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Background: Patient Safety and Quality Improvement (PSQI) are key components of graduate medical training, as detailed by the Accreditation Council for Graduate Medical Education (ACGME), with specific requirements that residents participate in experiential learning in PSQI during residency training. This study aimed to analyze the breadth of available and required PSQI educational experiences across dermatology residency programs in the United States., Objectives/methods: The objective of this study was to characterize the scope of PSQI educational experiences across dermatology residency programs. We electronically surveyed program directors of all ACGME-accredited dermatology residency programs from September 2023 to March 2024. Responses to the survey were anonymously collected with Research Electronic Data Capture (REDCap)., Results: Of the 145 dermatology programs surveyed, 37 program directors responded (25.5%). 89.2% of programs reported requiring residents to participate in PSQI educational experiences, with the most common being participation in a resident-led QI project (70.3%), which was also the most commonly available experience (91.2%). The least common required experience was observed simulated patient safety events and analyses. 83.8% of programs reported formal mechanisms to assess residents' competency in QI., Conclusions: This study highlights variation in PSQI experiences within dermatology residency programs across the United States. More than 10% of surveyed programs reported no required QI experiences during residency training despite ACGME program requirements. Additional gaps include variation in assessment of resident PSQI competencies. This study provides insight on the current landscape of PSQI education across dermatology residency programs and identifies opportunities to strengthen dermatology programs' PSQI educational offerings., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Glucagon-like-peptide-1 (GLP-1) agonists are an emerging class of medications used to manage type 2 diabetes mellitus (T2DM) and weight loss, with demonstrated efficacy in reducing hemoglobin A1c levels, body mass index, and adverse cardiovascular events. While previous studies have reviewed notable cutaneous adverse effects with other antidiabetic medications, little is known about GLP-1 agonist-induced cutaneous reactions. Nevertheless, rare but significant cutaneous adverse reactions have been reported, including but not limited to dermal hypersensitivity reactions, eosinophilic panniculitis, bullous pemphigoid, and morbilliform drug eruptions. As GLP-1 induced cutaneous reactions are diverse, diagnosis requires clinical suspicion, thorough history-taking, and supportive histopathological findings when available. Management involves cessation of the offending agent with a tailored regimen to address inflammatory and/or immunogenic etiologies as well as irritative symptoms. This review aims to consolidate available information from case reports and case series regarding rare skin-related adverse outcomes due to GLP-1 use, aiming to provide a comprehensive overview of the presentation, pathogenesis, and management for dermatologists and other clinicians., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Ecthyma gangrenosum is an uncommon cutaneous eruption that can initially present with painless macules, which rapidly evolve into necrotic ulcers. This study sought to characterize clinicopathologic features of ecthyma gangrenosum from a single integrated health system. Our cohort consisted of 82 individuals diagnosed with ecthyma gangrenosum. Lesions were most commonly found in the lower extremities (55%) and the truncal region (20%). A wide variety of fungal and bacterial etiologies were found among our cohort. The majority of patients with EG were immunocompromised (79%) and 38% of patients also experienced sepsis. The mortality rate seen in our cohort was approximately 34%. No statistical differences in mortality outcome due to EG related complications were seen between pathogen etiology, and distribution or location of lesions. Patients who were septic or immunocompromised died more frequently than non-septic or immunocompetent patients, suggesting poorer prognosis., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Music interventions in medicine have been shown to reduce anxiety and depression, decrease pain, and improve quality of life; however, a review of clinical music interventions in dermatology is lacking. Studies have shown that playing music for patients undergoing dermatologic procedures (Mohs surgery and anesthetic injections) can decrease pain and anxiety. Patients with pruritic conditions-such as psoriasis, neurodermatitis, atopic dermatitis, contact eczema, and situations requiring hemodialysis-have exhibited decreased levels of disease burden and pain when listening to preferred music, pre-chosen music, and live music. Studies suggest that listening to certain types of music may also alter serum cytokines, affecting the allergic wheal response. Additional research is necessary to determine the full potential and practical applications for clinical music interventions in dermatology. Future research should focus on targeting skin conditions that may benefit from the psychological, inflammatory, and immune effects of music., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

A major side effect of anti-neoplastic immunotherapy is the onset of dermatologic toxicities following the administration of several different immunotherapy drugs. We sought to assess the incidence and mortality of anti-neoplastic immunotherapy-associated dermatologic toxicities using a nationally representative sample of United States (US) adults. The National Inpatient Sample database was queried for encounters undergoing anti-neoplastic immunotherapy. Multiple logistic regression models were constructed to analyze incidence of dermatologic toxicity and associated mortality as well as calculate adjusted odds ratios (aOR) after controlling for age, race, sex, household income, and cancer type. Immunotherapy patients demonstrated greater odds of developing pruritus (aOR = 7.59; 95% CI 5.17-11.2; P < 0.001), rash (aOR = 2.81; 95% CI 2.00-3.94, P < 0.001), generalized (aOR = 5.32; 95% CI 3.35-8.43; P < 0.001) and localized (aOR = 2.67; 95% CI 1.01-7.05; P < 0.001) skin eruptions, and vitiligo (aOR = 13.3; 95% CI 5.15-34.4; P < 0.001) compared to patients who did not receive anti-neoplastic immunotherapy. There were no significant differences observed in incidence of non-scarring alopecia (P = 0.7), psoriasis (P = 0.094), and dermatitis (P = 0.9) between the two groups. Patients who underwent immunotherapy were more likely to develop dermatologic toxicity (aOR = 3.93; 95% CI 3.12-4.94; P < 0.001), however, no significant differences in mortality were observed. Patients undergoing anti-neoplastic immunotherapy have an increased risk of developing dermatologic toxicity compared to patients who did not receive anti-neoplastic immunotherapy., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

A recent mandate by the Centers for Medicare and Medicaid Services (CMS) required hospitals to publish prices online. This study examined the utility of CMS-mandated price estimators for dermatology procedures. Chargemasters and price-estimator tools from the five largest hospitals in each state (n = 250) were reviewed for accessibility. Price estimators were also searched for the presence of dermatologic procedures and their estimated prices. Of the 250 hospitals included, 89.6% of chargemasters and 92.8% of price estimators were accessible. Of the available chargemasters and price estimators, 98.7% and 63.8% contained pricing data on dermatologic procedures, respectively. The most common dermatology procedures listed were debridement of subcutaneous tissue (CPT 11042) with a median price of $1,135.50 (IQR $577-$3533.67; n = 80), followed by simple incision and drainage of skin abscess (CPT 10060) with a median price of $956.00 (IQR $465.50-$6506.00, n = 79), and single punch biopsy of skin (CPT 11104) with a median price of $506.06 (IQR $356.50-$922.08, n = 29). Although price estimator tools are widely available in patient-friendly and searchable formats, they are not optimized for shoppable dermatologic services. Adding more dermatologic procedures to patient-friendly price-estimator tools can help patients directly realize savings from price shopping., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Recent calls for increased transparency from dermatology residency programs have revealed important opportunities, particularly including information on program websites. One piece of information that may especially benefit applicants assessing potential training programs is the program's mission statement. From August 9, 2022, to August 21, 2022, the websites of all ACGME-accredited dermatology residencies were examined to investigate the use and content of mission statements. Statements were categorized based on inclusion of mission, vision, virtue/value, aims, and goals. A total of 133 out of 143 dermatology programs (93.0%) were included. Overall, 46.15% of programs used at least one of the five mission statement categories on their websites, while 53.85% used none. Programs used the category "mission" (39.85%) most, and "vision" (3.01%) least. There was overlap in word choice across categories. The word "care" was among the top four words used in every category. Other words to appear frequently across multiple categories included "dermatology" (4/5), "residents" (3/5), "knowledge" (2/5), and "provide" (2/5). Other top words included "clinical" in the mission category, "advanced" and "leaders" in the vision category, "excellence" and "diversity" in the value/virtue category, and "patient" and "professional" in the objective category. Explicitly stating residency program missions may not only help programs plan more effectively, but also help applicants who may be undecided about which programs best align with their career goals., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

With the onset of the COVID-19 pandemic, the dermatology residency application process rapidly transitioned in a number of dimensions. As in-person activities were canceled and USMLE Step 1 has become pass/fail, there have been several proposed changes to enhance the process, including a push for increased transparency. Given than most dermatology applicants use program websites to learn more about potential residency programs, we conducted a cross-sectional study to quantify how transparent dermatology residency program website were, relative to published guidelines. From February 11, 2022, to February 25, 2022, we examined the available websites of all ACGME-accredited dermatology residencies to determine transparency regarding information dissemination, selection criteria, interview process, program priorities, and program requirements and opportunities. 136 out of 143 dermatology programs (95.1%) were included. Overall, programs were most transparent with program requirements and opportunities (87.25%). This included information on hospital locations, subspecialty clinics, and rotation/call/didactic schedules. Programs were least transparent with sharing their selection and/or exclusion criteria (31.13%) and varied in how much information they shared about the interview process (39.34%), as well as program priorities (64.56%). Opportunities remain for dermatology programs to improve website transparency and aid applicants in this difficult-to-navigate process. These results identify real transparency gaps, with several potential foci for improvement. Our main study limitation is its focus on a single time-period; to ensure that this information remains up to date, ongoing efforts to periodically resurvey content changes is warranted. Our findings provide an overview of programs' successes and remaining opportunities to follow published transparency guidelines; overall, these findings may guide individual program directors aiming to improve the transparency of their dermatology residency programs and ultimately benefit our future workforce., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

International medical graduates (IMGs) comprise a quarter of the United States (US) physician workforce but are a diminishing minority among dermatologists. Studies on IMGs in other specialties have demonstrated their importance in addressing provider shortage in rural and medically underserved areas (MUAs), but this trend has not been systematically explored within dermatology. This study aims to assess the state-by-state distribution of IMG dermatologists in the US as compared to US medical graduates (USMGs) with focus on provider density in rural settings and MUAs. A national cross-sectional study was performed on actively practicing dermatologists who submitted Medicare claims within 1 year of July 2020; rural and MUA-serving status were determined based on federally designated rural-urban Continuum Codes and Census Bureau data. Nationally, the density of dermatologists has increased from 3.4 per 100,000 persons in 2016 to 3.66 per 100,000 persons in 2020. However, 70% of US states continue to have fewer than 4 dermatologists per 100,000 persons, the estimated minimum necessary to adequately care for a population. Among 12,009 dermatologists, only 576 (4.8%) are IMGs, with disparate distribution across the US: Kansas has the greatest percentage of IMGs with the latter comprising 8.3% of its state dermatology workforce, whereas 8 states have no IMGs. Notably, a significantly greater percentage of IMG dermatologists (43.9%) work in areas designated as MUAs compared to USMGs (37.4%) (P < 0.01). In contrast, a lower percentage of IMG dermatologists (2.8%) work in rural settings compared to USMGs (4.8%) (P = 0.03). Interestingly, no significant difference was observed when rural dermatologists were further stratified by MUA-serving status. These findings corroborate the importance of IMGs in providing greater access to dermatological care in areas with healthcare provider shortage. Further studies on the underlying causes of the decline of IMGs within dermatology are needed., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Alopecia areata (AA) is a psychologically distressing disorder for which few reliable treatments exist. Although oral tofacitinib has demonstrated efficacy in treating AA, it is not approved by the Food and Drug Administration (FDA) for this indication. To investigate and identify the challenges associated with securing insurance approval for oral tofacitinib for AA. We conducted a retrospective review of patient records from two academic medical centers to identify patients with AA in whom insurance approval was sought for oral tofacitinib from 2015-2019. We recorded information on prior authorization (PA) submissions, appeals, and peer-to-peer reviews. We noted whether patients were documented to experience negative impact on mood/QOL or suicidal ideation (SI) due to their disease. We identified 37 patients in whom insurance approval was sought for oral tofacitinib for the treatment of AA. PAs were initially denied for 36/37 (97%) patients. The most commonly cited reason for denial was "tofacitinib not covered for AA/off-label medication use" (n = 26/36; 72%). 26/37 (70%) patients ultimately failed to obtain coverage. Of the 11 (30%) patients who obtained coverage, 10 (91%) were privately insured, 0 (0%) had Medicare and 1 (9%) had Medicaid. 13 patients (34%) experienced documented diminished QOL/mood (including SI) due to their disease burden; 6/13 (46%) of these patients eventually secured insurance approval. Lack of FDA approval of oral tofacitinib for the treatment of AA creates challenges in caring for patients with this disease. Policymakers should consider the negative implications lack of FDA approval may have for patients with recalcitrant dermatologic conditions., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)