Medical Dermatology Research Articles

Consensus on the medical treatment of colon cancer

PURPOSE: To throw light on some of the issues in the choice of therapy for patients with metastatic colorectal cancer (mCRC) and to provide consensus recommendations on which combination(s) and sequence(s) of systemic therapy to be used in different treatment situations. MATERIAL AND METHODS: An expert panel comprising clinicians from Austria, Belgium, the Czech Republic, Germany, Hungary, Italy, Romania, Slovakia, Slovenia, Spain and the UK with expertise in medical oncology, clinical oncology, surgery and dermatology, and specialist knowledge of the treatment of patients with CRC was convened by the Central European Cooperative Oncology Group (CECOG) in Vienna in 2007. Members were then asked to agree on a consensus statement following a period of discussion at the end of a series of presentations. RESULTS AND CONCLUSIONS: The consensus recommendations for the state-of-the-art treatment of colon cancer arrived at by an "expert panel" of clinicians were that: oral 5-fluorouracil (5-FU) prodrugs or protracted intravenous infusion of the antimetabolite are preferable to bolus administration; all active drugs (fluoropyrimidines, irinotecan, oxaliplatin, bevacizumab, cetuximab) should be used during strategic patient management; after neoadjuvant treatment and consultation of an interdisciplinary team, surgery should be considered for metastatic disease wherever possible and "fit" elderly patients should not be denied the same treatment as younger patients.

Motor disorders: Evidence-based review of the use of botulinum toxins

Botulinum neurotoxin (BoNT) has emerged as a major therapeutic advance in the treatment of many disorders, affecting motor and non-motor systems. It has applications in numerous medical specialties, including neurology, rehabilitation medicine, ophthalmology, otolaryngology, gastroenterology, orthopedics, dermatology, and urology. The use of BoNT for pain disorders is an emerging and active area of interest. A task force of the Technology and Therapeutics Assessment Committee of the American Academy of Neurology performed a literature search for relevant, fully published, peer-reviewed articles related to clinical use of BoNT for neurological disorders. The panel was comprised of specialists with experience in the therapeutic use of BoNT for the indications under consideration or with expertise in guideline methodology. Authors reviewed, abstracted, and classified papers based on AAN criteria (Class I–IV). This lecture summarizes the evidence supporting the use of BoNT in neurological disorders, including adult and childhood spasticity and selected movement disorders.

The 8th Annual Las Vegas Dermatology Seminar

The 8th Annual Las Vegas Dermatology Seminar, as stated in its name, was held in Las Vegas, NV, USA on 8–11 November 2007. With an attendance of more than 300 people, this well-known event brought together prominent guest speakers from the USA, Italy, Mexico and the Czech Republic to present on numerous topics mostly related to medical dermatology. Additionally, the last day of the event was dedicated to cosmetic dermatology. The meeting had a strong clinical flavor with abundant and useful pearls for the practicing physician. The afternoon sessions focused on biologic therapy for psoriasis, and were targeted at third-year dermatology residents. The practical nature of the seminar was clearly revealed during the resident’s symposium, where most of the discussion time was devoted to the analysis of real-life cases/scenarios, preceded by a short and concise summary of biologics as individual drugs. This session concluded with an interesting discussion on optimal office effectiveness.

Who else is providing care in dermatology practices? Trends in the use of nonphysician clinicians

The US dermatology workforce, which is affected by a physician shortage, has reportedly seen a rapid and substantial influx of physician assistants (PAs) and nurse practitioners (NPs). Little is known about which dermatology practices use these practitioners, how they are supervised, and the services they are providing. We analyzed results of the American Academy of Dermatology's 2007 practice profile survey to learn more about patterns of nonphysician clinician (NPC) use. Of 3965 surveys mailed, responses were obtained from 1243 dermatologists (31% response rate). Comparison data were drawn from previous surveys conducted with a similar methodology in 2002 (35% response rate) and 2005 (30% response rate). Overall, 325 responding dermatologists (29.6%) reported using PAs, NPs, or both in their practices in 2007, a 43% increase from the proportion in 2002 (20.7%). PAs were more prevalent than NPs (23% vs 10%). By the year 2010, 36.2% of respondents plan to hire these NPCs. Younger cohorts of dermatologists were significantly more likely to use NPCs (P = .006), as were those in group and academic practices (P < .0001). Respondents seeking to hire additional dermatologists (P < .0001) and those with surgical or cosmetically focused practices (P < .001) were much more likely to use NPCs. Respondents reported supervising their NPCs on-site 92.8% of the time, but 31% were off-site 10% of the time or more. Most dermatologists allowed their NPCs to see new patients and established patients with new problems, and a minority of these patients were formally presented to a physician during extender visits. NPCs spent the majority of their time seeing medical dermatology patients, even if their supervising dermatologist was primarily engaged in surgical or cosmetic dermatology. Survey respondents might have inaccurately reported practice characteristics or might not be representative of all US dermatologists. In the setting of persistently long patient wait times and difficulty recruiting new physician staff, dermatologists have rapidly turned to PAs and NPs to help meet patient demand for care. These NPCs are primarily caring for new and established medical dermatology patients under indirect supervision. In the absence of explicit consensus or policy as to how the field should ensure future access to care for patients with skin disease, growth in the use of NPCs has continued, with significant variation in use and supervision patterns.

Recent advances in medical dermatology

Collectively, new developments in the field of medical dermatology will ultimately lead to improved patient care. We review several new findings in the dermatologic literature including the following: new questions regarding the malignant potential of anti-tumor necrosis factor agents, which are widely used for the treatment of moderate to severe psoriasis as well as psoriatic arthritis; anti-interleulin-12, a promising anticytokine for the treatment of psoriasis; diagnostic advances in the detection of latent Mycobacterium tuberculosis; advances in the primary prevention of human papillomavirus and herpes zoster; and new therapeutic options with existing medications for neuropathic pain and pruritus.

Patients seen and lessons learned

Patients can have a profound influence on physicians. Indeed, my decision to become a dermatologist was influenced by the experiences I (JJW) had with 2 patients. The first patient had a severe dermatologic condition and emphasizes the continued need for medical dermatology. The second patient demonstrates the importance of evaluation and treatment of cutaneous conditions by a skin specialist. Dr Tyring, the senior author, has been my mentor for the last 4 years, cultivating my interest in academic dermatology with a focus on medical dermatology.

Retaining the professionalism of cosmetic dermatology

Dermatology is one of the oldest specialties in medicine with both Old and New Testament biblical accounts of skin disease and healing. The leper, the psoriatic, and the patient covered with furuncles are all vividly described within its pages. Dermatology is also one of the most versatile areas within medicine with the ability to care for both sexes of all ages using both medical and surgical therapies. No other “specialty” retains such a generalization of skills. This tremendous variety within the specialty is in large part due to the innovations of cosmetic dermatology. Cosmetic dermatology has added many invasive and minimally invasive procedures to the traditional medical dermatology therapeutic armamentarium. Yet, recently, a number of challenges have arisen to the professionalism of cosmetic dermatology. I would like to address some of these issues. My first concern is that the skin care industry in general has recognized the value of a dermatologist evaluating or recommending their product offerings. For this reason, many products now bear the labeling “dermatologist recommended.” While there are no guidelines currently in place to specify exactly what dermatologist recommended means, there should be some implied professionalism behind this statement. In my opinion, dermatologist recommended should mean that an advisory board of cosmetic dermatologists with clinical and research expertise in the product area to be evaluated assemble and collectively discuss the merits of the technology. If the product is intended for global distribution, then the advisory board should be composed of an international selection of cosmetic dermatologists representing every continent where the product is to be sold. This is advantageous both for the dermatologist and the manufacturer. It raises the professionalism of the dermatologist-recommended claim and helps the manufacturer identify possible product problems or discover novel product improvements. My second concern regards the desire of some skin care marketing companies to link their product with the name or face of a well-respected dermatologist. While this may at first seem like a desirable relationship, I believe it detracts from the professionalism of cosmetic dermatology. In most cases, the dermatologist did not develop the products or perform any clinical testing. Usually, the dermatologist is hired as a spokesperson with little or no actual product use experience. It is impossible to be an objective professional and function as a spokesperson simultaneously. Thus, skin care marketing companies should realize that the promising career of a young cosmetic dermatologist could be ruined by a spokesperson role. Cosmetic dermatologists that have functioned as prominent spokespersons are rarely called upon to take the podium, since their objectivity from that point forward remains in question. Lastly, many cosmetic dermatologists are hesitant to become involved in clinical research because the time spent seeing patients is financially more productive. Involvement in clinical research is rewarding to both the specialty and the physician. It is only through clinical research that new products and procedures enter our specialty. Furthermore, it is the interest in further knowledge that prevents the cosmetic dermatologist from loosing interest. Physician burn out is quite common after 10–15 years in many areas of medicine. This need not be the case in cosmetic dermatology where something is always in the offering due to the outcomes of successful research. The Journal invites you to submit your original observations, ideas, and research to be considered for publication during the next year. One of the major goals of the Journal is to maintain the professionalism of cosmetic dermatology through the exchange of ideas and spread of knowledge. The professionalism of cosmetic dermatology can be maintained and enhanced by lending credence to the phrase “dermatologist recommended,” carefully separating professional roles from marketing roles, and publishing the results research activities. The Journal of Cosmetic Dermatology is dedicated to preserving the professionalism of cosmetic dermatology.

Medical Dermatology: A View to the Future

Medical Dermatology: A View to the Future

Prevalence of psychotropic medication use among cosmetic and medical dermatology patients: A comparative study

Little is known about the psychologic status of cosmetically oriented dermatology patients. We sought to determine the prevalence of psychotropic medication use among such patients to offer insight into the rates of psychopathology in this group. We conducted a retrospective chart review of patients seeking consultation at a cosmetic dermatology practice, recorded patients' use of psychotropic medicines, and compared this with data from a control group of medical dermatology patients. Both groups reported rates of psychotropic medication use above those expected in the general population. There was no statistically significant difference in the prevalence of psychotropic drug use between cosmetic (18%) and medical (17%) dermatology patients. There is not a one-to-one correspondence between psychotropic medication use and the presence of psychopathology. Data are based on patient health histories and, thus, may be subject to underreporting. There is a relatively high rate of psychotropic drug use among all patients seeking care from dermatologists, but this does not appear to be more common among patients interested in undergoing cosmetic procedures.

2005 Annual Meeting Abstracts of the Medical Dermatology Society

2005 Annual Meeting Abstracts of the Medical Dermatology Society

Combination Antimalarials in the Treatment of Cutaneous Dermatomyositis

To observe whether the use of antimalarials in combination resulted in significant improvement in the cutaneous signs and symptoms of patients with dermatomyositis who did not otherwise respond to the use of single-agent antimalarial therapy. Retrospective case series of 17 patients treated between January 1, 1991, and December 31, 2002. An ambulatory medical dermatology clinic in an academic center.Patients Patients had adult-onset dermatomyositis with predominantly cutaneous symptoms and a follow-up period at our clinic of at least 6 months. Cases in which it was not possible to assess the effect of treatment on cutaneous symptoms were not included. Intervention Treatment regimens varied and included the use of antimalarials, prednisone, methotrexate, and other medications. Physician-observed and patient-reported improvement based on erythema, pruritus, and extent of affected skin. Seven of 17 patients experienced at least near clearance in cutaneous symptoms with the use of antimalarial therapy alone: 4 of these patients required combination therapy (hydroxychloroquine sulfate-quinacrine hydrochloride or chloroquine phosphate-quinacrine), while 3 of them responded well to antimalarial monotherapy. The median time required to reach the response milestones on the final working therapeutic regimen was 3 months (mean, 4.8 months; range, 2-14 months). Six patients did not respond significantly to any type of therapy, including nonantimalarials. Our experience suggests that a significant subgroup of patients whose skin lesions have been unresponsive to a single antimalarial benefit from combination therapy with hydroxychloroquine and quinacrine or chloroquine and quinacrine, but controlled clinical trials are warranted to assess the extent of benefit.

Case mix measures and diagnosis‐related groups: opportunities and threats for inpatient dermatology

The changing healthcare environment world-wide is leading to extensive use of per case payment systems based on diagnosis-related groups (DRG). The aim of this study was to examine the impact of application of different DRG systems used in the German healthcare system. We retrospectively analysed 2334 clinical data sets of inpatients discharged from an academic dermatological inpatient unit in 2003. Data were regarded as providing high coding quality in compliance with the diagnosis and procedure classifications as well as coding standards. The application of the Australian AR-DRG version 4.1, the German G-DRG version 1.0, and the German G-DRG version 2004 was considered in detail. To evaluate more specific aspects, data were broken down into 11 groups based on the principle diagnosis. DRG cost weights and case mix index were used to compare coverage of inpatient dermatological services. Economic impacts were illustrated by case mix volumes and calculation of DRG payments. Case mix index results and the pending prospective revenues vary tremendously from the application of one or another of the DRG systems. The G-DRG version 2004 provides increased levels of case mix index that encourages, in particular, medical dermatology. The AR-DRG version 4.1 and the first German DRG version 1.0 appear to be less suitable to adequately cover inpatient dermatology. The G-DRG version 2004 has been greatly improved, probably due to proceeding calculation standards and DRG adjustments. The future of inpatient dermatology is subject to appropriate depiction of well-established treatment standards.

Medical student dermatology research in the United States

The development of academic researchers is important for the future success of dermatology, but few dermatology trainees are entering academic practice in the United States. Because many successful researchers begin to focus on research skills during medical school, an electronic survey was conducted to evaluate dermatology research opportunities and benchmarks for U.S. medical students. First- and second-year medical students participated in case studies, clinical research projects, and laboratory benchwork, but participation significantly increased during the third and fourth years. Funded programs had higher student participation than nonfunded programs and were also more likely to have medical students present their research at meetings. A wide variety of research opportunities are currently offered to U.S. medical students, so a lack of research opportunities in medical school does not explain the dwindling supply of academic dermatologists in the United States. Because funding appears to be an important factor for successful medical student research, new mechanisms of funding should be identified and developed.

Generational Differences in Practice Patterns of Dermatologists in the United States

To examine the effect of age and other demographic factors on dermatologists' practice characteristics. Anonymous practice profile survey. Dermatologist members of the American Academy of Dermatology Association. Analyzed survey questions included information about legal practice entity, geographic area served, weekly patient care hours, patients seen per hour, and scope of patient care activities. Of 4090 surveys sent, 1425 (35%) were returned. As the age of the cohorts increased, the percentage practicing in solo practices increased (range, 21%-39%), as did the percentage serving urban areas (range, 31%-46%). Measures of physician productivity increased in the older age cohorts; however, age was not a significant factor after controlling for other variables. More patient-hours per week were associated with male sex (P < .001), solo practices (P < .001), and non-urban-based practices (P = .04), whereas a greater number of patients per hour was associated with non-rural-based practices (P = .02) and male sex (P = .03). As the cohorts progressed in age, more time was spent practicing medical dermatology. The number of hours spent practicing cosmetic dermatology peaked in the 41- to 50-year-old cohort (P = .03). Practice patterns differ significantly among dermatologists of different ages. As the current cohorts age and new dermatologists emerge from training, changes in scope of practice and generational differences in productivity are likely to cause a contraction in the effective supply of dermatologists, which has important implications for dermatology workforce planning.

The Canadian Dermatology Workforce Survey: Implications for the Future of Canadian Dermatology—Who will be your skin expert?

To survey Canadian dermatologists for specialty-specific physician resource information including demographics, workload and future career plans. In 2001, the Canadian Dermatology Association (CDA) surveyed 555 dermatologists in Canada to gain specialty-specific physician resource information. Three hundred and seventy-one dermatologists (69%) provided information about themselves, their workloads and their future career goals. The average Canadian dermatologist is 52 years old and 35% of practicing dermatologists are over the age of 55. Eighty-nine percent of dermatologists practice in an urban setting, 19% include practice in a rural setting while less than 0.5% practice in remote areas. Canadian dermatologists spend 61% of their clinical time providing services in Medical Dermatology. Within 5 years, 50% of dermatologists reported that they plan to reduce their practices or retire. The Canadian Dermatology Workforce Survey provides a snapshot of the current practice of dermatology in Canada. It also serves to highlight the critical shortage of dermatologists, which will continue to worsen without immediate, innovative planning for the future.

A discrete speech recognition system for dermatology: 8 years of daily experience in a medical dermatology office.

A discrete speech recognition system was customized to recognize approximately 9,000 phrases and terms commonly used in dermatology, and has been used on a daily basis since 1984 to produce as many as 65 consult and follow up letters daily. The systems and procedures necessary for the practical use of this system are described, together with a discussion of the advantages and disadvantages of using this system to automate the transcription of dermatological dictation.

Valoración del daño corporal en Dermatología. Estudio jurisprudencial

Abstract.—Introduction: The importance of cutaneous sequels in body injury evaluation is a matter of growing interest that is hardly known for dermatologists. Sources and methods: Besides legal and referential research, we carried out a study of judicial sentences from Regional Courts in Castilla y León, Cantabria and La Rioja (Spain) for the 1995-1998 period. Out of 4,073 sentences, we analysed 169 cases that established indemnities for posttraumatic cutaneous sequels. Results: Judicial descriptions of cutaneous sequels are clearly deficient. Only 24% of the cases reported a more-or-less precise description of the lesions. A reference to the esthetic damage on the victim was reported in 67% of the sentences. 23% of them included the evaluation of body injuries and 4% referred to the particular evaluation of cutaneous sequels. The high cost implied in cutaneous body injury is noticeable if we consider that the percentage of indemnifications for cutaneous scars in nearly 30% of the cases exceeded 50% out of the total. The average payable amount «per scar» in the period and place subject to study was 310.382 pesetas (euros). Conclusions: a more precise evaluation of cutaneous body injuries makes necessary the intervention of Surgical and Medical Dermatology, providing for the training of forensic surgeons and estimators of body injuries, the direct evaluation of significant sequels, and the therapeutic possibilities at each case.

PRESERVING MEDICAL DERMATOLOGY: A Colleague Lost, a Call to Arms, and a Plan for Battle

Change within dermatology as a clinical discipline is expected and inevitable. However dermatology may change as a medical specialty in the new millennium, there will still be patients with medical dermatologic disease whose optimal care will depend on skin disease specialists' having the highest level of training and experience in medical dermatology. Dermatologists who have subspecialized in medical dermatology will provide the role models for new generations of dermatologists, perform the patient-oriented research, and care for the more complicated patients. Thus, if during its evolution, dermatology loses the ability to train and support medical dermatologists, it will be weakened as the discipline that can best care for skin disease. Clearly, the loss of talented academicians such as the person whose career was outlined in the case report presented at the beginning of this article should be a huge warning sign that the future of medical dermatology as a specialty is uncertain. The Medical Dermatology Society hopes to develop a coalition with all other leadership organizations within dermatology to deal with this problem effectively. There is a need for a broader discussion within organized dermatology of the growing crisis in this area and how all dermatology leadership organizations working together can develop an action plan for effectively dealing with this important but challenging problem. Dermatology must ask itself what it wants to look like as a medical specialty in the future. Without an steady stream of young clinician-investigators focused on the many challenging problems in medical dermatology, dermatology will not exist as the specialty it is today.

Too few or too many dermatologists? Difficulties in assessing optimal workforce size.

Discussions of the dermatology workforce have been dominated in the last 3 decades by concerns of an impending surplus. The aim of this article is to provide new data on the supply of dermatologists and to reassess estimates of future demand in light of growing anecdotal evidence suggesting a shortage. The US supply of dermatologists has risen to 3.3 per 100 000 population, and this growing workforce continues to be geographically maldistributed. A number of factors, including a possible increase in the number of surgical and cosmetic procedures being performed, might make this growing supply less available for the care of medical dermatology patients, complicating any supply projections. Precise estimates of future demand are also difficult because changes in disease prevalence, medical technology, and the health care delivery system are not always predictable. In an era when regulatory bodies are making more centralized decisions about residency training, the field must attempt to estimate and anticipate future needs. Simply allowing others to make decisions about the future size of the workforce based on outdated data risks an oversupply or undersupply, either of which will have detrimental effects on dermatologists and their patients.

Cosmetology, cosmetics, cosmeceuticals: definitions and regulations

The growth of the cosmetic industry, together with the dramatic increase in advances in cosmetic chemistry, has been one of increasing interface with dermatologists. The change especially in dermatology has found less emphasis on medical dermatology and growth in the areas of cosmetic dermatology and dermatologic surgery. With this, the dermatologist has had to become more aware of principles and products in the field of cosmetics. The use of these newer products as an adjunct to the practice of dermatology coincides nicely with recent international congresses, whose theme has been “healthy skin for all” and variations on such. Perhaps the major body for the oversight of this growth remains the U.S. Food and Drug Administration (FDA), which for many parts of the world provides the assurance of safety and quality for various foods, drugs, and cosmetics. The mandate for much current regulation and oversight began in 1938 with the Food, Drug, and Cosmetic Act, which placed active oversight on various drugs and cosmetics and was further modified in 1960 by the Delaney Amendment, which focused on the growing awareness of carcinogenic potential of various agents, topical and systemic. 1 Since the radium scare of the 1920s and 1930s, the increasing use of synthetic materials has focused on delayed long-term potential cancer risks and health hazards. More recently, such agents as Dioxin, Agent Orange, and certain other fungicides and pesticides have seemingly justified this new role of the FDA. Of particular confusion at the present time are certain dyes—FD&C Red #3, FD&C Yellow #5, hair dyes—and other agents that are essential in the cosmetic and “cosmeceutical” practice. The variability of interpretation of safety still confounds easy interpretation of the administration’s role in the approval of new uses, particularly in the cosmeceutical area. At the present time, FD&C Red #3 has been