compatible computer using commercially available software. MAIN OUTCOME MEASURES: Ultimate strength, stiffness, and elongation before suture rupture. RESULTS: Strength of the barbed sutures (mean [SD] ultimate strength, 39.5 [9.0] N) was intermediate between that of 2.0 (55.0 N) and 3.0 (36.4 N) nonbarbed sutures and was not significantly different from that of 3.0 nonbarbed sutures (P = .5). Barbed 2.0 polypropylene sutures differed significantly (P < .001) from each of the other types of nonbarbed sutures on measures of stiffness and elongation. Elongation of barbed sutures was closest to that of 3.0 nonbarbed sutures (P = .002). Stiffness of the barbed sutures (mean [SD], 4.7 [0.7] N/mm) was markedly in excess of that of any of the other suture types (P < .001). CONCLUSIONS: Barbed 2.0 polypropylene sutures seem to be at least as strong as 3.0 nonbarbed polypropylene sutures. As such, barbed sutures are significantly stronger than their rated strength, which has been stated as comparable to 4.0 nonbarbed sutures. This has implications for the long-term in vivo safety of barbed sutures.

High throughput drug screening for human immunodeficiency virus type 1 reactivating compounds.

The ability of human immunodeficiency virus type 1 (HIV-1) to persist in a latent stage in memory T cells in the presence of antiretroviral therapy poses a major obstacle to the development of an HIV-1 therapy with curative intent. As latently infected cells are phenotypically not distinguishable from uninfected cells, therapeutic reactivation of the latent infection, followed by the death of the host cell induced by viral cytopathicity, is considered the only means to eliminate this viral reservoir. To identify compounds with the potential to reactivate latent HIV-1, we have developed a series of latently HIV-1-infected reporter cell lines that allow for high throughput drug screening (HTS) in a 384-well plate-based format. The latent reporter cell lines use enhanced green fluorescence protein (eGFP) as a direct and quantitative marker of HIV-1 expression. To aid identification of specific compounds, the cells are engineered to constitutively express a second, red fluorescent protein that has no spectral overlap with eGFP, which allows for the simultaneous quantification of cell viability (inversely correlated to compound toxicity). Thus, these reporters enable prioritization of compounds most likely to have a favorable therapeutic window. The high dynamic signal range and the excellent reproducibility of the primary screening assay result in a Z' -factor of 0.89, which characterizes the HTS system as very robust. The assay has been implemented for automated drug screening, and we here discuss the advantages and limitations of the HTS system based on the data obtained for 1,600 compounds during a limited proof-of-concept drug screen.

A hairy development in hypertrichosis: a brief review of Ambras syndrome.

Ambras syndrome was described less than 20 years ago. The initial report focused on the subtle, but important distinguishing characteristics that separate this from other forms of congenital hypertrichosis. This review, we examine this fascinating syndrome, and the current scientific perspectives in discussion. This review will help increase and expand our knowledge base of this uncommon syndrome, and should encourage future dermatologic analysis and reports on Ambras syndrome.

So you want to be a dermasurgeon: how to get training or choose a fellowship.

BACKGROUND There are many routes to obtaining training in dermasurgery. OBJECTIVE The objective is to discuss some considerations that may guide selection of dermasurgery training. METHODS Current training options are reviewed. RESULTS Some considerations that may guide selection of type of dermasurgery training include: (1) individual temperament; (2) the subtype of dermasurgery in which training is desired (Mohs, cosmetic surgery, laser); (3) family and geographic factors; (4) preference for private practice versus academic career; and (5) proportion of future practice to be devoted to dermasurgery. CONCLUSIONS There are a growing number of training choices for budding dermasurgeons, with multiple options available for each set of particular circumstances.

Sterility assessment of multiple use botulinum A exotoxin vials: a prospective simulation.

BACKGROUND: A preponderance of evidence now indicates that storage of reconstituted botulinum toxin solution for longer than the 4 hours recommended by the manufacturer does not result in loss of effectiveness. OBJECTIVE: Then purpose of this study was to assess whether serial re-extraction of reconstituted botulinum toxin solution from vials undergoing prolonged storage is associated with increased risk of microbial contamination. METHODS: Consecutive 100-U vials of botulinun A exotoxin were reconstituted with 2.5 mL each of normal saline with preservative (benzyl alcohol). Within 1 week after reconstitution, each vial was used to treat 1 to 3 patients, for a total of 60 to 80 U used. Thereafter, each vial was stored in a plastic kidney basin in an unlocked, multiuse medication refrigerator. Two weeks later, a randomly assigned nurse removed the vial from the refrigerator and withdrew and discarded 0.1 mL (5 U) using the same technique used for therapeutic extractions. Iterations of this withdrawal and discarding procedure were continued until a 0.1-mL aliquot could not be withdrawn without prying off the metal cover. Once this threshold was reached, the vial was sent to the microbiology laboratory for sterility testing using a thioglycolate broth. RESULTS: In all, 127 vials were handled per protocol. On average (mean), vials underwent 4.5 access procedures, including 1.6 therapeutic extractions for a total of 76 U removed during a period of 7 weeks. Sterility analysis with thioglycolate broth indicated no evidence of contamination. LIMITATIONS: Preservative-containing saline was used for reconstitution. CONCLUSION: Routine refrigerator storage of medication vials containing reconstituted botulinum toxin does not result in microbial contamination of the contents even after serial re-extraction of solution from these vials, and after handling of such vials by multiple personnel. Storage and subsequent reuse of botulinum toxin appears safe for at least 7 weeks after reconstitution.

Pyoderma gangrenosum related to a new granulocyte colony-stimulating factor.

A 23-year-old Caucasian man diagnosed with stage IVB Hodgkin's disease was referred to a university oncology section after completing 1.5 cycles of chemotherapy. His chemotherapy consisted of doxorubicin HCL, bleomycin, dacarbazine, and vinblastine, with prophylactic administration of a granulocyte colony stimulating factor. He had developed postchemotherapy complications of possible cellulitis and necrotizing fasciitis that required wound debridement. The wound and tissue cultures were negative. Biopsies taken at the time revealed a dense inflammatory infiltrate consistent with an abscess. Over the course of 2 months, the wound healed with systemic antibiotics. The patient was reluctant to resume chemotherapy for his Hodgkin's disease because of his previous presumed skin infections. However, positive emission tomographic scanning revealed disease progression. Doxorubicin, bleomycin, dacarbazine, and prophylactic pegfilgrastim (a granulocyte colony-stimulating factor), were administered. Vinblastine was excluded from the new regimen. Shortly after chemotherapy and an injection of pegfilgrastim, the patient developed poorly defined, rapidly progressive erythema, edema, and pain in his right forearm. He presented to the emergency room, was evaluated by the orthopedics service, and taken to the operating room for debridement of suspected necrotizing fasciitis. When the dermatology service consulted the following day, the patient had developed an erythematous, edematous, tender plaque on his chest. After developing two additional lesions that began to ulcerate despite treatment with imipenem, vancomycin, clindamycin, rifampin, and gentamicin, the patient consented to a skin biopsy. His wound cultures continued to be negative.

Long-term safety of spironolactone in acne: results of an 8-year followup study.

BACKGROUND: Spironolactone has been used for over 20 years as an antiandrogen in the treatment of acne and hirsutism. No long-term studies of the safety of spironolactone used in this manner have been published. We present a study of the long-term safety and tolerance of spironolactone in 91 women with acne who were followed for up to 8 years. METHODS: A survey questionnaire was sent to 210 patients, and a comparison chart review of all patients to whom the survey was sent was made. RESULTS: Ninety-one completed surveys were analyzed, comprising 506 person-years of followup and 200 person-years of spironolactone exposure. Mean treatment length was 28.5 months (range = 0.5-122 months). During the 8-year followup period, there were no cases of serious illness attributable to spironolactone use. Side effects were present in 59% and resulted in cessation of the drug in 15%. Diuretic effect and menstrual irregularities were the most common adverse effects. CONCLUSIONS: After 200 person-years of exposure to spironolactone and 506 person-years of followup over 8 years, no serious illnesses thought to be attributed to spironolactone were reported. The long-term use of spironolactone in the treatment of acne in women appears to be safe. Side effects, however, are common, although not usually a cause for stopping the drug.