US Dermatologists Research Articles

Knowledge, Attitudes, and Practices Regarding Herpes Zoster Vaccination Among Specialists.

Recombinant zoster vaccine has been recommended by the US Advisory Committee on Immunization Practices (ACIP) for the prevention of herpes zoster (HZ) in immunocompetent adults aged at least 50 years since 2018. In January 2022, this was extended to immunodeficient/immunosuppressed adults aged at least 19 years. Key study objectives were to assess specialists' knowledge of the ACIP HZ vaccination recommendations, their attitudes toward HZ vaccination, and HZ vaccination practices/barriers. This cross-sectional, web-based survey (conducted in March 2022) included US dermatologists, gastroenterologists, infectious disease specialists, oncologists, and rheumatologists who treat patients with psoriasis, inflammatory bowel disease, human immunodeficiency syndrome, solid tumors/hematological malignancies, and rheumatoid arthritis, respectively. Although most of the 613 specialists correctly identified the ACIP HZ vaccination recommendations for adults aged at least 50 years (84%) and immunodeficient/immunosuppressed adults aged at least 19 years (67%), only 29% knew that recombinant zoster vaccine is recommended for individuals who have previously received zoster vaccine live, and only 18% knew all current ACIP recommendations. For patients with the diseases listed, 84% of specialists thought that HZ is a serious risk, 75% that HZ vaccination is extremely/very important, and 69% were extremely/very likely to recommend HZ vaccination. Only 36% administer vaccines themselves, mainly because patients receive vaccinations from others. Barriers to vaccination included more urgent/acute issues, insufficient time, and lack of patient motivation/willingness. Full knowledge of the ACIP HZ vaccination recommendations among the surveyed specialists was low. There may be a need to educate specialists to improve adherence to these recommendations. [Figure: see text].

Analysis of trends in US dermatologist density and geographic distribution

Analysis of trends in US dermatologist density and geographic distribution

A survey of United States dermatologists' knowledge, attitudes, and practices with intramuscular triamcinolone.

Since the 1970s, intramuscular triamcinolone (IMT) has been available as an option for systemic corticosteroid use in dermatology. Although shown to be safe and effective in early studies, this method of systemic corticosteroid delivery fell out of favor in the 1980s in many United States residency programs. To identify factors associated with US dermatologists' preferences for and use of IMT we surveyed a random sample of US board-certified dermatologists to assess knowledge, attitudes, and practices regarding IMT in dermatologists' daily clinical practice. A total of 844 out of 2000 dermatologists completed the survey (42.2%). Only 55.0% reported feeling comfortable using IMT for steroid-responsive dermatoses, while 90.4% felt comfortable using oral corticosteroids for steroid-responsive dermatoses. Most participants (59.2%) did not prefer IMT over oral corticosteroids when both were indicated. One third (33.3%) of the participants reported that none of the faculty during their residency advocated using IMT. Receiving education on IMT indications (OR = 1.96 [95% CI: 1.46-2.63]) and encouragement to use IMT (OR = 4.29 [95% CI: 3.01-6.11]) during residency were positively associated with use of IMT at least once a month in current practice. Current knowledge, attitudes, and practices surrounding IMT vary amongst practicing dermatologists. Modifiable factors such as training could improve comfort with use of this short-term systemic steroid treatment modality.

The influence of dermoscopy education over 14 years at a single institution: A retrospective cohort study

To the Editor: Dermoscopy has been shown to improve the benign to malignant ratio for suspected melanoma, 1 Bafounta M.L. Beauchet A. Aegerter P. Saiag P. Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Results of a meta-analysis using techniques adapted to the evaluation of diagnostic tests. Arch Dermatol. 2001; 137: 1343-1350 Crossref PubMed Google Scholar ,2 Carli P. De Giorgi V. Crocetti E. et al. Improvement of malignant/benign ratio in excised melanocytic lesions in the 'dermoscopy era': a retrospective study 1997-2001. Br J Dermatol. 2004; 150: 687-692 Crossref PubMed Scopus (195) Google Scholar but not all dermatologists use dermoscopy. 3 Murzaku E.C. Hayan S. Rao B.K. Methods and rates of dermoscopy usage: a cross-sectional survey of US dermatologists stratified by years in practice. J Am Acad Dermatol. 2014; 71: 393-395 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Previously, we reported the clinical accuracy for identifying melanoma in our institution in 2005, 4 Soares T.F. Laman S.D. Yiannias J.A. et al. Factors leading to the biopsy of 1547 pigmented lesions at Mayo Clinic, Scottsdale, Arizona, in 2005. Int J Dermatol. 2009; 48: 1053-1056 Crossref PubMed Scopus (14) Google Scholar when dermoscopy use and training was limited in the department. In 2006, our department made formal comprehensive formal training available to all providers with annual review. We aimed to review the outcomes and clinical accuracy for identifying melanoma in 2019 to assess the benefit of the comprehensive dermoscopy curriculum.

The perspectives of 606 US dermatologists on active surveillance for low-risk basal cell carcinoma.

In this survey study of over 600 US dermatologists, identical clinical scenarios (10mm primary asymptomatic BCC) were presented except for randomly varied patient characteristics including age, life expectancy, and tumor location. Most dermatologists (62%) recommended active surveillance for patients with advanced age (91 years) and a 1-year life expectancy. The odds ratio for choosing active surveillance was 20.31 (95% CI 14.10-35.30) comparing a patient with a 1-year life expectancy to a healthy patient.

Treatment Patterns and Treatment Satisfaction Among Adults with Alopecia Areata in the United States.

Alopecia areata (AA), an autoimmune disease, is characterized by non-scarring hair loss involving the scalp, face, and/or body. Prior to 2022, no US Food and Drug Administration (FDA)-approved treatments for AA were available in the USA; existing treatment options had limited efficacy and durability and are often associated with side effects. This study aimed to evaluate the current AA treatment patterns and treatment satisfaction as reported by dermatologists. Real-world data from a 2019 cross-sectional survey of US dermatologists and their adult patients with AA were analyzed. Dermatologists provided comprehensive data on their patients with AA, including AA dermatologist-assessed severity, treatments, treatment duration, treatment satisfaction, and reasons for dissatisfaction. The switching patterns among the proportion of patients on each of the treatment groups at the time of survey and, for those with prescription history, were reported. A total of 442 patients with AA, treated by 90 dermatologists, were included in this analysis. At the time of survey, 45% of patients were being prescribed a combination of corticosteroids, 21% injectable corticosteroids, 11% topical corticosteroids/topical calcineurin inhibitor, and 10% immunomodulator as monotherapy or in combination. The majority (65%) of patients had no prior reported therapy. Among patients who were reported to have a prior therapy, frequent switching was to combination corticosteroids, injectable corticosteroids, and immunomodulators. Overall treatment dissatisfaction was high (24% dissatisfied and 29% neutral) and increased with AA severity. This analysis provides a snapshot of the different local and systemic treatment options currently being used in a real-world treatment setting. Unfortunately, none of these treatments provide a sustainable, safe, and relapse-free solution, which leads to high treatment dissatisfaction rates and hence indicates a significant unmet need for the new and advanced treatment options for patients with AA.

32834 Patient and dermatologist perspectives on unmet needs in hidradenitis suppurativa

Objective: To report patient journey and disease management of HS from the perspectives of US dermatologists and patients. Methods: Dermatologists with expertise in HS, general dermatologists, and patients with HS participated in this prospective web-based survey study. Dermatologists completed a 33-question survey focused on disease awareness, referral practices, and treatment patterns. Patients completed a 46-question survey that included demographics, disease characteristics, journey to care, treatment history, and HS awareness. Results: Overall, 47 patients and 30 dermatologists (6 of whom were HS experts) participated in this study. The majority of patients (73%) experienced first HS symptoms before the age of 20 years, and 47% of patients reported >10 years from symptom onset to HS diagnosis. Dermatologists and patients both reported challenges with the referral process, with 47% of referred patients reporting the process as “very difficult.” Patients reported they were most frequently (51%) diagnosed by a dermatologist. Before seeking medical help, 70% of patients tried nonprescription therapies for their symptoms. Topical therapy and antibiotics were the most commonly prescribed first-line treatment for mild to moderate HS, and biologics were for severe HS. Most patients (63%) reported that biologic treatment improved their condition, and 41% of patients reported that time to initiate a biologic was >2 years from diagnosis. Additionally, patients and dermatologists both reported high levels of psychological burden experienced by patients. Conclusion: Increased awareness of HS is necessary to address unmet needs, including reducing diagnosis delays and optimizing treatment strategies, to ensure comprehensive care and improved outcomes.

32295 Looking beyond scalp hair loss: Factors influencing dermatologists’ assessment of alopecia areata severity

Background: Severity criteria for AA currently rely on extent of scalp hair loss (HL) without formally assessing other relevant factors that may influence disease severity. Objective: Identify factors beyond extent (percent) of scalp HL that are associated with dermatologist assessed AA severity. Methods: Real-world data from a 2019 cross-sectional survey of US dermatologists and their adult AA patients were analyzed. Dermatologists provided assessments of patients’ clinical characteristics. Two methodologies were used to evaluate the predictive power of risk factors including percent scalp HL: classification and regression tree (CART) and multinomial logistic regression (MLR) models. Seven domains of dermatologist-reported risk factors were sequentially tested: HL percent, patient impairments, disease/treatment history, demographics, dermatologist treatment satisfaction, comorbidities, and dermatologist characteristics. Results: Patients’ (n = 442) mean (SD) age was 39.3 (13.8) years, time since diagnosis was 4.5 (7.5) years, 51% female. Patient’s AA severity as assessed by the dermatologist was 20% mild, 53% moderate and 27% severe. CART identified percent scalp HL as the primary differentiator between Mild (0-10%), Moderate (11-40%) and Severe (≥41%) AA; treatment success was an additional predictor that differentiated between mild and moderate severity. In MLR, scalp HL was the most important risk factor (generalized R-sq = 60% out of 70% in the final model). Additional differentiating factors included fear of recurrence and day-to-day activity impairment. Conclusions: Although dermatologists’ assessment of AA severity primarily relies on extent of scalp HL, it is also influenced by a combination of physician-related (treatment success) and patient-related (fear of recurrence and activity impairment) factors.

Variance from published guidelines and changes in temporal trends in the management of cutaneous malignant melanoma: a 5-year update.

This study aimed to assess the current management of melanoma from relative to present guidelines and determine changes 5 years ago. An eight-question survey was sent to practicing US dermatologists using the same methodology and questions from our JAAD study. Overall, saucerization/scoop biopsy (48%) was the most commonly used method. The most commonly chosen margin for melanoma in-situ (MMIS) removal was 6-10 mm (51% of respondents). For CMM with a depth greater than 1 mm, the most commonly chosen margins were in the 1.1-1.9 cm range (55% of respondents). More respondents referred cases of MMIS and CMM out for treatment as compared to 2016. Academic dermatologists in 2021 were 8% less likely to treat MMIS as compared to all other practice types in 2021, whereas 7% more likely to treat CMM greater than 1 mm. Academic dermatologists in 2016, as compared to 2021, were 4% more likely to treat MMIS and 19% more likely to treat CMM greater than 1 mm. A total of 91% of respondents reported having some change in their management of CMM. Our study findings suggest that a knowledge gap still exists representing a continued educational opportunity to more effectively distribute and implement CMM management guidelines.

374 529 dermatologists’ perspectives on active surveillance for low-risk basal cell carcinoma

Active surveillance (AS) might be an appropriate management option for frail older adults with low-risk basal cell carcinoma (BCC) when risks of treatment outweigh benefits. However, AS is not yet incorporated in US clinical guidelines for BCC. The goal of this study was to investigate dermatologists’ perspectives on AS, by identifying clinical scenarios in which this option would be recommended. An online survey including demographic questions and clinical scenarios was emailed to 11,476 US dermatologists in December 2021 with 2 reminders. Each clinical scenario was identical except for characteristics that randomly varied including patient age (91 or 71 years), life expectancy (healthy, 3-year- or, 1-year life expectancy), and tumor location (arm or shin). Dermatologists were asked “Which BCC management option would you recommend to this patient?”. We compared responses using logistic regression to define odds ratios. 529 dermatologists responded (4.6% response rate); 43% women, 60% general dermatologists, 12% dermatologic surgery, 63% >10 years of experience, 56% group or private practice, 20% academic. AS was the preferred choice (58% of responses) for patients with 1-year life expectancy, 38% for patients with 3-year life expectancy and 6% for healthy patients. The odds ratio comparing AS in 91- to 71-year-old patient was 1.64 (95%CI 1.27-2.12), 9.33 (95%CI 5.71-15.25) comparing 3-year life expectancy to a healthy patient and 20.44 (95%CI 12.52-33.35) comparing 1-year life expectancy to a healthy patient. No significant differences were noted when comparing tumor location on the arm to the shin. In this survey study of over 500 dermatologists, most recommended active surveillance in situations of limited life expectancy and advanced age. This may help guide clinical guidelines and future trials of active surveillance.

Pustular and Erythrodermic Psoriasis in Patients Treated With Oral Glucocorticoids: A Survey of United States Dermatologists.

Dermatology dogma has cautioned against the use of orally administered glucocorticoids (OAG) in the treatment of psoriasis, largely due to concerns of life-threatening generalized pustular psoriasis (GPP) and erythrodermic psoriasis (EP). However, studies show that OAG are frequently used for psoriasis, often by dermatologists. Given the widespread use of OAG, we see an urgency in examining the relationship between OAG usage and the development of GPP and EP. This anonymous electronic survey of 50 US dermatologists examines OAG use in the management of psoriasis and the frequency at which dermatologists report seeing associated adverse outcomes of GPP and EP. Overall, 9 out of 50 (18%) respondents occasionally prescribe OAG to patients with psoriasis. Dermatologists who prescribe OAG tended to be younger than those who did not, with two-thirds in clinical practice for 0-10 years. Among all respondents, 16% (8/50) had experienced one or more patients developing GPP/EP in the context of OAG treatment for psoriasis. Our study suggests that OAG for the management of psoriasis is not uncommon among U.S. dermatologists, despite nearly universal awareness of its risks. Our observed low prevalence of GPP and EP emphasizes the need for prospective studies to better characterize OAG’s risk/benefit profile in psoriasis. J Drugs Dermatol. 2022;21(4):427-429. doi:10.36849/JDD.6242.

Geographic practice preferences of graduating medical students pursuing careers in dermatology

Geographic practice preferences of graduating medical students pursuing careers in dermatology

A Review of International Teledermatology

Background The use of teledermatology has been evolving slowly for the delivery of health care to remote and underserved populations. Advancements in technology and the recent COVID-19 pandemic have hastened its use internationally. Objective An international survey was done to assess teledermatology use before and during the COVID-19 pandemic. Methods In addition to an updated literature review from 2015 to 2021, a survey instrument was formatted in Google Forms in English and distributed electronically to international personal contacts of the authors, as well as to international dermatology and teledermatology societies of members of the International League of Dermatological Societies and members of the International Society of Teledermatology. Answers from US dermatologists were excluded. Results 110 survey responses were received from 33 countries. Barriers to the use of teledermatology have fallen considerably in the last year. Conclusions Teledermatology use has increased significantly in recent years in both government-sponsored and private health care systems and individual practices. There are no recognized international practice guidelines and there is variable use within countries. Many barriers remain to increasing the use of teledermatology. Conflicts of Interest None declared.

Analysis of utilization, cost and, prescription trends of onychomycosis medications among Medicare patients

To the Editor: Oral terbinafine and itraconazole as well as topical ciclopirox, efinaconazole, and tavaborole solutions have been approved by the US Food and Drug Administration for onychomycosis treatment.1Lipner S.R. Pharmacotherapy for onychomycosis: new and emerging treatments.Expert Opin Pharmacother. 2019; 20: 725-735Crossref PubMed Scopus (21) Google Scholar,2Lipner S.R. Scher R.K. Onychomycosis: treatment and prevention of recurrence.J Am Acad Dermatol. 2019; 80: 853-867Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Our objectives were to analyze onychomycosis antifungal prescription cost and trends in utilization by dermatologists. Medicare provider utilization and payment data, part D, 2013-2018,3Medicare provider utilization and payment data: part D [database].https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Part-D-PrescriberDate accessed: December 15, 2020Google Scholar were searched for oral terbinafine and itraconazole as well as topical ciclopirox, efinaconazole, and tavaborole prescribed by US dermatologists. Other provider types were excluded. Microsoft Excel was used to perform data analysis. Supply day was calculated by dividing the dispensed amount by the maximum medication used in 1 day. Total cost was calculated as cost per supply day multiplied by the number of supply days. Among oral antifungals, terbinafine claims experienced an annual average growth rate of 6.7%, with total spending increased by 15.1%, during 2013-2018 (Table I). This increase in claim outpaced the corresponding increase in total spending because of decreased cost per supply day ($0.36 to $0.24) (Table II). Comparatively, on average, itraconazole use was 150-fold lower than terbinafine use, with claims peaking in 2014, then decreasing by 0.9% annually, with total spending decreased by 35.6% overall (Table I). Itraconazole cost per supply day decreased by 7.4% during the study period (Table I).Table ITotal number of claims, drug supply days, and cost of oral terbinafine, oral itraconazole, topical ciclopirox, topical efinaconazole, and topical tavaboroleTotal number of claimsYearTerbinafineItraconazoleCiclopiroxEfinaconazoleTavaborole201328,86324978,77300201430,34029685,885940201531,89224288,1692343312201635,30213695,6181688401201737,554225108,8841518253201839,990209119,3821839199Total drug supply daysYearTerbinafineItraconazoleCiclopiroxEfinaconazoleTavaborole2013905,84555071,929,303002014964,00062442,149,1572641020151,023,05247492,246,03370,63010,00820161,156,63525852,490,64055,09512,47620171,233,47245612,888,04749,433738220181,338,74938323,220,61156,5806155Total Cost, $YearTerbinafineItraconazoleCiclopiroxEfinaconazoleTavaborole2013307,332.646,793.24,798,218.70.00.02014283,302.657,236.05,024,159.753,858.40.02015258,128.548,492.34,518,402.01,507,515.8339,722.62016311,248.124,785.74,752,927.41,361,291.7475,897.22017315,195.635,921.45,379,693.41,333,304.5311,679.72018353,805.630,145.55,625,524.21,665,178.7297,213.5 Open table in a new tab Table IICost per supply day of oral terbinafine, oral itraconazole, topical ciclopirox, topical efinaconazole, and topical tavaboroleYearCost per supply day terbinafine, $20130.3420140.2920150.2520160.2720170.2620180.26YearCost per supply day itraconazole, $20138.5020149.17201510.2120169.5920177.8820187.87YearCost per supply day ciclopirox, $20132.5020142.3020152.0020161.9020171.9020181.70YearCost per supply day efinaconazole, $2013None201420.40201521.30201624.70201727.00201829.40YearCost per supply day tavaborole, $2013None2014None201533.90201638.10201742.20201848.30 Open table in a new tab Among topical antifungals, ciclopirox claims experienced an annual average growth rate of 8.7%, with total spending increased by 66.9% overall (Table I). This increase in claim outpaced the increase in spending because of decreased cost per supply day ($2.50 to $1.70) (Table II). Efinaconazole claims peaked in 2015 and then decreased by 5.6% annually (Table I). However, both the total cost and cost per supply day increased yearly by 3091% and 144%, respectively, during 2014-2018 (Table II). Tavaborole claims decreased by 0.9% annually during 2015-2018, and the total cost decreased by 12.5% (Table I). Tavaborole cost per supply day increased by 42.4% annually during 2014-2018 (Table II). During 2013-2018, dermatologists had increased overall prescriptions of terbinafine and ciclopirox in the Medicare population, outpacing Medicare enrollment growth (14.3% increase during 2013-2018).4Centers for Medicare and Medicaid ServicesTwelve-year ever-enrolled trends report (2006-2018 data).https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and- Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/DataStatisticalResources/Downloads/MedicareMedicaidDualEnrollmentEverEnrolledTren dsDataBrief2006-2018.pdfDate: 2020Date accessed: December 15, 2020Google Scholar The reasons are likely multifactorial, including easy accessibility, availability of generics, low costs, and excellent safety profiles and efficacies.5Lin K. Lipner S.R. Modeling of usage and estimation of cost for efinaconazole 10% topical solution in the treatment of onychomycosis.J Am Acad Dermatol. 2020; 83: 227-228Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Itraconazole claims did not increase, likely because of higher cost, frequent drug-drug interactions, and unfavorable safety profile compared with that of terbinafine. Although efinaconazole and tavaborole have no reported systemic adverse events, their claims remained relatively flat, likely because of higher cost and lower accessibility and efficacy compared with those of alternatives. Future prescribing patterns will likely change because of patent expirations, availability of lower-priced generics, new antifungal approvals, and the development of devices for onychomycosis treatment. Our study included only Medicare patients, with the exclusion of Medicare Advantage, Medicaid, private insurance plans, and self-pay patients. The database includes only dermatologists who prescribe a medication ≥10 times, limiting our analysis. Because onychomycosis is the most common nail disease seen in clinical practice and Medicare enrollment continues to increase,4Centers for Medicare and Medicaid ServicesTwelve-year ever-enrolled trends report (2006-2018 data).https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and- Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/DataStatisticalResources/Downloads/MedicareMedicaidDualEnrollmentEverEnrolledTren dsDataBrief2006-2018.pdfDate: 2020Date accessed: December 15, 2020Google Scholar treatment choices will have a greater impact on health care costs. Dermatologists should consider clinical presentations, comorbidities, efficacy, safety profile, and cost while prescribing therapy for onychomycosis. Further research should focus on utilization, cost, and prescriptions trends in addition to onychomycosis patients with other insurances. Dr Lipner has served as a consultant for Verrica, Hoth Therapeutics, and Ortho-dermatologics. Dr Wang has no conflicts of interest to declare.

Differential Impact of COVID-19 on Urban Versus Rural Dermatologic Practice Logistics and Recovery: A Cross-Sectional Investigation of the First Wave

Background: COVID-19 materially delayed patient visits and potential skin cancer biopsies/diagnoses among US dermatology practices. However, given a likely heterogenous impact across the US, this study sought to determine COVID-19’s effect on urban versus rural dermatology practices. Methods: Data were analyzed from the first 1000 responses to 3 pre-validated surveys of 9891 practicing US dermatologists comparing outpatient volumes and scheduling issues for the week of February 17th to the week of March 16th (Survey 1), April 13th (Survey 2) and May 18th, 2020 (Survey 3). First 3 US zip-code digits were compared to US Census Bureau data to determine “Urban/Rural” status. Representativeness with AAD membership was confirmed. Statistical significance was calculated using chi-square with Marascuilo procedure and two-tailed independent t-test/ANOVA with post-hoc Tukey-Kramer testing. Results: In April 2020 urban practices reported more closed practices (21.4% vs 5.8%, p<0.0001) and predicted significantly larger patient volume decreases (-45.2% vs -31.4%, p<0.0001) and practice closures (11.9% vs. 2.5% p<0.0001) in the following 2 weeks. In May 2020, urban areas saw significantly fewer patients/week (90.9 vs 142.4 p<0.0001), larger decrease in patient volume relative to May 2019 (-49.4% vs -35.1%, p<0.0001), and conducted more telemedicine visits (27.0% vs 15.1%, p<0.0001). Significantly more rural practices reported already being at baseline volume (Mean Difference 6.2%, 95% CI 2.7%-9.8%) while urban practices predicted return to baseline volume by August (5.7, 95% CI 2.1%-9.3%) or were unsure (5.6, 95% CI 1.6%-9.7%). Conclusion: The initial COVID-19 pandemic differentially affected urban dermatology practices. The effects of the pandemic were mitigated in part by increased use telemedicine. Future studies may further elucidate COVID-19’s effect on clinical practice and highlight areas for improvement in practice logistics and patient care.

Assessment of dermatologist-patient race and ethnicity concordance in the Medicare population

Assessment of dermatologist-patient race and ethnicity concordance in the Medicare population

The Ongoing Impact of COVID-19 on US Dermatology Practices

Background: COVID-19 is significantly impacting healthcare delivery worldwide. Chen et al anecdotally reported the impact on dermatology outpatient care at the outbreak epicenter in Wuhan, China, but nothing has yet been assessed for the US. The purpose of this study was to determine the magnitude of the ongoing impact of COVID-19 on US dermatology outpatient care. Methods: After pre-validation, 2 surveys comparing outpatient volumes and scheduling issues for the weeks of February 17th versus the week of March 16th, 2020 (Survey 1) and April 13th, 2020 (Survey 2) and for estimation of trends in the next several weeks was emailed to 9,891 US Dermatologists on 3/21(Survey 1) and 4/18(Survey 2)(Tables S1a & S1b). Because of the importance of this information and the need for rapid dissemination, only data from the first 1,000 respondents (collected in the initial 36 hours) were included in each survey. In Survey 1, 30 responses were removed due to ineligible geography or errors in survey entry, leaving 970 for the analysis. Survey 2 consisted of 1,000 eligible respondents. Demographics (Table 1) representativeness with AAD membership was confirmed (Table S2). Statistical significance was calculated using chi-square, difference-of-proportions, and two-tailed independent t-tests. Results: COVID-19 impact was material (Table 2). From the 3rd week in February to the 3rd week in March to the 3rd week in April, the average number of patients seen fell from 149.4 to 63.4 to 28.2(p<0.0001), practice days from 4.2 to 3.1 and then rose to 3.5(p<0.0001) and biopsies from 19.8 to 7.7 to 3.5(p<0.0001). Although by 3/16 there were only 24.5k cases nationally, the early-phase decrease in patient volume and office days suggests the magnitude of disease concern impact was greater than actual prevalence. Postponement of non-essential appointments increased from 35.5% to 79.4% to 95.6%(p<0.00001). In Survey 1, 66.3% of respondents estimated a >50% decrease in patient volume in the coming 2 weeks (18.9% completely closing practices) and, disturbingly, 47.2% of respondents in the 2nd survey estimated an additional 50%+ decrease in patient volume in the next 2 weeks. 54.6% (Survey 1) of postponed appointments were for >4 weeks with an additional 25.4% not rescheduled. Discussion: A greater negative impact was found in US “hotspot” regions (36% (Survey 1) and 34% (Survey 2) of respondents-Figure S1) for week 3/16-20 for practice days (3.0 hotspots vs. 3.3 non-hotspots) and patients seen (56.2 in hotspots vs. 70.0 in non-hotspots); and for week 4/13-18 (3.4 in hotspots vs 3.5 in non-hotspots) and patients seen (25.3 in hotspots vs 29.7 in non-hotspots). No significant differing telemedicine usage (39.5% hotspots vs 37.2% non-hotspots) or practice closure (21.0% hotspots vs 17.6% non-hotspots) was found in Survey 1 (March); however, a significant difference in telemedicine usage (54.5% hotspots vs 45.5% non-hotspots) and practice closure (25.4% hotspots vs 16.4% non-hotspots, when compared to a typical April week) was found in Survey 2 (April). Mean estimated telemedicine visits overall for the next 2 weeks was 37.8% (Survey 1) and 45.9% (Survey 2). Academic/University/Institutional dermatologists were significantly more likely to use telemedicine (Survey 1=57.1%, Survey 2=68.6%) than private practitioners (Survey 1=35.5%, Survey 2=46.2%). Telemedicine usage was less likely for dermatologists with >30 practice years (>30=32.4% vs 40.0%) and this trend continued in April with only 37.2% of more experienced dermatologists using telemendine. However, telemedicine usage does not have an impact on the deferred/postponed biopsies that had already occurred during the March (mean=10.7) or April (mean=7.9) weeks as well as those predicted to be subsequently postponed. Limitations include that this study reflects a “snapshot” which could materially change given the dynamically evolving situation. Estimations could have led to recall bias and the 10.1% response rate could have introduced sampling and non-response bias. Those with lower work volumes could have been more likely to have time to respond, but this bias was minimized by weekend-only data collection. However, the large sample size and representative distribution mitigate selection bias and standard statistical testing demonstrated significance. Conclusion: Our findings demonstrate the significant early impact of COVID-19 on US dermatologic care and can help better understand national trends. With an estimated 49.9 million annual US dermatology office visits, the 50%+ decrease in predicted visits could be devastating. Beyond telemedicine, other innovative approaches will need to be developed and implemented to help delivery of essential dermatology care during this crisis.

18341 Comparing safety of blue versus red light illumination in photodynamic therapy using 10% aminolevulinic acid gel on >75-cm2 treatment areas

Background: With a growing desire by US dermatologists for field treatment of actinic keratosis (AKs) and patient compliance, photodynamic therapy (PDT) has become an important treatment modality AKs. With blue light illumination in PDT, 10% aminolevulinic-acid gel (ALA gel; Biofrontera) produces fewer local skin reactions (LSR) compared with 20% ALA solution (DUSA). However, it is unclear whether LSR in PDT with ALA gel differs with blue versus red light illumination.

Patch Test Clinic Start-up: From Basics to Pearls.

Allergic contact dermatitis is a prevalent burdensome condition affecting millions of Americans. Patch testing, the criterion-standard allergic contact dermatitis diagnostic tool, is underused by US dermatologists. Incorporating patch testing into modern dermatology practices is achievable with utilization of accurate resources and sustainable support. This review focuses on the basics of patch testing and provides practical pearls to assist novice providers in establishing a contact dermatitis specialty practice.

Dermatologists' Perceptions and Use of Electronic Health Record Systems

Introduction: Electronic Health Records (EHR) have been adopted and integrated into medical practices over the past 20 years. Many positive and negative implications have been described by physicians using EHR. This study aims to US dermatologists' perceptions and use of EHR within their clinical practice. Methods: A validated survey was administered to US dermatologists at a national educational conference to assess use and perceptions of EHR. Results Seventy-two percent (291/400) of those sampled completed greater than 90% survey and were included in outcome analysis. Eighty-six percent of the participants were currently using or had used EHR. Most dermatologists felt that EHR negatively impacted their workflow efficiency and face-to-face time with patients. A portion of dermatologists thought that EHR improved their documentation. Limitations: Selection bias may have led those with strong beliefs with EHR more likely to complete the entire survey. Conclusion: Despite widespread adoption, most dermatologists have a negative impression of EHR and felt that it interfered with their ability to effectively see patients. Interventions to improve EHR should focus on improving workflow efficiency and maximizing the amount of time dermatologists can spend with patients.