Academic Dermatology Department Research Articles

A gender-based comparison of promotion and research productivity in academic dermatology

Gender disparities within academic promotion have been reported in several medicalspecialties. Female representationin association with research productivity has not been reported among academic dermatologists. Asresearch productivity is a heavily weighted factor in determining promotion, we sought to determinewhether gender disparities in academic rank and scholarly impact, measured by the h-index, exist inacademic dermatology. In 2015, the authors determined gender and academic rank using academic dermatologydepartment websites. H- index and publication range were determined using the Scopus database.Rank, h-index, and publication range were compared between male and female academic dermatologists. The h-index of academic dermatologists increased with successive academic rank fromAssistant Professor through Professor (p<0.001), although no significant difference existed betweenChairs and Professors. Publication range also increased with each successive rank from AssistantProfessor through Professor (p<0.001), with no statistical significant difference betweenpublication range of Chairs and Professors. Overall, men had higher h-indices than femalecolleagues (p<0.001). This difference was maintained when controlling for academic rank amongAssistant Professors, Professors, and Chairs and when controlling for publication range in years. Women in academic dermatology are underrepresented among senior academic ranks. Thedifference in scholarly productivity between male and female academic dermatologists may contributeto this disparity. Recommendation for earlyinvolvement in research activities may help minimize this gap.

Coexistence of autoimmune bullous diseases (AIBDs) and psoriasis: A series of 145 cases

Many case reports have described the coexistence of autoimmune bullous diseases (AIBDs) and psoriasis. Among them, anti-laminin γ1 (p200) pemphigoid is the best known. We sought to characterize patients with AIBDs and psoriasis and to investigate common AIBDs occurring in these patients. This retrospective study included 145 patients with coexisting AIBD and psoriasis given a diagnosis from January 1, 1996, to July 31, 2013, at an academic dermatology department. Of these, 134 were consultation cases regarding AIBD diagnosis. Ratio of male to female patients was 5.7:1. Psoriasis onset preceded AIBD onset in most patients. Mean age at AIBD onset was 65.4 years, and mean duration between psoriasis and AIBD onset was 14.6 years. Most cases had single AIBD, whereas 16 cases had combined AIBDs. Bullous pemphigoid was the most prevalent (63.4%) followed by anti-laminin γ1 pemphigoid (37.2%). Consultation cases may not have included mild AIBD cases. This study confirmed the association of psoriasis and anti-laminin γ1 pemphigoid. However, because bullous pemphigoid is a much more common disease, it is seen more frequently in patients with psoriasis than anti-laminin γ1 pemphigoid.

Predictive value of biopsy specimens suspicious for melanoma: Support for 6-mm criterion in the ABCD rule

Clinical detection of melanoma can be challenging. The number of biopsy specimens performed to diagnose 1 melanoma is a measure of efficiency of skin cancer detection, but few data are available to describe this measure from US health care. We studied the diagnosis of melanoma among biopsy specimens of clinically concerning pigmented lesions at an academic dermatology department. We searched for all biopsy specimens that were performed because of clinical suspicion of melanoma in 2013. Characteristics of the patient, lesion, and clinician performing the biopsy, and the final pathology diagnosis were recorded. A total of 2643 biopsy specimens from 2213 patients submitted by 43 providers were included. Melanoma was diagnosed in 165 cases (positive predictive value 6.4%, 95% confidence interval 5.5%-7.4%). Older age (P < .001), male gender (P = .045), and nontrunk location (P < .001) were predictors of higher probability of melanoma detection. Lesions larger than 6 mm in size had higher positive predictive value 11.5% (8.8%-14.1%) than smaller lesions 2.6% (1.6%-3.6%). Factors influencing the decision to biopsy a lesion may be difficult to evaluate retrospectively. At an academic medical center, 16 clinically concerning lesions were biopsied to diagnose 1 melanoma. Biopsy specimens of clinically concerning pigmented lesions larger than 6 mm on older men had the highest yield.

Survey of an academic dermatology department with electronic medical records

Survey of an academic dermatology department with electronic medical records

Evaluation of the definitions of "high-risk" cutaneous squamous cell carcinoma using the american joint committee on cancer staging criteria and national comprehensive cancer network guidelines.

Recent guidelines from the American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) have been proposed for the assessment of “high-risk” cutaneous squamous cell carcinomas (cSCCs). Though different in perspective, both guidelines share the common goals of trying to identify “high-risk” cSCCs and improving patient outcomes. Thus, in theory, both definitions should identify a similar proportion of “high-risk” tumors. We sought to evaluate the AJCC and NCCN definitions of “high-risk” cSCCs and to assess their concordance. Methods. A retrospective review of head and neck cSCCs seen by an academic dermatology department from July 2010 to November 2011 was performed. Results. By AJCC criteria, most tumors (n = 211,82.1%) were of Stage 1; 46 tumors (13.9%) were of Stage 2. Almost all were of Stage 2 due to size alone (≥2 cm); one tumor was “upstaged” due to “high-risk features.” Using the NCCN taxonomy, 231 (87%) of tumors were “high-risk.” Discussion. This analysis demonstrates discordance between AJCC and NCCN definitions of “high-risk” cSCC. Few cSCCs are of Stage 2 by AJCC criteria, while most are “high-risk” by the NCCN guidelines. While the current guidelines represent significant progress, further studies are needed to generate a unified definition of “high-risk” cSCC to optimize management.

High Frequency of Genital Lichen Sclerosus in a Prospective Series of 76 Patients With Morphea

To compare the frequency of genital lichen sclerosus (LS) in patients with morphea with that of control patients. A prospective multicenter study. Four French academic dermatology departments: Strasbourg, Montpellier, Tenon Hospital Paris, and Henri Mondor Hospital Créteil. Patients were recruited from November 1, 2008, through June 30, 2010. Seventy-six patients with morphea and 101 age- and sex-matched controls, who underwent complete clinical examination, were enrolled. A complete clinical examination and, if deemed necessary, a cutaneous biopsy. The frequency of genital LS. There were 58 women and 18 men (a 3:1 ratio) with a median age of 59 years. Mean (range) age at diagnosis was 54 (13-87) years. Forty-nine patients had plaque morphea, 9 had generalized morphea, and 18 had linear morphea. Three patients (3%) in the control group and 29 patients (38%) with morphea had LS (odds ratio, 19.8; 95% CI, 5.7-106.9; P < .001). Twenty-two patients with plaque morphea (45%) and only 1 patient with linear morphea (6%) had associated genital LS. Genital LS is significantly more frequent in patients with morphea than in unaffected individuals. Forty-five percent of patients with plaque morphea have associated LS. Complete clinical examination, including careful inspection of genital mucosa, should therefore be mandatory in patients with morphea because genital LS bears a risk of evolution into squamous cell carcinoma and thus needs treatment with topical corticosteroids.

Melanocyte-keratinocyte transplantation procedure in the treatment of vitiligo: The experience of an academic medical center in the United States

Vitiligo is a disfiguring disease with limited treatment options. Surgical treatment is underused in the United States because of perceived risk of infection, costs, and difficulty of the procedure. We sought to determine the efficacy and safety of the melanocyte-keratinocyte transplantation procedure (MKTP) in an academic dermatology department in the United States. This prospective, uncontrolled, open-label study enrolled patients aged 18 years or older with a self-reported history of vitiligo and no new or expanding lesions for at least 6 months before surgery. Patients with a history of koebnerization or keloid formation were excluded. Patients underwent autologous MKTP. Repigmentation during a 3- to 6-month follow-up period was assessed categorically and by modified Vitiligo Area Scoring Index. Safety was assessed by frequency of adverse events. Of the 28 patients who underwent 36 procedures, 23 patients who underwent 29 procedures completed the 3- to 6-month follow-up period. Data for these 29 procedures show excellent repigmentation (ie, 95%-100%) after the MKTP in 17%, and good repigmentation (ie, 65%-94%) in 31%. Fair (64%-25%) and poor (24%-0%) repigmentation were achieved in 10% and 41% of patients, respectively. Average percent change in Vitiligo Area Scoring Index was -45% (95% confidence interval -64% to -26%), signifying an improvement in pigmentation. Limitations include small sample size and lack of a control group. The MKTP is an effective and well-tolerated procedure based upon categorical and Vitiligo Area Scoring Index assessments of repigmentation.

Systemic therapy for primary hyperhidrosis: A retrospective study of 59 patients treated with glycopyrrolate or clonidine

Data regarding systemic medications in the management of hyperhidrosis (HH) are limited. The goal of this study was to provide evidence for the safety and efficacy of systemic medications for primary HH. A retrospective chart review was conducted of patients seen at an academic dermatology department prescribed systemic medications for primary HH. A total of 71 patients were prescribed systemic agents. Twelve patients (17%) were lost to follow-up and were excluded from further analysis. A total of 59 patients with at least 2 months of follow-up data (mean age 28.9 ± 12.0 years; 37 women, 22 men; mean follow-up 19.5 months) were included in the analysis. Palmoplantar and/or axillary HH was most common (42/59; 71%); followed by generalized (9/59; 15%) and craniofacial (8/59; 14%) HH. Glycopyrrolate (generally 1-2 mg once or twice daily) was prescribed to 45 patients, with response rate of 67% (30/45). Fifteen treatment failures included 6 nonresponders and 9 with adverse effects, including xerostomia and gastrointestinal disturbance. Clonidine (0.1 mg twice daily) was prescribed to 13 patients, with a response rate of 46% (6/13). Seven treatment failures included 3 nonresponders and 4 with adverse effects, all relating to decreased blood pressure. One patient responded to oxybutynin at 5 mg twice daily. There were no significant differences in efficacy (P = .21; odds ratios 0.43, 95% confidence interval 0.12-1.5) or adverse effects (P = .46; odds ratios 1.78, 95% confidence interval 0.44-7.1) in comparing glycopyrrolate versus clonidine. This was a retrospective study from a single, university-based population. Systemic therapy with glycopyrrolate or clonidine can be effective for HH. Nearly two-thirds responded to therapy, and less than a quarter had treatment-limiting adverse effects, all of which were self-limited and nonserious.

Use of complementary and alternative medicine by patients seen at the dermatology department of a tertiary care center

The use of complementary and alternative medicine (CAM) among patients with dermatologic conditions has not been well studied. The aim of this study was to evaluate the frequency and pattern of CAM use in patients referred to the dermatology department of a tertiary care center. Patients referred to the dermatology department of an academic tertiary referral center between February 2, 2010, and February 10, 2010, were invited to participate in an 86-question survey regarding CAM use during the previous year. A total of 300 patients completed the survey, of whom 154 (51%) were women. Eighty-two percent ( n = 247) of the respondents had used some type of CAM during the previous year. The most frequently used treatment and technique was massage therapy (33%), and the most commonly used vitamin was vitamin C (31%). Herbs or other dietary supplements were used by 58% ( n = 173) of patients. Seventy-eight percent ( n = 235) of patients stated that physicians should consider incorporating CAM approaches into their treatment recommendations, and 89% of patients ( n = 267) stated that our dermatology department should study CAM approaches in research studies. CAM utilization is high among patients at a large academic dermatology department. Patients indicated a strong preference for having CAM approaches incorporated into their treatment recommendations and believed in the value of clinical studies to further refine the role of CAM.

A survey of dermatology residency program directors' views on mentorship

It is increasingly recognized that mentoring is important in the career development of resident physicians. The purpose of the study was to determine the views of residency Program Directors on mentorship through a cross sectional survey. Respondents included program directors of academic dermatology departments in the United States. Fifty-three of 108 program directors completed an on-line survey (response rate 49%). Eighty-one percent of respondents indicated that mentorship played a 'somewhat' or 'very important' role in their own career development and a similar proportion considered it important for residents to have mentors. Fifty percent of program directors identified a need for more structured mentorship within the residency program. Compared to male program directors, a greater proportion of female program directors stated that mentorship played a very important role in their career development (89% vs. 36%, p=0.007) and a lesser proportion stated that it was important for female dermatology residents to specifically have access to female mentors (11.1% vs. 67.4%, p=0.003). Program Directors viewed mentoring as an important resource for their residents' professional development. A need was identified for additional strategies to help residents find mentors.

Extracorporeal photopheresis in recalcitrant lupus erythematosus

Conflict of interest: none declared. A 36‐year‐old woman was referred February 2007 to the outpatient clinic in of an academic dermatology department for investigation of a skin rash. She had a history of unilateral deafness related to a delayed diagnosis of cholesteatoma. She also had Sjögren’s syndrome (SS), which had been diagnosed 4 years earlier when she presented with a typical sicca syndrome. At that time, she had Chisholm–Mason stage IV salivary gland involvement and anti‐Ro (SSA) and anti‐La (SSB) auto‐antibodies were found. She also had distal tubular acidosis with normal renal function and without proteinuria, as a minor renal involvement of the SS. Onychomycosis had been suspected at a visit in January 2007 and she was treated with terbinafine. Five weeks after starting this treatment, a widespread erythematosquamous and annular rash developed, involving the trunk, limbs and face, leading to her referral to the dermatology department. Histological examination of a skin biopsy found intense interface dermatitis with vacuolization of basal cells and numerous necrotic keratinocytes scattered among the epidermis, consistent with subacute cutaneous LE. A drug‐induced flare of subacute cutaneous LE associated with the presence of Ro (SSA) antibodies, was suspected.

A gender gap in the dermatology literature? Cross-sectional analysis of manuscript authorship trends in dermatology journals during 3 decades

Despite a dramatic influx of female dermatologists during the last 30 years, women in academic dermatology departments remain relatively clustered in junior faculty positions. Research in other specialties showing a disparity in the academic productivity of women has led to many hypotheses regarding factors that may place them at a competitive disadvantage. It is unknown, however, whether similar differences in academic productivity might also serve as barriers to advancement in dermatology, or whether any productivity gap actually exists in this specialty that experienced a more substantial entry of women. Because publication in peer-reviewed journals is one of the core measures of academic productivity used in the promotion process, we evaluated trends in the prevalence of female authorship in top dermatology journals during the last 3 decades. We conducted an observational study of trends in the sex distribution of US authors in 3 prestigious general dermatology journals (in 1976, 1986, 1996, and 2006) and 3 subspecialty dermatology journals (in 2006 only). Journals were chosen based on published impact factors and citation half-lives. During the last 3 decades, the proportion of women authoring manuscripts in the 3 major general dermatology journals increased from 12% to 48% of US-affiliated first authors (P < .001) and from 6.2% to 31% of US-affiliated senior authors (P < .001). Separate analyses by journal and by article type showed similar increases. The prevalence of female authors in subspecialty journals in 2006 was slightly more variable. Although the publications selected for this study capture many of the most respected US journals in dermatology, they may not be representative of all journals in which dermatologists publish. Female dermatologists are authoring publications in growing numbers that match or exceed their prevalence in the academic and overall workforce. This suggests that other factors (differences in productivity outside of the publishing arena, differences in job descriptions or opportunities, differences in career aspirations, a lack of institutional support or flexibility, or gender bias) may be associated with the ongoing reduced advancement of women to senior academic dermatology ranks relative to their male colleagues, and further research is warranted to explore these possibilities.

Academic Dermatology Manpower

To assess the total number, recruitment rate, departure rate, and growth rate of full-time academic dermatologists in the United States over the last decade. Mail survey. Academic dermatology departments in the United States. Respondents among 113 chairs or chiefs of academic dermatology departments or their designees. The total number of full-time academic dermatologists including departures and recruitments in 4 selected academic years (1994-1995, 1998-1999, 2001-2002, and 2003-2004). Of the 113 academic dermatology departments, 89 (79%) responded. During the 4 selected academic years, more dermatologists joined academia (n = 255) than departed (n = 200). Those recruited into academia were predominantly graduating fellows (35%), residents (30%), and in private practice (16%). Of those who left academia, their primary roles were clinician-educator (55%), followed by dermatologic surgeon (16%). Most of those who departed went into private practice (65%). From 1994-1995 to 2001-2002, the recruitment rate increased by 36% (from 10.1% to 13.7%), and the departure rate increased by 88% (from 5.8% to 10.9%), resulting in a 35% decrease in growth rate (from 4.3% to 2.8%). Retention of academic dermatologists is as important as recruitment. Our results confirm that insufficient retention has contributed to a substantial decrease in the growth rate of academic dermatologists. Future efforts to increase academic manpower must focus on retention as well as recruitment, particularly of clinician-educators. Specific strategies for improving retention include identifying or establishing funding sources for teaching/mentoring and clinical research. Recruitment efforts may be improved by focusing on fellows and private practitioners with academic affiliations.

Factors Affecting the Recurrence Rate of Basal Cell Carcinoma

The aim of this retrospective survey was to determine recurrence rates after treatment of basal cell carcinomas in a single academic dermatology department. A total of 1016 patients with 1593 histologically verified basal cell carcinomas (n=1212 primary and n=381 relapsing) were included. Tumour localization, T-stage and the method of treatment were significant predictors of the risk of recurrence (forward Cox regression, p <0.001). The relapse rate for primary basal cell carcinomas on the scalp was highest (odds ratio (OR)=2.8, 95% confidence interval (CI) 1.5-5.3). T2 and T3 tumours showed a 2- and 3-fold increased relapse rate, respectively, compared with T1 basal cell carcinomas. Radiotherapy and surgical excision had the lowest relapse rates, whereas curettage and photodynamic therapy resulted in 5-year relapse rates of up to 70%. Patients with chronic skin diseases had a 50% lower risk of relapse than healthy patients (OR=0.5, CI=0.3-0.8). Recurrent basal cell carcinomas had a higher relapse rate than primary lesions (OR=1.8, CI=1.4-2.2). Patients treated in a specialized skin cancer unit had a 6.4-fold (CI=2.4-17.4) higher cure rate compared with those treated by less experienced physicians. Thus, in an uncontrolled, real-life situation curettage or photodynamic therapy are associated with significantly higher relapse risk than excision and radiotherapy and therefore should not be used for high risk primary tumours or recurrent tumours. Treatment in the setting of a specialized skin cancer unit yields a much lower relapse rate.

Practice management for academic dermatology departments.

Practice management in the academic medical center (AMC) is different than in other environments. Practice is only a part of the practitioner's mission within an AMC. Practice revenue will be subject to a tax or overhead by both the school and the department. Contract and practice guidelines cannot be tailored to the needs of the dermatology practice, because contracts and guidelines are negotiated globally for all of the practices within the AMC. Personnel, on which the practice depends, may report to hospitals and clinics rather than to the practice's management. Even control of the practice's manager may be diluted by a dual or "dotted line" reporting relationship between the department manager and the school practice manager. Although more constraints exist within the AMC, there are some strategic and operational choices that affect a practice's success. Among these are: (1) selection of services offered; (2) creation of satellites; (3) stimulation of faculty effort; (4) enhancement of faculty billing knowledge; and (5) creation of a "tie" between staff and the practice.

The changing status of inpatient dermatology at American academic dermatology programs

Background: Changes in health care delivery financing such as the adoption of the diagnosis-related groups (DRG) in 1983 has affected inpatient services of dermatology programs across the United States. Objective: The purpose of this study was to define the present status of inpatient dermatology at academic medical centers compared with 1982. Methods: Questionnaires inquiring about the state of inpatient service were sent to the chairpersons of each dermatology residency program in the United States. Results: Of the 71 programs responding, 79% reported a reduction in inpatient activity. Nearly half of the dermatology programs with dedicated dermatology beds in 1982 reported not continuing to have these in 1997 (41 to 24). The average number of patients admitted for skin disease decreased from 119 in 1982 to 36.5 in 1997, and the average daily census decreased from 8.9 to 2.2. Conclusion: There has been a decline in the number of patients hospitalized by academic dermatology departments and a shift of some patients hospitalized to beds where the attending is other than a dermatologist.(J Am Acad Dermatol 1999;40:755-7.)

On the importance of the clinician-educator. Dermatology fellowship for academic clinician teachers.

Within each academic dermatology department there usually exists one clinician who is viewed as the "gold standard" against which diagnostic and therapeutic acumen are measured. As a patient with a puzzling disorder is discussed at rounds, it is to this master that the final word falls, whose recommendation for treatment gets the nod; it is to his or her words that people remain quiet and listen intently. They are commonly also the leading teachers in the medical centers, passing on to succeeding generations the factual knowledge, spiced with bits of philosophy, ethics, and anecdote, that helps to ensure the development of dermatology residents into superb practitioners. They are often the ones most responsible for generating medical student interest in our specialty. Such individuals in our current lingo are "clinician-educators," the rock residents depend on to provide role models to emulate in the diagnosis, care, and treatment of our patients and to whom the community looks to for help in caring for their patients with the most difficult diagnoses.