Dermatology Training Research Articles

Measuring the severity of topical 5-fluorouracil toxicity.

Topical 5% 5-fluorouracil (5-FU) is known to cause toxicity, such as erythema, pain, and crusting/erosions. We sought to develop a scale to measure this toxicity and test the scale for reliability. A scale was developed involving four parameters: erythema severity, percentage of face involved in erythema, crusting/erosions severity, and percentage of face involved in crusting/erosions. Thirteen raters graded 99 sets of photographs from the Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) Trial using these parameters. Intraclass correlation overall for 13 raters was 0.82 (95% CI 0.77-0.86). There was no statistically significant trend in reliability by level of training in dermatology. This scale is a reliable method of evaluating the severity of toxicity from topical 5-fluorouracil and can be used by dermatologists and nondermatologists alike.

Psoriasis and psoriatic arthritis educational initiatives: an update from the 2013 GRAPPA Annual Meeting.

At the 2013 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members were updated on educational areas in psoriasis and psoriatic arthritis (PsA). Discussions included (1) the psoriasis and PsA GRAPPA video project, comprising a set of educational online videos that provide standardized psoriatic disease endpoint training to clinicians and researchers; (2) the GRAPPA Educational Outreach Project, focused on cross-disciplinary education for rheumatologists and dermatologists and including several collaborations to expand educational sessions globally; (3) the Dermatology and Rheumatology Trainee Educational Initiative, that provides psoriatic disease education to medical students, residents, and fellows training in dermatology and/or rheumatology; and (4) the GRAPPA Educational Slide Library, developed as a resource for GRAPPA members for their own educational presentations.

Dermatology curriculum for internal medicine residents: a randomized trial.

Physicians in specialties other than dermatology care for the majority of patients with skin diseases, yet most physicians receive little training in dermatology. The primary objective of this study was to determine whether there would be a sizable (20%) improvement in posttraining scores for internal medicine residents after completing 1 of 3 assigned curricula. A secondary objective was to determine whether there were significant differences in improvement among the 3 resident cohorts after completing their curriculum. Finally, we explored the residents' change in perceived clinical knowledge postcurriculum. Thirty-six postgraduate year 2 internal medicine residents were randomized to complete 1 of 3 one-month dermatology curricula (didactic, clinical, or combined). The main outcome measure was performance on different sets of Medical Knowledge Self-Assessment Program (MKSAP)-15 questions at study entry and completion. A secondary outcome was self-rated performance in 3 clinical domains. All participants completed the study. All curricula led to an improvement in MKSAP-15 scores, but only students who completed the didactic curriculum demonstrated a 20% improvement in posttraining scores. A larger number of residents completing the clinical and didactic curricula rated their clinical performance as improved compared to those who completed the combined curriculum. While all 3 curricula led to improvement, as measured by a standardized assessment, a didactic curriculum in dermatology resulted in the largest improvement in knowledge as measured by a multiple-choice test.

A seminar on gardens for the health of the skin

This is a report on a seminar held on January 12, 2013, at the Regional Dermatology Training Centre in Tanzania, sponsored by the International Society of Dermatology as part of its Taskforce Program for Skin Care for All: Community Dermatology. There were four themes: (i) Gardens attached to health centers increase their attractiveness and result in increased attendance and, thus, increase the utilization of effective skin care interventions. Literature on the positive effect of greenery surrounding health centers on health and the environment is reviewed. (ii) Adding an expert on agriculture to the staff of health centers in Rwanda has provided nutrition and safe medicines. (iii) In southern India, these interventions are channeled through the empowerment of tribal women in an area noted for anxiety due to unemployment in the tea and forestry industry. The gardens are used for teaching about nutrition and herbal medicines, and the women are further attracted by childcare facilities. (iv) Measuring barrier function defects gives early warning of malnutrition of the skin after damage by trauma or by ultraviolet radiation. Higher cost research techniques may help to provide the science required to produce its evidence base. In conclusion, Gardens for health should be adopted as policy by skin care providers.

Histological review of skin cancers in African Albinos: a 10-year retrospective review

BackgroundSkin cancer is rare among Africans and albinism is an established risk for skin cancer in this population. Ultraviolet radiation is highest at the equator and African albinos living close to the equator have the highest risk of developing skin cancers.MethodsThis was a retrospective study that involved histological review of all specimens with skin cancers from African albinos submitted to The Regional Dermatology Training Center in Moshi, Tanzania from 2002 to 2011.ResultsA total of 134 biopsies from 86 patients with a male to female ratio of 1:1 were reviewed. Head and neck was the commonest (n = 75, 56.0%) site affected by skin cancers. Squamous cell carcinoma (SCC) was more common than basal cell carcinoma (BCC) with a ratio of 1.2:1. Only one Acral lentiginous melanoma was reported. Majority (55.6%) of SCC were well differentiated while nodular BCC (75%) was the most common type of BCC.ConclusionsSquamous cell carcinoma is more common than basal cell carcinoma in African albinos.

An update on pediatric cutaneous drug eruptions

One of the early lessons learned in dermatology training is “any drug, any rash.” This maxim quickly summarizes the vast array of cutaneous reactions that can be seen in response to systemic medications. We have reviewed common and unusual drug eruptions in pediatric patients that span the morphologic spectrum. These reactions can have an equally broad range of severity, from harmless to lethal, and by the end of this paper the reader will be better equipped to sort one from the other.

Cosmetic Dermatologic Surgical Training in US Dermatology Residency Programs

The public and other medical specialties expect dermatologists who offer cosmetic dermatology services to provide competent care. There are numerous barriers to achieving cosmetic dermatology competency during residency. Many dermatology residents enter the workforce planning to provide cosmetic services. If a training gap exists, this may adversely affect patient safety. To identify resources available for hands-on cosmetic dermatology training in US dermatology residency training programs and to assess program director (PD) attitudes toward cosmetic dermatology training during residency and strategies, including discounted pricing, used by training programs to overcome barriers related to resident-performed cosmetic dermatology procedures. An online survey in academic dermatology practices among PDs of US dermatology residency programs. Frequency of cosmetic dermatology devices and injectables used for dermatology resident hands-on cosmetic dermatology training, categorizing PD attitudes toward cosmetic dermatology training during residency and describing residency-related discounted pricing models. Responses from PDs were received from 53 of 114 (46%) US dermatology residency programs. All but 3 programs (94%) offered hands-on cosmetic dermatology training using botulinum toxin, and 47 of 53 (89%) provided training with hyaluronic acid fillers. Pulsed dye lasers represented the most common laser use experienced by residents (41 of 52 [79%]), followed by Q-switched Nd:YAG (30 of 52 [58%]). Discounted procedures were offered by 32 of 53 (60%) programs, with botulinum toxin (30 of 32 [94%]) and fillers (27 of 32 [84%]) most prevalent and with vascular lasers (17 of 32 [53%]) and hair removal lasers (12 of 32 [38%]) less common. Various discounting methods were used. Only 20 of 53 (38%) PDs believed that cosmetic dermatology should be a necessary aspect of residency training; 14 of 52 (27%) PDs thought that residents should not be required to perform any cosmetic dermatology procedures. Although almost every program provides hands-on cosmetic dermatology training, there are barriers to training, including patient preferences, costs of procedures and products, and PD attitudes toward cosmetic dermatology training. To promote patient safety, procedural competency is imperative.

Image Training, Using Random Images of Melanoma, Performs as Well as the ABC(D) Criteria in Enabling Novices to Distinguish Between Melanoma and Mimics of Melanoma

Robust experimental evidence supporting many attempts to facilitate early melanoma diagnosis is lacking. In an experimental study using a browser interface we have examined diagnostic accuracy, sensitivity and specificity of novices in distinguishing between melanomas and mimics of melanoma. We show that rule-based ABC methods and image training, based on random images of melanoma, improve specificity to similar degrees, with-out effects on sensitivity, leading to small improvements in overall accuracy. There was a significant effect of age with older subjects performing better. Although both the ABC method and image training groups showed improved performance over the control group, overall performance was poor. For instance, for a task in which 1 in 4 test images was a melanoma, and 3 out of 4 benign, both interventions (ABC or image training) increased accuracy from the control value of 53% to around 61%. For reference, dermatology trainees performed at a much higher level of accuracy. Our study provides little support for the use of such methods in public education, but suggests ways in which performance might be improved.

Pediatric Dermatology Training Survey of United States Dermatology Residency Programs

Variability exists in pediatric dermatology education for dermatology residents. We sought to formally assess the pediatric dermatology curriculum and experience in a dermatology residency program. Three unique surveys were developed for dermatology residents, residency program directors, and pediatric dermatology fellowship program directors. The surveys consisted of questions pertaining to residency program characteristics. Sixty-three graduating third-year residents, 51 residency program directors, and 18 pediatric dermatology fellowship program directors responded. Residents in programs with one or more full-time pediatric dermatologist were more likely to feel very competent treating children and were more likely to be somewhat or extremely satisfied with their pediatric curriculums than residents in programs with no full-time pediatric dermatologist (50.0% vs 5.9%, p = 0.002, and 85.3% vs 52.9%, p < 0.001, respectively). Residents in programs with no full-time pediatric dermatologist were the only residents who were somewhat or extremely dissatisfied with their pediatric training. Residency program directors were more satisfied with their curriculums when there was one or more pediatric dermatologist on staff (p < 0.01). Residents in programs with pediatric dermatology fellowships were much more likely to report being extremely satisfied than residents in programs without a pediatric dermatology fellowship (83.3% vs 21.2%; p < 0.001). The results of this survey support the need for dermatology residency programs to continue to strengthen their pediatric dermatology curriculums, especially through the recruitment of full-time pediatric dermatologists.

Dermatology training in the U.K.: does it reflect the changing demographics of our population?

Funding sources: Funding for this study was provided by London Ethnic Skin Limited. Dear Editor, The U.K. has seen an increase in the proportion of the ‘nonwhite’ population by 61% between 2001 (8·7%) and 2011 (14%), with the proportion of black Africans doubling over this period.1 Studies have shown that among different ethnic and racial groups, cutaneous disorders may vary in both prevalence and clinical manifestation.2 In light of this, as well as the observed changes in the U.K. demographics, it is important that dermatologists are adequately trained to diagnose and manage dermatoses pertinent to our ethnic population. For this reason, we conducted a questionnaire‐based study to ascertain whether the current U.K. dermatology training programme for specialist registrars provides adequate training in the diagnosis and management of diseases pertinent to the ethnic population. We identified 217 dermatology trainees (specialty training level ST3–ST6, including those out of programme) and 77 junior consultants (within 2 years of receiving their Certificate of Completion of Specialist Training) from the database of the U.K. Joint Royal Colleges of Physicians Training Board (JRCPTB) as being eligible for inclusion into the study. A web link to our online questionnaire was sent to this target group via: (i) the monthly e‐mail bulletin of the British Association of Dermatologists (BAD); (ii) letters posted to all National Health Service hospitals with a dermatology department in the U.K.; and (iii) an e‐mail bulletin distributed twice to dermatology trainees via regional trainee representatives.

Sharps Injuries and Reporting Practices of U.S. Dermatologists

Sharps injuries pose considerable risk to physicians. We examined prevalence and rates of reporting of sharps injuries of dermatologists and dermatology trainees, focusing on motivations for and barriers to reporting. We identified types of procedures carrying highest risk. To characterize the factors influencing sharps injuries and reporting practices. Current dermatology residents, fellows, and practicing dermatologists were surveyed using an anonymous electronic survey regarding needlestick injuries. Of 336 dermatologist respondents (26.5% response rate [336/1,268]), 286 (85.1%) reported having had a sharps injury; 116 (40.6%) had occurred within the past year. Sixty-eight injuries occurred during surgery (58.6%), and 106 were perceived to be self-inflicted (91.4%). Physicians most likely to report recent sharps injuries were trainees (26/41, 63.4%), dermatologic surgeons (24/64, 37.5%), and medical dermatologists (3/11, 27.3%). One hundred eighty-three (64%) respondents reported having ever had a sharps injury that went unreported. Dermatologists at academic institutions were more likely to report injuries than those in solo (odds ratio [OR]=2.97, P=.23) or group (OR=2.29, P<.001) practice. Sharps injuries are common among dermatologists. Underreporting is common and places providers and patients at risk of blood-borne illnesses.

Melanoma in primary care. The role of the general practitioner

The British Association of Dermatologists and the National Cancer Control Programme in Ireland discourage all GPs from biopsying any lesions suspicious of melanoma. The aim of this study was to assess whether or not it is safe and practical for a general practitioner with extra training in dermatology and skin surgery to assess suspicious skin lesions and treat low risk melanomas. The outcome of 56 new melanomas (31 invasive, 7 in situ and 18 lentigo maligna) in 53 patients, managed by a GP with extra training in dermatology and skin surgery, over a 20 year period, was examined. Forty-eight (86 %) of the melanomas had the initial biopsy carried out in primary care. The average time from presentation to the practice to the date of the biopsy was 8 days for the in situ and invasive melanomas and 17 days for the lentigo malignas. Twenty-eight (50 %) of the melanomas were considered low risk (in situ, invasive <1 mm deep or lentigo maligna) and were treated successfully in primary care according to the Australian and New Zealand guidelines, without any surgical complications. GPs with extra training in skin cancer and skin surgery could assess most suspicious skin lesions with dermoscopy and if necessary, biopsy most of these lesions in primary care. This would lead to a quicker diagnosis, more rapid pathway to definitive treatment, lower cost and more convenience to the patient, especially for those living in rural areas.

Estudio de las consultas por motivos dermatológicos en atención primaria y especializada

IntroductionThere are few studies on the prevalence of skin diseases, and very few reports of the percentage of consultations for dermatological reasons in primary and specialized care. ObjectivesSince most of studies of dermatology in primary care have focused on referrals to secondary care or emergency dermatology services, we aimed to study consultations for dermatologic problems in primary and specialized care. We also aimed to assess the percentage of diagnostic agreement between dermatologists and primary care physicians. Material and methodWe conducted an observational, descriptive, cross-sectorial study over a 3-month period in a primary care center in our health district and in our specialized outpatient unit in the Virgen de Macarena District in Seville (Spain). ResultsConsultations for dermatological reasons in health centers constitute a significant percentage (5.4%) of visits. The most common reason for consultation was eczema. Most patients were treated by the primary care physician without the need for referral. The percentage of diagnostic agreement between primary and specialized care was 27.3%. DiscussionThe high demand for consultations due to dermatological reasons in health centers justifies the need for adequate training in dermatology among primary care physicians. Most patients attended in general dermatology consultations (93.6%) are discharged without further follow-up. Comparison of the results of our study with those of the few studies available on the topic revealed differences in attendance rates and diagnostic agreement.

In Defense of Skin: Antimicrobial Peptides have their Day

Professor Richard L Gallo completed an undergraduate degree in Biology at the University of Chicago (IL, USA). He then went on to receive his MD degree and PhD in Radiation Biology and Biophysics from the University of Rochester School of Medicine (NY, USA). He completed an internship in Pediatrics at Johns Hopkins Hospital (MD, USA) before training in Dermatology and completing a postdoctoral fellowship in Cell and Developmental Biology at Harvard Medical School (MA, USA). While working as an Assistant Professor at Harvard Medical School, Professor Gallo made a landmark discovery by identifying the presence of antimicrobial peptides in mammalian skin. In 1999, he became an Associate Professor of Medicine and Pediatrics at the University of California, San Diego (CA, USA), and Chief of Dermatology at the VA San Diego (CA, USA). Currently, he is a Professor of Medicine and Pediatrics and Chief of the Division of Dermatology at the University of California, San Diego. His research is focused on the role of the human innate immune system in skin, with a particular interest in antimicrobial peptides and the basic functions of the skin microbiome. To date, Professor Gallo has been involved in several important observations demonstrating the physiologic relevance of innate immunity in mice and the role of these pathways in several human diseases, work that has been published in a number of prestigious journals. He has received numerous awards for his research including the Montagna, Sulzberger, CERIES, Mertz, Nobel and Rene' Touraine Lectureships, and he has been elected to the American Society of Clinical Investigation and Association of American Physicians. His research is supported by grants from the NIH, the Veterans Administration and private foundations.

Difficulty giving feedback on underperformance undermines the educational value of multi-source feedback

Background: Multi-source feedback (MSF) was intended to provide both a summative and formative assessment of doctors’ attitudes and behaviours.Aims: To explore the influences of feedback quality and trainees’ acceptance of the assessment on formative educational gains from MSF.Methods: Semi-structured interviews were conducted with a convenience sample of eight dermatology trainees, from an insider researcher position, following two pilot interviews. Interviews were manually transcribed and coded to permit template analysis, a subtype of thematic analysis.Results: The interview data indicated that MSF provides relatively little formative educational gains largely because of a paucity of constructive feedback on sub-optimal performance. This was due to difficulties encountered by raters giving developmental feedback, in particular, potential loss of anonymity, and by trainees selecting raters expected to give favourable comments. Dual use of MSF as a summative assessment in annual appraisals also inhibited educational gains by promotion of a ‘tick box’ mentality in which trainees’ need to pass their assessment superseded their desire for self-improvement.Conclusions: A relative lack of developmental feedback limits the formative educational gains from MSF and could provide false reassurance that might reinforce negative behaviours.

The prescribing practices of nurses who care for patients with skin conditions: a questionnaire survey

To explore the practice of nurses who prescribe medication for patients with skin conditions. Nurses have lead roles in dermatology services. In the United Kingdom, nurses in primary care frequently prescribe medicines for skin conditions, but there are concerns about role preparation and access to continuing professional development. The prescribing practices of nurse independent supplementary prescribers who care for patients with skin conditions are under-researched. Cross-sectional survey. An online questionnaire was used to survey 186 nurses who prescribed for skin conditions from May-July 2010. Data were analysed using descriptive statistics and nonparametric tests. The majority worked in primary care (78%) and general practice (111, 59.7%). Twenty (10.8%) had specialist modules (at diploma, degree or master's level), 104 (55.9%) had dermatology training (e.g. study days), 44 (23.7%) had no training, and a further 18 (9.6%) did not respond. Oral antibiotics, topical antifungal and antibacterial drugs were frequently prescribed. Nurses with specialist dermatology training used their qualification in a greater number of ways, prescribed the broadest range of products and prescribed more items per week. Over 70% reporting on continuing professional development had been able to access it. A large number of nurses in primary care prescribe medicines for skin conditions and are involved in medicines management activities. Lack of specialist dermatology training is a concern and associated with lower prescribing-related activities. Access to dermatology training and continuing professional development are required to support nurse development in this area of practice and maximise benefits. Nurse prescribers' involvement in medicines management activities has important implications in terms of improving access to services, efficiency and cost savings. To maximise their contribution, improved provision of specialist dermatology training is required. This will be of interest to education providers and service planners in the UK and countries around the world.

Clinical photography in dermatology: Ethical and medico-legal considerations in the age of digital and smartphone technology

Clinical photography has long been an important aspect in the management of dermatological pathology and has many applications in contemporary dermatology practice. With the continuous evolution of digital and smartphone technology, clinicians must maintain ethical and medico-legal standards. This article reviews how dermatology trainees are utilising this technology in their clinical practice and what procedures they follow when taking photos of patients. We review the ethical and legal considerations of clinical photography in dermatology and present a hypothetical medico-legal scenario. Dermatology registrars were surveyed on their use of personal smartphones and digital equipment for photographing patients in their clinical practice. Numerous medico-legal providers were approached to provide medico-legal advice about a hypothetical scenario. We found that the use of these technologies is prevalent among dermatology registrars and all respondents reported regular use. Clinicians should routinely obtain and document adequate patient consent in relation to clinical photography, utilise strict privacy settings on smartphones and other digital devices and ensure that the images are stored on these devices for minimal periods. Express consent documentation in the clinical file puts the clinician in a more defensible position if a complaint is made to the medical board or privacy commissioner.

Dermoscopy use in the next generation: A survey of Australian dermatology trainees

The use of dermoscopy is rapidly expanding. The dermatoscope is now used in everyday practice. We sought to investigate the use of dermoscopy by Australian dermatology trainees. An invitation to complete a web-based survey was sent via e-mail. The survey was composed of a combination of questions from a standardised survey of the International Dermoscopy Society, a previously published dermoscopy survey of Australian consultant dermatologists and questions posed by us. Two-sided Fisher's exact tests, χ(2) tests and exact χ(2) tests for trend were used to assess differences between Australian consultants (n = 99) and trainee dermatologists (n = 44). The response rate was 55% (44/80 trainees). There were 32% (n = 14) male and 68% (n = 30) female respondents. The mean age was 33-years (SD = 5.41). All respondents used dermoscopy with most (55%, n = 24) having used a dermatoscope for 3-5 years. When asked whether a dermatoscope was an essential tool for a trainee dermatologist, 96% (n = 42) responded yes. There was a statistically significant difference in answers of consultants and trainees to questions on identifying melanomas early in the curable stage, the use of dermoscopy in non-pigmented tumours, helping to improve record-keeping, documentation for medical liability and anticipation for future use of dermoscopy (P < 0.05). This survey of trainee dermatologists compared the dermoscopy practices recorded in a previous publication involving consultant dermatologists, in addition to questions asked by us. We outline what the practices of dermoscopy use could be in the next generation of dermatologists in Australia.

Online learning in a dermatology clerkship: Piloting the new American Academy of Dermatology Medical Student Core Curriculum

Multiple studies have shown that both current and future primary care providers have insufficient education and training in dermatology. To address the limitations and wide variability in medical student dermatology instruction, the American Academy of Dermatology (AAD) created a standardized, online curriculum for both dermatology learners and educators. We sought to determine the impact of the integration of the AAD online curriculum into a 2-week introductory dermatology clerkship for fourth-year medical students. In addition to their clinical duties, we assigned 18 online modules at a rate of 1 to 3 per day. We evaluated knowledge acquisition using a 50-item, multiple-choice pretest and posttest. Postmodule and end-of-course questionnaires contained both closed and open-ended items soliciting students' perceptions about usability and satisfaction. All 51 participants significantly improved in their dermatology knowledge (P < .001). The majority of students found the modules easy to navigate (95%) and worth their time (93%). All respondents supported the continuation of the modules as part of the dermatology clerkship. Without a control group who did not experience the online curriculum, we are unable to isolate the specific impact of the online modules on students' learning. This study demonstrates the successful integration of this educational resource into a 2-week, university-based dermatology clerkship. Students' perceptions regarding usability and satisfaction were overwhelmingly positive, suggesting that the online curriculum is highly acceptable to learners. Widespread use of this curriculum may be a significant advancement in standardized dermatology learning for medical students.

The importance of dedicated dermoscopy training during residency: A survey of US dermatology chief residents

Studies have shown low satisfaction levels among dermatology residents with respect to dermoscopy training. Many desire additional instruction. We surveyed graduating chief residents to assess current education practices among US dermatology training programs with respect to the role of dermoscopy as an aid in the management of pigmented lesions. An online survey was sent to 139 chief residents of US dermatology training programs. A 59% response rate was achieved. Of responding chief residents, 94% use dermoscopy. Although 92% of chief residents received dermoscopy training, only 48% trained with a pigmented lesion specialist. Among those training without a specialist, less than half received classroom or bedside teaching compared with 77% of those who trained with a specialist. Of those who trained with a specialist, 77% were satisfied with their training compared with only 30% who trained without a specialist (P < .0001). Those who trained with a specialist were more likely to agree that dermoscopy can help differentiate melanoma from benign lesions (77% vs 47%; P = .0065). Response bias and limiting the survey to chief residents potentially limits our ability to generalize these results to all US dermatology trainees. Although many residents use dermoscopy as a diagnostic tool, the lack of dedicated dermoscopy training remains a potential barrier to increasing residents' diagnostic confidence in the management of pigmented lesions. Increasing the amount of dedicated instruction on this topic is one possible approach to enhance resident satisfaction, potentially increasing their competency in the management of atypical nevi.