Dermatology Clinic Research Articles

Application of Lean Six Sigma in Dermatology Practice

The Lean Six Sigma (LSS) methodology integrates two quality improvement techniques to enhance efficiency, reduce waste, and improve the quality of processes and products within an organization. While it has found application in various healthcare settings, to the best of our knowledge, there is currently no literature addressing its utilization in a community dermatology clinic. This study aimed to identify efficiency issues within a local dermatology clinic and implement targeted strategies to bolster collaboration, streamline processes, reduce wait times, augment patient volume, and enhance clinical outcomes and the quality of care. Five areas for improvement were identified: the building complex, front office, EMA system, medical assistants, and general improvements. The executed changes effectively standardized multiple processes, mitigated the potential for errors, and minimized task duration. These findings underscore the efficacy of LSS as a potent tool for enhancing efficiency and reducing waste. Efforts should be directed toward the incorporation of LSS techniques for quality improvement within healthcare systems, both internally and across interconnected entities.

Secondary Oral Squamous Cell Carcinoma following Haematopoietic Stem Cell Transplantation.

We report 10 cases of oral squamous cell carcinoma (SCC) post-haematopoietic stem cell transplant (HSCT).. Median latency from HSCT to oral SCC diagnosis was 10 years (range: 4-17 years) with 90% reporting a history of chronic graft-versus-host disease (cGVHD) and 40% exhibited active severe manifestations of oral GVHD. Clinical findings at diagnosis included induration, ulceration, tenderness, bleeding, hyperkeratosis, speckling and lymphadenopathy. The tongue and buccal mucosa were the commonest sites affected. Disease stage at presentation ranged from T1N0M0 to T4N2M0. Management included surgical resection in 90% of cases ± chemo/radiotherapy. Median follow-up for the cohort was l years with 50% mortality rate. SCC-specific mortality was 30%. Our data highlight the importance of regular, active oral and cutaneous surveillance of post-HSCT patients in specialised dermatology clinics, irrespective of GVHD severity and length of iatrogenic immunosuppression.

Social media use among adolescents with acne: A cross-sectional survey study.

Social media is increasingly used by patients for the management of skin conditions like acne, despite the potential risk for low-quality information. This study surveyed 45 participants between the ages of 12 and 17 years to investigate factors that could be associated with social media use among adolescents with acne. The likelihood of social media use was not significantly increased by clinical severity of acne, more severe physical barriers (greater than or equal to 20 miles to the dermatology clinic), more severe temporal barriers (waiting 12 or more weeks for a first dermatology appointment), or worsened quality of life (assessed via the Skindex-Teen score). This study increases understanding of adolescents' social media behaviors, particularly as a way to seek information for skin conditions like acne.

Pediatric dermatologists versus AI bots: Evaluating the medical knowledge and diagnostic capabilities of ChatGPT.

This study evaluates the clinical accuracy of OpenAI's ChatGPT in pediatric dermatology by comparing its responses on multiple-choice and case-based questions to those of pediatric dermatologists. ChatGPT's versions 3.5 and 4.0 were tested against questions from the American Board of Dermatology and the "Photoquiz" section of Pediatric Dermatology. Results show that human pediatric dermatology clinicians generally outperformed both ChatGPT iterations, though ChatGPT-4.0 demonstrated comparable performance in some areas. The study highlights the potential of AI tools in aiding clinicians with medical knowledge and decision-making, while also emphasizing the need for continual advancements and clinician oversight in using such technologies.

Analyzing the Benefits and Costs of the Safe Step Act on Patients, Physicians, and Insurers

Pharmaceutical expenditures in the United States, particularly in dermatology, have grown rapidly, driven by expensive topical and biologic treatments. Insurers are employing cost-containing strategies such as step therapy, which mandates the use of lower-cost treatments before more expensive medications. The bipartisan Safe Step Act aims to enhance step therapy policies by introducing a transparent process for requesting exceptions and reasonable timelines for the process. However, there is limited analysis on how the Safe Step Act would affect the healthcare environment. We examine the policies of the Safe Step Act and existing literature on prior authorizations and discuss how the bill could affect patients, physicians, and insurers. While the act could expedite access to necessary medications and prevent irreversible harm to patients from delaying efficacious treatment, it falls short in relieving the administrative burdens on dermatology clinics. Although there is no ideal solution for managing healthcare costs, measures like step therapy encourage cost-effective treatments and optimizing care for the population. Curtailing step therapy with the exemptions process of the Safe Step Act might streamline patient access to treatments but could impede cost-containment strategies, weaken the bargaining power of insurers, and result in higher insurance premiums.

Methylisothiazolinone sensitisation in New Zealand is decreasing.

In the last 10 years methylisothiazolinone (MI) emerged as a global cause of preservative-related ACD. New Zealand has liberal regulations for the MI concentration limit in cosmetic products compared to Europe and Australia. The aim of this study was to evaluate the prevalence of MI sensitisation in New Zealand, explore sources of MI exposure and make recommendations on New Zealand regulations for MI use. This retrospective study included data from patients who underwent patch testing with MI from 2008 to 2021 in a tertiary hospital dermatology clinic and a private dermatology clinic in Auckland, New Zealand. Patient baseline characteristics were recorded along with results of patch testing. Sources of MI exposure were identified from medical records. Over the study period, 1049 patch tests were performed in 1044 patients. MI was only tested as a stand-alone allergen from 2015; positive reactions to MI increased from 5.3% in 2015 to a peak of 11.9% in 2017 and then decreased to 6.4% in 2021. The most common source of MI exposure was shampoo or conditioner (27.7% of all relevant reactions) followed by occupational exposures to paints, biocides or glue (19.1%). Both sensitisation and ACD to MI appear to be decreasing, likely secondary to changes in product compounding due to stricter concentration limits internationally. We recommend New Zealand adopt lower MI concentration limits for cosmetics to match the limits of Australia and Europe.

Experimental investigation on the transient vascular thermal response to laser irradiation by a high-speed infrared thermal camera

Based on the photothermal effect, laser can be used to treat vascular diseases (VD) in clinic of dermatology and ophthalmology. Transient vascular thermal response to laser irradiation during millisecond laser pulse is the key phenomenon in treatment process, which has not been carefully investigated before. In this study, target blood vessels in dorsal skin chamber (DSC) animal model were irradiated by a pulsed 532 nm diode laser and a 1064 nm Nd:YAG laser. The directed thermal responses (temperature variation) were recorded by a high-speed infrared thermal camera with a repetition rate of 1000 Hz. The temperature variation during and after single pulse irradiation and multipulse irradiation were investigated. The variation of blood absorption coefficient was explored based on the temperature increment in each laser pulse. The thermal properties of dorsal skin, especially the thermal diffusivity, were evaluated based on the temperature decay after each laser pulse. The interfacial heat transfer between the blood and the surroundings was also calculated based on the thermal images and compared to the correlation proposed before. The results show that the blood absorption to laser will increase by a maximum of 1.9 immediately after blood temperature exceeds threshold value, e.g., 68oC in both single pulse (pulse duration >100 ms) and multi-pulse laser irradiation. The tissue optical properties (thermal diffusivity) keep almost constant after millisecond laser heating. Also, a general correlation for interfacial heating transfer between blood and surroundings was developed, in which the influences of vessel shape and laser wavelength are incorporated. The interfacial heat transfer between blood and surrounding can be accurately quantified.

Efficacy of JAK inhibitors in the treatment of psoriasiform atopic dermatitis.

Atopic dermatitis (AD) is a common inflammatory skin disease with multiple clinical manifestations. Among AD phenotypes, psoriasiform AD shows the coexisting of eczematous itching lesions in flexural areas with psoriasiform plaques. The use of anti-IL-4 and anti-IL-13 in psoriasiform AD may lead to therapeutic failure or worsening of manifestations. A recent Delphi consensus proposed JAK inhibitors (JAKi) as a viable alternative, even in the first line, in patients with different clinical phenotypes of AD, including psoriasiform AD. A retrospective analysis of patients in our dermatology clinic with moderate-severe AD and treated with JAKi was performed. Among the 192 overall patients, 21 had psoriasiform AD. EASI, p-NRS and DLQI were the severity scores considered and their reduction was observed in all 21 patients at weeks 4, 16 and 24 of treatment. At week 16 the percentage of patients achieving EASI-75 and EASI-90 was 80.95% and 66.67%, respectively. While at week 24 95.23% of patients achieved EASI-75 and 85.71% obtained EASI-90. No adverse event lead to treatment interruption. This study confirmed the clinical effectiveness of JAKi treatment in adult patients with moderate-to-severe psoriasiform AD, with a good safety profile. These drugs are proposed as the first choice for the treatment of this form of AD, although further studies with larger cohorts are required.

Mild cognitive impairment in pemphigus.

Pemphigus is a group of autoimmune blistering disorders that have been associated with dementia in previous studies. Mild cognitive impairment (MCI) can be the first stage of progression into dementia. The objective of the present study was to evaluate the frequency of MCI in pemphigus patients compared to a control group. This case-control study included 80 patients with pemphigus referred to the dermatology clinics of Shohadaye Tajrish and Loghman Hakim hospitals, Tehran, Iran, in 2021. A group of 80 individuals without pemphigus who visited the same clinics for cosmetic consultation or interventions were regarded as controls. Age, sex, marital status, and education were recorded for all participants. Disease duration, medications, and severity were noted for pemphigus patients. The Persian version of the Montreal Cognitive Assessment (MoCA) test was used to assess cognitive function. MCI was significantly more frequent in pemphigus patients than in controls (55% vs. 37.5%, P = 0.026). Furthermore, the total MoCA score was significantly lower in pemphigus patients compared to controls (23.98 ± 3.77 vs. 25.21 ± 3.45, P = 0.032); however, among MoCA's different domains, only the executive functions score was significantly lower in pemphigus patients (P = 0.010). After adjustment, multivariable logistic regression analysis revealed that every 1-year higher education in patients decreased the odds of MCI by 52% (adjusted odds ratio = 0.483, 95% confidence interval 0.326; 0.715, P < 0.001). The frequency of MCI was found to be significantly higher, and overall scores of the MoCA test, as well as its executive function domain, were significantly lower among pemphigus patients in this study compared to the control group. Additionally, a higher level of education was associated with decreased odds of MCI in pemphigus patients. Identifying pemphigus patients with MCI through the use of the MoCA test can facilitate early intervention, enabling them to seek help and support.

Stressful life events and the occurrence of skin cancer.

It is widely acknowledged that emotional states can influence skin conditions, yet limited research has delved into the impact of stress on skin cancer development. This retrospective study sought to expand the perspective on skin cancer risk factors by investigating the complex relationship between stressful life events and the incidence of skin cancer. The sample included 268 individuals followed-up in a dermatological clinic, in three groups: Patients who had previously been diagnosed with cutaneous melanoma and are currently in remission (32%), those who had been diagnosed with non-melanoma skin cancer (30%), and a control group who are at risk for skin cancer (38%). Participants filled in questionnaires regarding childhood and adulthood life events, and loss and gain of resources following their subjectively most stressful event in adulthood. Multinomial logistic regression was used to examine the associations of life events with skin cancer occurrence, and mediating and moderating effects of resource loss/gain. Adverse childhood experiences were associated with melanoma occurrence, with the melanoma group reporting significantly more such experiences compared to the control group (p<0.001). Resource loss from subjectively significant stressful life events in adulthood partially mediated the association between adverse childhood experiences and melanoma incidence. The findings suggest that there may be intricate connections between stress, life events, adaptation to change, and skin cancer, which future research may further unravel. This study underscores the need for a more comprehensive approach to stress management, coping strategies development, and skin cancer prevention in healthcare settings.

Evaluation of the efficacy and safety of cold laser (Diode 808 nm) therapy in the treatment of localized plaque psoriasis: clinical, dermoscopic and ultrastructural study

Background Psoriasis is a chronic, recurring, and immune-mediated inflammatory skin disease. Throughout the period of the last few decades, phototherapy has become widely used in treating stable psoriatic lesions. For the treatment of psoriasis, several light/laser therapies with distinct modes of action have been developed. Cold laser therapy might be an effective therapeutic choice for localized plaque psoriasis. Objective To assess the safety and efficacy of cold laser therapy clinically and microscopically in localized plaque psoriasis treatment. Patients and methods 40 patients with localized mild plaque psoriasis were selected from the Dermatology and Venereology outpatient clinic–Tanta University Hospitals and enrolled in the clinical trial. They were treated by cold laser 808 nm wavelength (Endolaser 422, Enraf–nonious B.V. Rotterdam, Netherlands) one session for 10 min on each plaque twice weekly separated by 2 days until clinical cure or for a maximum of 8 weeks. Evaluation was done immediately after the last session by taking the average of three blinded dermatologists of the photos, the modified Psoriasis Area and Severity Index [mPASI], dermoscopic examination, patients’ satisfaction scale and histopathological and electron microscopic examination of punch biopsy specimens taken before and after the end of treatment from psoriatic lesions in four patients only. Results There was a statistically significant clinical improvement after the end of treatment compared with before treatment as 16 patients (40%) showed excellent improvement, 8 patients (20%) showed good improvement, 9 patients (22.5%) showed mild improvement, and 7 patients (17.5%) showed poor improvement. As regard mPASI, a statistically significant decrease in mPASI was found after the end of treatment (P&lt;0.001). Regarding dermoscopic examination, a statistically significant reduction in the percentage of patients showing dermoscopic red dots and white scales after the end of treatment (P&lt;0.01). As regard the patients’ satisfaction scale, 82.5% of patients were satisfied from the results. Histopathological and ultrastructural evaluation revealed normalization of the psoriatic microscopic changes with cold laser. Conclusion The use of cold laser therapy for the management of localized mild plaque psoriasis is safe, tolerable, effective, and can be used as an alternative therapy for psoriasis.

The effect of COVID-19 disease on patients diagnosed with skin cancer in the dermatology clinic

Objective: We aimed to define the impact of the pandemic on patients presenting to dermatology clinic with skin cancer. Methods: In our study, the characteristics of patients who attended our dermatology clinic before six months and after six months of March 11, 2020, and whose biopsies diagnosed as basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM) were evaluated and compared regarding before and after COVID-19 pandemic Results: Patients with BCC attending to the dermatology clinic were found to be younger in the pandemic period (p&lt;0.05). Gender, duration of skin tumors, primary lesions, and their locations were found to be not statistically significant (p&gt;0.05). Conclusion: Patients with suspicious skin lesions could be encouraged to visit a hospital with appropriate COVID-19 protection. Alternatively, teledermatology could be used to evaluate whether the lesions should be excised or biopsied.

Welche Faktoren beeinflussen die Teilnahme am gesetzlichen Hautkrebsscreenings in Deutschland?

Due to increasing skin cancer incidence, Germany implemented a statutory nationwide routine skin cancer screening (rSCS) in 2008. The present study aims (1) to analyze which patient factors are associated with the participation in rSCS in Germany and (2) to investigate reasons for nonparticipation. Participants and nonparticipants of rSCS (≥35years) were recruited in routine care in nine dermatological outpatient clinics. Reasons for (non)participation, knowledge about skin cancer as well as clinical and socioeconomic data were obtained. Stratified by groups, descriptive analyses and binary logistic regression analyses for associations with participation were performed. Of the 294 rSCS participants and 162 nonparticipants, 46.5% were male with a mean age of 54.5 ±12.7years. In total, 87.1% had sunburns in childhood and 47.1% used sunbeds before. Higher age, female gender, previous sunbed use, and concern for and knowledge of skin cancer were significantly associated with previous rSCS participation. Of the nonparticipants, 46% were unaware of the option for free rSCS and 40% justified their nonparticipation on the basis of feeling healthy. The reasons for nonparticipation in rSCS, such as sociodemographic characteristics and risk behavior, should be known in order to optimize rSCS programs.

Current prescribing for pyoderma gangrenosum in the UK and access to biologic medications: Results from a UK Dermatology Clinical Trials Network (UKDCTN) survey of UK Dermatologists.

Pyoderma gangrenosum (PG) is an ulcerative inflammatory disorder affecting the lower legs in 80% of cases. The use of biologic medications to treat PG is increasing although there is a limited evidence base to guide treatment choices. In some health systems, such as the UK NHS, limitations are placed on biologic prescribing for PG leading to wide variations in prescribing. A survey of mainly UK clinicians showed that prednisolone remains the first line treatment for PG (90%). Biologics have been used by 66% of clinicians as second line therapy but 19% have had prescribing requests declined. Further research is needed to determine optimal treatment strategies for PG.

Which factors influence the participation in statutory skin cancer screenings in Germany?

Due to increasing skin cancer incidence, Germany implemented a statutory nationwide routine skin cancer screening (rSCS) in 2008. The present study aims (1) to analyze which patient factors are associated with the participation in rSCS in Germany and (2) to investigate reasons for nonparticipation. Participants and nonparticipants of rSCS (≥35years) were recruited in routine care in nine dermatological outpatient clinics. Reasons for (non-)participation, knowledge about skin cancer as well as clinical and socioeconomic data were obtained. Stratified by groups, descriptive analyses and binary logistic regression analyses for associations with participation were performed. Of the 294 rSCS participants and 162 non-participants, 46.5% were male with a mean age of 54.5 ±12.7years. In total, 87.1% had sunburns in childhood and 47.1% used sunbeds before. Higher age, female gender, previous sunbed use, and concern for and knowledge of skin cancer were significantly associated with previous rSCS participation. Of the non-participants, 46% were unaware of the option for free rSCS and 40% justified their nonparticipation on the basis of feeling healthy. The reasons for nonparticipation in rSCS, such as sociodemographic characteristics and risk behavior, should be known in order to optimize rSCS programs.

The Impact of Shared Assistance between Dermatology and Internal Medicine on Patients with Psoriasis.

Background: The care of psoriatic patients requires a multidisciplinary approach that addresses not only skin involvement but also cardiovascular risk factors. Coordination between dermatology and internal medicine departments, with a specific focus on treatment and long-term follow-up, can substantially improve the course of a disease and its associated complications. Objective: to evaluate the effects of the holistic management of patients with psoriasis by a multidisciplinary team consisting of dermatology and internal medicine specialists. Methods: We conducted an observational, prospective, single-center case-control study between October 2016 and December 2019 in San Jorge University Hospital (Huesca, Spain). Cases included patients undergoing follow-up in the combined dermatology and internal medicine clinic. The control group consisted of an equivalent number of randomly selected, age- and sex-matched patients with moderate-to-severe psoriasis who were seen in the general dermatology department of the same hospital during the same time period. Main outcomes and measures: The primary outcome was the control of psoriatic disease and cardiovascular risk factors such as weight, blood pressure, waist circumference, body mass index (BMI), SCORE index (Systematic Coronary Risk Evaluation), and blood test parameters, as well as diet, physical exercise, and habits such as tobacco and alcohol consumption. To compare data collected over time, data were grouped into three time periods: baseline (t1), intermediate (t2), and final (t3). Results: The case group consisted of 27 patients, and the control group consisted of 25 patients. Multivariate analysis was used to evaluate the relationship between the 10-year risk of experiencing a cardiovascular event (SCORE) and the clinical characteristics and analytical variables of patients with psoriasis and controls (n = 52). The variables that were significantly associated with a higher 10-year risk of experiencing a cardiovascular event were age (OR, 1.33; CI95% 1.21-1.50; p < 0.001); smoking (OR, 5.05, CI95% 1.07-27.37; p = 0.047); PASI (OR, 7.98, CI95% 2.32-35.86; p = 0.003); BSA (OR, 1.22, CI95% 1.01-1.49; p = 0.044); and being a control patient (OR, 3.26; CI95% 0.84-13.56; p = 0.029). Conclusions: Pharmacological and behavioral interventions carried out as part of the procedure of the multidisciplinary clinic resulted in improvements in the following variables relative to the control group: PASI, BSA, DLQI, PSOLIFE, lipid profile, insulin and HOMA-IR GGT levels, vitamin D levels, and SCORE. These findings indicate the beneficial effect of the multidisciplinary clinic, which reduced the risk of cardiovascular events in psoriatic patients with metabolic comorbidities.

Does Molluscum Contagiosum Need to be Managed Differently in Atopic Children?

The association between molluscum contagiosum and concomitant atopic dermatitis and its impact on clinical features and treatment outcomes remains unclear. This retrospective study, conducted in the paediatric dermatology clinic of a tertiary medical centre, aimed to compare molluscum patients with and without atopic dermatitis. A total of 615 children with molluscum were included, 13.17% of whom had atopic dermatitis. While the latter group exhibited higher lesion count and itchiness (p=0.026 and p=0.044, respectively), no significant differences were observed in average lesion diameter, ulceration, purulence, and erythema (p=0.239, p=0.730, p=0.682, and p=0.296, respectively). Both groups showed comparable responses to molluscum-specific and supportive treatments, with no distinct difference in outcomes or recurrence of visits. It was concluded that atopic dermatitis does not exacerbate molluscum morbidity, inflammation markers, treatment outcomes or recurrence rates.

Comment on 'The positive HIV result in a routine systemics screening in a dermatology clinic'.

We were intrigued with the correspondence by Gonçalveset al, ‘The positive HIV result in a routine systemics screening in a dermatology clinic’, published very recently in Clinical and Experimental Dermatology.

A Triple Laser Combination Treatment for Facial Angiofibromata Management in Tuberous Sclerosis and Literature Review

Background: Angiofibromas are a common facial manifestation of Tuberous Sclerosis (TS). However, current treatments have proven ineffective due to high recurrence rates and non-compliance. To address this issue, we developed a new triple laser therapy protocol for more effective management of angiofibromas. We conducted tests to validate its efficacy. Methods: This is a prospective study of 10 patients with TS (4 women and 6 men, mean 26.3 years old {15-37 y/o}) with angiofibromata who received triple sequential laser therapy at our private dermatological clinic conducted from January 2000 to December 2022. We evaluated the outcome with the Facial Angiofibromata Severity Index (FASI) via clinical photography (0, 6 months, 1 year, 2 years) and Dermatology Life Quality Index (DLQI). Results: All patients had a successful recovery without any complications. Among these 10 patients, 4 experienced localised recurrences at their 6th-month follow-up. These recurrences were treated with a second single CO2 laser session. After 2 years of follow-up, we observed no recurring facial cutaneous manifestations. Furthermore, all patients experienced a decrease in their FASI score after treatment. According to the Visual Analogue Scale (VAS), patients reported 95% satisfaction, and DLQI indicated only a minor impact on their everyday lives. Conclusion: We believe that this protocol of 3-step Laser treatment is effective, safe, and compliable for patients with facial angiofibromata, providing a satisfactory outcome adaptable to the daily dermatological and plastic surgery practice.

A Woman with Leonine Facies and Monoclonal Gammopathy.

A 32-year-old woman presented to the dermatology clinic with a three-year history of progressive skin thickening. On examination, skin of glabella was thickened with longitudinal furrows, resulting in leonine facies. Skin-colored to reddish-brown, firm, waxy, closely spaced papules partially coalescing to form sheets of induration with circular punched out areas of sparing in between, over face, neck, trunk, abdomen, arms and thighs. She additionally complaint of tingling sensation and occasional pain over lateral side of hands. Punch biopsy obtained from a papule over the nape of neck revealed fibroblast proliferation with collagen and mucin deposition in upper and mid-reticular dermis.