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ImportanceScoring systems for Stevens-Johnson syndrome and epidermal necrolysis (EN) only estimate patient prognosis and are weighted toward comorbidities and systemic features; morphologic terminology for EN lesions is inconsistent.ObjectivesTo establish consensus among expert dermatologists on EN terminology, morphologic progression, and most-affected sites, and to build a framework for developing a skin-directed scoring system for EN.Evidence ReviewA Delphi consensus using the RAND/UCLA appropriateness criteria was initiated with a core group from the Society of Dermatology Hospitalists to establish agreement on the optimal design for an EN cutaneous scoring instrument, terminology, morphologic traits, and sites of involvement.FindingsIn round 1, the 54 participating dermatology hospitalists reached consensus on all 49 statements (30 appropriate, 3 inappropriate, 16 uncertain). In round 2, they agreed on another 15 statements (8 appropriate, 7 uncertain). There was consistent agreement on the need for a skin-specific instrument; on the most-often affected skin sites (head and neck, chest, upper back, ocular mucosa, oral mucosa); and that blanching erythema, dusky erythema, targetoid erythema, vesicles/bullae, desquamation, and erosions comprise the morphologic traits of EN and can be consistently differentiated.Conclusions and RelevanceThis consensus exercise confirmed the need for an EN skin-directed scoring system, nomenclature, and differentiation of specific morphologic traits, and identified the sites most affected. It also established a baseline consensus for a standardized EN instrument with consistent terminology.

Physician participation in asylum medicine through forensic medical evaluations increases the likelihood that asylum seekers are granted legal status. Based on a review of existing literature and input from content experts, we designed and implemented a forensic dermatology curriculum for dermatology residents at University of California, San Francisco. Our pilot curriculum led to improvements in learners' attitudes regarding physician participation in asylum medicine and their confidence in describing skin findings of torture or abuse.

STUDY OBJECTIVE: To determine whether obstructive sleep apnea (OSA) risk is associated with depression and anxiety symptoms in women with polycystic ovary syndrome (PCOS). METHODS: This is a cross-sectional study of women with PCOS, by the Rotterdam criteria, seen at a single academic center between June 2017 and June 2020. Depression symptoms, anxiety symptoms, and OSA risk were assessed with the self-administered Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Berlin questionnaires, respectively. Univariate and multivariate logistic regression analyses were used to determine the odds of moderate/severe symptoms of depression (PHQ-9 ≥ 10) and anxiety (GAD-7 ≥ 10) in the high-risk vs low-risk OSA groups. The primary multivariate model adjusted for age, body mass index, free testosterone, and insulin resistance. RESULTS: Of the 200 participants, the mean age was 28.0 years and 38% screened high risk for OSA. Women who screened high-risk OSA had > 3 times the odds of moderate/severe depression (odds ratio [OR]: 3.19; 95% confidence interval [CI]: 1.76–5.78; P < .001) and > 2 times the odds of having moderate/severe anxiety (OR: 2.49; 95% CI: 1.34–4.64; P = .004). These associations were only slightly attenuated in the adjusted models: the adjusted OR for moderate/severe depression was 3.06 (95% CI: 1.36–6.88; P = .01) and the aOR for moderate/severe anxiety was 2.39 (95% CI: 1.03–5.59; P = .04). CONCLUSIONS: Among women with PCOS, those at high risk of OSA experienced elevated depression and anxiety symptoms compared with those at low risk for OSA, independent of the effects of age, body mass index, hyperandrogenism, and insulin resistance. CITATION: Zhou X, Jaswa E, Pasch L, Shinkai K, Cedars MI, Huddleston HG. Association of obstructive sleep apnea risk with depression and anxiety symptoms in women with polycystic ovary syndrome. J Clin Sleep Med. 2021;17(10):XXX–XXX.

Dermatology consultation for cases of presumed cellulitis improves diagnostic accuracy and management. However, access to in-person consultation remains limited, a gap that could be filled with teledermatology. Augmented teledermatology may improve outcomes. In this cross-sectional study, 20 dermatologists (60% of whom reported conducting inpatient consults > 1 month per year) reviewed 10 real-life cases representing either cellulitis or pseudocellulitis as diagnosed by in-person dermatology consultation. For each case, respondents recorded their diagnosis, confidence, and management decisions after viewing the history and standard teledermatology photos, the responses to a physician-reported cellulitis questionnaire, and finally thermal images. Overall mean diagnostic accuracy increased from 84% ± 4% with the history and physical to 89% ± 3% when adding a cellulitis questionnaire and thermal images (p = 0.23). Accuracy for cellulitis cases specifically significantly increased from 76% ± 6–88% ± 4% when adding a cellulitis questionnaire and thermal images (p = 0.049). Accuracy for pseudocellulitis was consistently ≥ 94%. Augmented teledermatology with a standardized questionnaire and thermal images improved diagnostic accuracy for cases of cellulitis and may increase physician confidence. Dermatologists were able to accurately diagnose regardless of experience with inpatient consults, increasing the pool of potential dermatologists who could diagnose cellulitis remotely.

The purpose of this narrative review article is to describe the current literature on the psoriasis inpatient population, discuss considerations for admission, and provide updated recommendations for inpatient psoriasis workup, management, and post-discharge follow-up. Studies report variable rates of psoriasis hospitalizations in the last decade even with the advent of highly efficacious outpatient therapies. Inequities in access to these therapies have resulted in disparities in the psoriasis inpatient population. Patients with severe variants of psoriasis, including generalized pustular and erythrodermic psoriasis, often have severe systemic complications and require immediate stabilization and supportive care. Traditional, rapid acting systemic therapies, including cyclosporine and infliximab, are efficacious, though the interleukin-17 inhibitors, secukinumab, ixekizumab, and brodalumab, may represent reasonable options. The interleukin-36 inhibitor, spesolimab, is a new and promising therapy under investigation for generalized pustular psoriasis. Psoriasis patients presenting with severe variants of disease, including pustular and erythrodermic psoriasis, in combination with systemic findings such as infection or compromised hemodynamic status, require hospitalization. Supportive measures to address systemic signs and complications are needed. Topical treatments with rapid acting systemic therapies should be employed to improve skin symptoms. Racial, ethnic, and insurance disparities exist in the hospitalized psoriasis patient population, highlighting the need for providers to obtain thorough sociodemographic histories and establish strong therapeutic alliances with these patients, identifying stable treatment options to prevent future exacerbations and hospitalizations.

Physician participation in asylum medicine through forensic medical evaluations increases the likelihood that asylum seekers are granted legal status. Based on a review of existing literature and input from content experts, we designed and implemented a forensic dermatology curriculum for dermatology residents at University of California, San Francisco. Our pilot curriculum led to improvements in learners' attitudes regarding physician participation in asylum medicine and their confidence in describing skin findings of torture or abuse.

Cellulitis is a common clinical diagnosis in the outpatient and inpatient setting; studies have demonstrated a surprisingly high misdiagnosis rate: nearly one-third of cases are other conditions (ie, pseudocellulitis). This high rate of misdiagnosis is thought to contribute to nearly $515 million in avoidable health care spending in the United States each year; leading to the delayed or missed diagnosis of pseudocellulitis and to delays in appropriate treatment. There is a broad differential diagnosis for pseudocellulitis, which includes inflammatory and noninflammatory conditions of the skin. Accurate diagnosis of the specific condition causing pseudocellulitis is crucial to management, which varies greatly.

Pyoderma gangrenosum (PG) is an inflammatory condition characterized by chronic cutaneous ulcerations. There are three proposed PG diagnostic frameworks (Su, PARACELSUS, Delphi); however, they lack consensus, and their performance has not yet been validated in a well-defined cohort of patients with PG. In this cross-sectional retrospective cohort study, we sought to evaluate and compare the concordance of these diagnostic frameworks within a single-institution cohort of patients with PG. There were 47 patients from an initial 76 identified by International Classification of Diseases-9 and/or International Classification of Diseases-10 codes, where two PG experts agreed in their diagnosis of PG on the basis of clinical descriptions, photographs, and pathology. This group was the PG cohort by which we evaluated the performance and concordance of the diagnostic frameworks. The PARACELSUS score identified the highest proportion of patients with PG (89% [42 of 47 patients]), followed by Delphi and Su criteria, each at 74% (35 of 47 patients). Assessment of multirater agreement found that the three criteria agreed in their diagnoses for 72% of the patients (95% confidence interval = 60-85%); chance-adjusted agreement was determined to be 0.44 (95% confidence = 0.16-0.68, Fleiss' kappa). Future research should seek to refine these diagnostic frameworks and identify targeted methods of testing to reduce rates of PG misdiagnosis and patient misclassification in clinical trials.

Dermatology remains the second least diverse specialty in medicine. This lack of diversity has important implications for the future of the specialty. This narrative review provides updated evidence on barriers at different stages of medical education training that impede academic advancement for underrepresented minority (URM) learners pursuing careers in dermatology.

Objective To [1] characterize depression symptoms over time and [2] test the hypothesis that adverse metabolic parameters would associate with risk of enduring depression risk in women with polycystic ovary syndrome (PCOS). Design Prospective cohort study. Setting University center. Patient(s) One hundred sixty-three women with PCOS. Intervention(s) The Beck Depression Inventory Fast Screen (BDI-FS) was self-administered at baseline and follow-up to identify depression risk, using a cutoff score >4. Main Outcome Measure(s) BDI-FS scores. Result(s) Median baseline age was 29.0 years, and median follow-up interval was 5.5 years. Fifty-nine of 163 women had positive depression screens at baseline (36%); 52 women (32%) screened positive at follow-up. Median change in BDI-II score was 0 (interquartile range, –2, 1) over the study period. Of the 59 women at risk for depression at baseline, 22 screened negative at follow-up (37%), while 37 women remained at risk (63%). Considering these 59 women with positive depression screens at baseline, higher body mass index (BMI) was associated with increased odds of enduring depression risk at follow-up (adjusted odds ratio = 1.09; 95% confidence interval, 1.00, 1.18), in a multivariate logistic regression model. Compared with women with normal body weight at baseline, obese women (BMI >30 kg/m2) had five-fold increased odds of enduring depression risk at follow-up (adjusted odds ratio = 5.07; 95% confidence interval, 1.07, 24.0). Conclusion(s) The prevalence of depression was relatively stable over time in a cohort of women with PCOS. Elevated BMI is a hallmark of enduring depression risk. These results may assist providers in developing targeted intervention strategies to reduce the prevalence of long-term depressive symptoms in women with PCOS.

IMPORTANCE: Enzyme-inducing antiseizure medications (eiASMs) have been hypothesized to be associated with long-term risks of cardiovascular disease. OBJECTIVE: To quantify and model the putative hazard of cardiovascular disease secondary to eiASM use. DESIGN, SETTING, AND PARTICIPANTS: This cohort study covered January 1990 to March 2019 (median [IQR] follow-up, 9 [4-15], years). The study linked primary care and hospital electronic health records at National Health Service hospitals in England. People aged 18 years or older diagnosed as having epilepsy after January 1, 1990, were included. All eligible patients were included with a waiver of consent. No patients were approached who withdrew consent. Analysis began January 2021 and ended August 2021. EXPOSURES: Receipt of 4 consecutive eiASMs (carbamazepine, eslicarbazepine, oxcarbazepine, phenobarbital, phenytoin, primidone, rufinamide, or topiramate) following an adult-onset (age ≥18 years) epilepsy diagnosis or repeated exposure in a weighted cumulative exposure model. MAIN OUTCOMES AND MEASURES: Three cohorts were isolated, 1 of which comprised all adults meeting a case definition for epilepsy diagnosed after 1990, 1 comprised incident cases diagnosed after 1998 (hospital linkage date), and 1 was limited to adults diagnosed with epilepsy at 65 years or older. Outcome was incident cardiovascular disease (ischemic heart disease or ischemic or hemorrhagic stroke). Hazard of incident cardiovascular disease was evaluated using adjusted propensity-matched survival analyses and weighted cumulative exposure models. RESULTS: Of 10 916 166 adults, 50 888 (0.6%) were identified as having period-prevalent cases (median [IQR] age, 32 [19-50] years; 16 584 [53%] female), of whom 31 479 (62%) were diagnosed on or after 1990 and were free of cardiovascular disease at baseline. In a propensity-matched Cox proportional hazards model adjusted for age, sex, baseline socioeconomic status, and cardiovascular risk factors, the hazard ratio for incident cardiovascular disease was 1.21 (95% CI, 1.06-1.39) for those receiving eiASMs. The absolute difference in cumulative hazard diverges by more than 1% and greater after 10 years. For those with persistent exposure beyond 4 prescriptions, the median hazard ratio increased from amedian (IQR) of 1.54 (1.28-1.79) when taking a relative defined daily dose of an eiASM of 1 to 2.38 (1.52-3.56) with a relative defined daily dose of 2 throughout a maximum of 25 years’ follow-up compared with those not receiving an eiASM. The hazard was elevated but attenuated when restricting analyses to incident cases or those diagnosed when older than 65 years. CONCLUSIONS AND RELEVANCE: The hazard of incident cardiovascular disease is higher in those receiving eiASMs. The association is dose dependent and the absolute difference in hazard seems to reach clinical significance by approximately 10 years from first exposure.

Acute generalized exanthematous pustulosis (AGEP) is an acute, self-limited, widespread cutaneous eruption characterized by the development of numerous, non-follicular, sterile pustules on a background of erythematous, edematous skin. The eruption usually develops within hours to days of exposure to medications (antibiotics, antifungals, calcium channel blockers, and carbamazepine most commonly), but it has also been documented to be associated with various infections (mostly viral), spider bites, and herbal medications. After the inciting medication is removed or precipitant infection clears, the skin reaction resolves spontaneously within 1–2 weeks. The histologic hallmark of AGEP is spongiform subcorneal and/or intraepidermal pustules with marked papillary edema, polymorphous perivascular infiltrates with neutrophils, and exocytosis of some eosinophils. AGEP is immunologically mediated by a T cell-orchestrated neutrophil response through the expression of neutrophilotactic chemokines such as CXCL8.

Cellulitis is a common clinical diagnosis in the outpatient and inpatient setting; studies have demonstrated a surprisingly high misdiagnosis rate: nearly one-third of cases are other conditions (ie, pseudocellulitis). This high rate of misdiagnosis is thought to contribute to nearly $515 million in avoidable health care spending in the United States each year; leading to the delayed or missed diagnosis of pseudocellulitis and to delays in appropriate treatment. There is a broad differential diagnosis for pseudocellulitis, which includes inflammatory and noninflammatory conditions of the skin. Accurate diagnosis of the specific condition causing pseudocellulitis is crucial to management, which varies greatly.

Pyoderma gangrenosum (PG) lacks consensus regarding treatment, and no prior studies assess treatment satisfaction in PG. To determine patient-reported satisfaction in the treatment of PG, and associations with satisfaction. Multicenter one time cross-sectional survey for patients who received systemic medication(s) to treat PG. Thirty-five patients completed the survey (mean age: 54.0 years, 65.7% female, response rate: 81.4%). Mean (± SD) SATMED-Q score was 75.0 (±16.2, range: 67.6-85.3). Older patients (72.6 ± 23.6 for 18-39 years, 74.4 ± 16.1 for 40-59, 77.1 ± 11.6 for 60+), plus those with higher incomes (72.9 ± 20.3 for $0-49 000; 74.0 ± 17.6 for $50000-99 000; 79.0 ± 14.6 for $100000+) and education status (69.4 ± 14.3 for high school equivalent, 72.9 ± 15.9 for undergraduate, 91.7 ± 10.6 for graduate), were more satisfied with treatment. Ulcerative PG had higher SATMED-Q scores (79.0 ± 13.2) than other subtypes (66.2 ± 19.3). For local therapy, wound care, or pain control, 63.2%, 100%, and 75% were satisfied, respectively. The mean DLQI was 8.6 (±7.6, range: 0-29), and higher DLQI was associated with decreased satisfaction. Satisfaction with providers was positively correlated with global satisfaction (Pearson's r = 0.638). The presence of pain and/or depression influenced both SATMED-Q (72.8 ± 18.8 with pain, 78.3 ± 11.2 without; 68.2 ± 18.8 with depression, 80.1 ± 12.2 without) and DLQI scores (12.1 ± 8.1 with pain, 3.9 ± 3.4 without; 10.3 ± 7.1 with depression, 7.4 ± 8.0 without). To optimize the patient experience, non-modifiable associations should be individually considered, and potentially modifiable associations such as satisfaction with specific providers, pain, and depression, may be targeted for management. This article is protected by copyright. All rights reserved.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis with unclear etiology and is associated with notable morbidity. Due to the rarity of PG, there are limited large, multicentered, randomized trials to guide management. We aim to highlight best practices in PG management through survey responses from expert medical dermatologists.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that presents with rapidly developing, painful skin ulcers hallmarked by undermined borders and peripheral erythema. Epidemiological studies indicate that the average age of PG onset is in the mid-40s, with an incidence of a few cases per million person-years. PG is often associated with a variety of other immune-mediated diseases, most commonly inflammatory bowel disease and rheumatoid arthritis. The cause of PG is not well understood, but PG is generally considered an autoinflammatory disorder. Studies have focused on the role of T cells, especially at the wound margin; these cells may support the destructive autoinflammatory response by the innate immune system. PG is difficult to diagnose as several differential diagnoses are possible; in addition to clinical examination, laboratory tests of biopsied wound tissue are required for an accurate diagnosis, and new validated diagnostic criteria will facilitate the process. Treatment of PG typically starts with fast-acting immunosuppressive drugs (corticosteroids and/or cyclosporine) to reduce inflammation followed by the addition of more slowly acting immunosuppressive drugs with superior adverse event profiles, including biologics (in particular, anti-tumour necrosis factor (TNF) agents). Appropriate wound care is also essential. Future research should focus on PG-specific outcome measures and PG quality-of-life studies.

PURPOSE To examine validity evidence for a standardized patient scenario assessing medical students' ability to promote value using patient-centered communication (in response to a patient requesting an unnecessary test) and to explore the potential effect of various implementation and curricular factors on student scores. METHOD Third-year medical students (N = 516) from 5 U.S. MD-granting medical schools completed the communication scenario between 2014 and 2017 as part of a larger objective structured clinical examination (OSCE). Centralized raters assessed performance using an 11-item checklist. The authors collected multiple sources of validity evidence. RESULTS The mean checklist score was 0.85 (standard deviation 0.09). Interrater reliability for checklist scores was excellent (0.87, 95% confidence interval = 0.78-0.93). Generalizability and Phi-coefficients were, respectively, 0.65 and 0.57. Scores decreased as the number of OSCE stations increased (r = -0.15, P = .001) and increased when they were used for summative purposes (r = 0.26, P < .001). Scores were not associated with curricular time devoted to high-value care (r = 0.02, P = .67) and decreased when more clerkships were completed before the assessment (r = -0.12, P = .006). CONCLUSIONS This multisite study provides validity evidence supporting the use of scenario scores to assess the ability of medical students to promote value in clinical encounters using patient-centered communication. Findings illuminate the potential effect of OSCE structure and purpose on student performance and suggest clerkship learning experiences may not reinforce what students are taught in the formal curriculum regarding high-value care. Devoting more time to the topic appears insufficient to counteract this erosion.

Importance Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of severe mucocutaneous drug reaction associated with significant morbidity and mortality. A previously developed SJS/TEN-specific severity-of-illness model (Score of Toxic Epidermal Necrolysis [SCORTEN]) has been reported to overestimate and underestimate SJS/TEN-related in-hospital mortality in various populations. Objective To derive a risk prediction model for in-hospital mortality among patients with SJS/TEN and to compare prognostic accuracy with the SCORTEN model in a multi-institutional cohort of patients in the United States. Design, Setting, and Participants Data from a multicenter cohort of patients 18 years and older treated for SJS/TEN between January 1, 2000, and June 1, 2015, were obtained from inpatient consult databases and electronic medical record systems at 18 medical centers in the United States as part of the Society for Dermatology Hospitalists. A risk model was derived based on data from 370 of these patients. Model discrimination (calculated as area under the receiver operating characteristic curve [AUC]) and calibration (calculated as predicted vs observed mortality, and examined using the Hosmer-Lemeshow goodness-of-fit statistic) were assessed, and the predictive accuracy was compared with that of SCORTEN. All analysis took place between December 2016 and April 2018. Main Outcomes and Measures In-hospital mortality. Results Among 370 patients (mean [SD] age 49.0 [19.1] years; 195 [52.7%] women), 54 (15.14%) did not survive to hospital discharge. Five covariates, measured at the time of admission, were independent predictors of in-hospital mortality: age in years (odds ratio [OR], 1.05; 95% CI, 1.02-1.07), body surface area (BSA) in percentage of epidermal detachment (OR, 1.02; 95% CI, 1.01-1.04), serum bicarbonate level below 20 mmol/L (OR, 2.90; 95% CI, 1.43-5.88), active cancer (OR, 4.40; 95% CI, 1.82-10.61), and dialysis prior to admission (OR, 15.94; 95% CI, 3.38-66.30). A severity-of-illness score was calculated by taking the sum of 1 point each for age 50 years or older, epidermal detachment greater than 10% of BSA, and serum bicarbonate level below 20 mmol/L; 2 points for the presence of active cancer; and 3 points for dialysis prior to admission. The score was named ABCD-10 (age, bicarbonate, cancer, dialysis, 10% BSA). The ABCD-10 model showed good discrimination (AUC, 0.816; 95% CI, 0.759-0.872) and calibration (Hosmer-Lemeshow goodness of fit test, P = .30). For SCORTEN, on admission, the AUC was 0.827 (95% CI, 0.774-0.879) and was not significantly different from that of the ABCD-10 model (P = .72). Conclusions and Relevance In this cohort of patients with SJS/TEN, ABCD-10 accurately predicted in-hospital mortality, with discrimination that was not significantly different from SCORTEN. Additional research is needed to validate ABCD-10 in other populations. Future use of a new mortality prediction model may provide improved prognostic information for contemporary patients, including those enrolled in observational studies and therapeutic trials.

Burnout is increasing in all fields of medicine, including dermatology. The coronavirus disease 2019 (COVID-19) pandemic presented new and additional challenges for dermatologists.Dermatologists of different ages, areas of expertise, and practice settings were convened in 5 focus group to describe the impact of the COVID-19 pandemic on their clinical practice, working environment, and personal lives.Qualitative analysis of the discussions w\s performed on the result of the 5 focus groups of dermatologists (n = 22). Groups were prompted with questions relating to their jobs, personal lives, teledermatology, and pandemic. Responses were recorded, transcribed, deidentified, and coded for recurring themes. The focus groups occurred via a secure videoconferencing platform between December 2020 and January 2021. All participants were currently practicing dermatology in a variety of setting including academic institutions, private practices, and multiple practice types. General dermatologists, residents in training, dermatologic surgeons, dermatopathologists, and dermatologists with significant administrative or educational duties were included.We identified 4 main themes from the focus group discussions regarding dermatologist and physician wellbeing during the COVID-19 pandemic: (1) adjusting to new administrative, staffing, and educational demands; (2) integration of work as a dermatologist with family life; (3) new technologies such as teledermatology; and (4) adjusting to change with redefining personal and professional priorities.The small number of participants in our convenience cohort disproportionately represented academic dermatologists. Impacts of regional COVID-19 vaccination rates and ideological differences in different geographical locations were not assessed. All of our participants were located in the United States. Physicians severely impacted by health or financial concerns may not have been able to participate in our study. We did not have a comparison group and did not measure or assess burnout in individual participants.During the COVID-19 pandemic, there were common changes and stressors that dermatologists experienced, which affected physician wellbeing. Identifying and addressing these changes could offer the opportunity to improve the wellbeing of dermatologists.

IMPORTANCE: Acute generalized exanthematous pustulosis (AGEP) is a rare, severe cutaneous adverse reaction associated with systemic complications. Currently available data are largely limited to small retrospective case series. OBJECTIVE: To describe the clinical characteristics, disease course, and outcomes of a heterogeneous group of patients with AGEP across the US. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of a case series of patients was conducted from January 1, 2000, through July 31, 2020. All 340 included cases throughout 10 academic health systems in the US were scored retrospectively using the EuroSCAR scoring system, and patients with a score corresponding to probable or definite AGEP and aged 18 years or older were included. MAIN OUTCOMES AND MEASURES: Patient demographic characteristics, clinical course, suspected causative agent, treatment, and short- and long-term outcomes. RESULTS: Most of the 340 included patients were women (214 [62.9%]), White (206 [60.6%]), and non-Hispanic (239 [70.3%]); mean (SD) age was 57.8 (17.4) years. A total of 154 of 310 patients (49.7%) had a temperature greater than or equal to 38.0 °C that lasted for a median of 2 (IQR, 1-4) days. Of 309 patients, 263 (85.1%) developed absolute neutrophilia and 161 patients (52.1%) developed either absolute or relative eosinophilia. Suspected causes of AGEP were medications (291 [85.6%]), intravenous contrast agents (7 [2.1%]), infection (3 [0.9%]), or unknown (39 [11.5%]). In 151 cases in which a single medication was identified, 63 (41.7%) were β-lactam antimicrobials, 51 (33.8%) were non–β-lactam antimicrobials, 9 (6.0%) were anticonvulsants, and 5 (3.3%) were calcium channel blockers. The median time from medication initiation to AGEP start date was 3 (IQR, 1-9) days. Twenty-five of 298 patients (8.4%) had an acute elevation of aspartate aminotransferase and alanine aminotransferase levels, with a peak at 6 (IQR, 3-9) days. Twenty-five of 319 patients (7.8%) experienced acute kidney insufficiency, with the median time to peak creatinine level being 4 (IQR, 2-5) days after the AGEP start date. Treatments included topical corticosteroids (277 [81.5%], either alone or in combination), systemic corticosteroids (109 [32.1%]), cyclosporine (10 [2.9%]), or supportive care only (36 [10.6%]). All-cause mortality within 30 days was 3.5% (n = 12), none of which was suspected to be due to AGEP. CONCLUSIONS AND RELEVANCE: This retrospective case series evaluation of 340 patients, the largest known study cohort to date, suggests that AGEP onset is acute, is usually triggered by recent exposure to an antimicrobial, may be associated with liver or kidney complications in a minority of patients, and that discontinuation of the triggering treatment may lead to improvement or resolution.

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare, severe mucocutaneous reaction with few large cohorts reported. This multicenter retrospective study included patients with SJS/TEN seen by inpatient consultative dermatologists at 18 academic medical centers in the United States. A total of 377 adult patients with SJS/TEN between January 1, 2000 and June 1, 2015 were entered, including 260 of 377 (69%) from 2010 onward. The most frequent cause of SJS/TEN was medication reaction in 338 of 377 (89.7%), most often to trimethoprim/sulfamethoxazole (89/338; 26.3%). Most patients were managed in an intensive care (100/368; 27.2%) or burn unit (151/368; 41.0%). Most received pharmacologic therapy (266/376; 70.7%) versus supportive care alone (110/376; 29.3%)-typically corticosteroids (113/266; 42.5%), intravenous immunoglobulin (94/266; 35.3%), or both therapies (54/266; 20.3%). Based on day 1 SCORTEN predicted mortality, approximately 78 in-hospital deaths were expected (77.7/368; 21%), but the observed mortality of 54 patients (54/368; 14.7%) was significantly lower (standardized mortality ratio = 0.70; 95% confidence interval = 0.58-0.79). Stratified by therapy received, the standardized mortality ratio was lowest among those receiving both steroids and intravenous immunoglobulin (standardized mortality ratio = 0.52; 95% confidence interval 0.21-0.79). This large cohort provides contemporary information regarding US patients with SJS/TEN. Mortality, although substantial, was significantly lower than predicted. Although the precise role of pharmacotherapy remains unclear, co-administration of corticosteroids and intravenous immunoglobulin, among other therapies, may warrant further study.

Eczema herpeticum (EH) is characterized by viral infection of a preexisting inflammatory dermatosis and is associated with considerable morbidity. In this cross-sectional study, we sought to determine the incidence, risk factors, comorbidities, costs of care, length of stay, and mortality in hospitalized U.S. children with EH. The Nationwide Inpatient Sample 2002–2012, containing a 20% sample of all U.S. hospitalizations, was analyzed. We used a validated approach involving International Classification of Diseases, Ninth Revision–Clinical Modification codes to identify patients primarily admitted for EH (n = 4,655 weighted). The mean annual incidence of hospitalization for EH per million children ranged from 4.03 to 7.30, increasing significantly from 2008 to 2012. EH was associated with younger age (odds ratio [95% confidence interval] for 3–4 years = 1.29 [1.02–1.64]) and nonwhite race/ethnicity (black = 2.93 [2.35–3.66], Asian=4.41 [3.34–5.83], Native American = 2.96 [1.51–5.78]) but was less likely to occur in areas with lower income quartiles (quartile 1, 0.66 [0.53–0.84]; quartile 2, = 0.68 [0.54–0.87]; quartile 3, 0.70 [0.56–0.88]). EH was associated with atopic dermatitis (11.72 [9.48–14.49]). Increased length of stay and costs of care were associated with Asian race. Mean length of stay was 3.86 ± 0.09 days, and mean cost of care was $5,237.6 ± 160.6. Overall mortality was 0.1%. EH in hospitalized children poses a substantial burden to the health care system.

Rosacea fulminans is a rare inflammatory condition of the central face marked by the abrupt onset of erythematous coalescing papules, pustules, nodules, and draining sinuses. Due to infrequent reporting in the literature, the pathophysiology, classification, and nomenclature of this condition remain controversial. This comprehensive review evaluated a total of 135 cases of rosacea fulminans for clinical and histopathologic features and reported treatment strategies. Patients were 91% female with an average age of onset of 31.3 years. Only 19% of cases reported duration of symptoms longer than 3 months, and reports of recurrence were uncommon. A majority of patients had history of rosacea or flushing, and common triggers included hormonal shifts, emotional stress, and medications. Extrafacial or systemic involvement was rare. Though oral and topical antibiotics were frequently utilized to treat rosacea fulminans, there was a clear shift in reported treatments for rosacea fulminans following the introduction of isotretinoin use in 1987, marked by increased reliance on isotretinoin in addition to topical and systemic corticosteroids. Newer treatments were associated with superior improvement compared with antibiotic monotherapy, most notably dramatically reduced rates of scarring, though reduced rates of disease recurrence were not evident. Several patterns revealed through this review reinforce the classification of rosacea fulminans as a severe yet distinct variant of rosacea and highlight key distinguishing clinical features and treatment options for optimal management.

Background: The complex interplay between ethnicity, Fitzpatrick skin type (FST), and hirsutism in patients with polycystic ovarian syndrome (PCOS) is poorly understood. Objective: In this cross-sectional, retrospective analysis, we examined the prevalence, severity, and distribution of hirsutism with clinician-rated site-specific and total modified Ferriman-Gallwey (mFG) visual scoring in a diverse cohort of American patients with PCOS. Methods: Independent analyses were conducted on the basis of patient-reported FST ratings and ethnicity. Results: In this PCOS cohort, a correlation was found between hirsutism and ethnicity and the highest prevalence of hirsutism and total mFG scores was observed in Hispanic, Middle Eastern, African American, and South Asian patients. A positive correlation between hirsutism and FST was also observed with an increasing prevalence of hirsutism in the group of patients with higher FSTs. Significant trends in the anatomic distribution of hirsutism were observed between ethnic groups as well. A higher facial mFG score was found in African American patients but higher mFG scores in the truncal and extremity regions were observed in Middle Eastern patients. Truncal hirsutism was also associated with higher FSTs. Conclusions: Ethnicity and FST may be important variables in both the quantitative and qualitative presentations of hirsutism in women with PCOS and should be considered in the diagnostic evaluation of any patient who is suspected of having the condition. Previously published studies that examined ethnicity, FST, and hirsutism in homogeneous cohorts limited comparison and generalizability but the strength of this study lies in its detailed analysis within a single large and diverse PCOS cohort. Validated studies are needed to determine whether clinical criteria for hirsutism should be adjusted for ethnicity and FST in the PCOS population and particularly within diverse cohorts and patients of mixed ancestry. Keywords: PCOS, hirsutism, ethnicity, Fitzpatrick skin type, hyperandrogenism, modified Ferriman-Gallwey

A consultative dermatology service plays an important role in patient care and education in the hospital setting. Optimizing education in balance with high-quality dermatology consultative services is both a challenge and an opportunity for dermatology consultation teams. There is an emergence of new information about how dermatology can best be taught in the hospital, much of which relies on principles of workplace learning as well as the science of how learning and teaching best happen in work settings. These best practices are summarized in this narrative review with integrated discussion of concepts from outpatient dermatology education and lessons learned from other inpatient teaching models. In addition, consultative dermatology curricula should utilize a blended curriculum model comprised of patient care and active learning and self-study modalities. Specific educational methods will discuss 2 strategies: (1) direct patient-care activities (ie, bedside teaching rounds) and (2) nonpatient care activities (ie, case presentations, didactic sessions, online modules, and reading lists).

IMPORTANCE: Alcohol flushing syndrome (AFS, also known as Asian glow and Asian flush) affects 20% to 47% of East Asians and causes significant psychosocial distress. There are no approved treatments for this condition. OBJECTIVE: To determine whether brimonidine gel, 0.33%, decreases facial erythema in patients with AFS after consumption of alcohol. DESIGN, SETTING, AND PARTICIPANTS: In this randomized clinical trial, 20 healthy volunteers of East Asian descent with a self-reported history of AFS were recruited between April 2018 and March 2019. INTERVENTIONS: Participants were randomized to application of brimonidine gel to either the left or right half of their face. Placebo control was applied to the opposite side. After 30 minutes, participants ingested alcohol. MAIN OUTCOMES AND MEASURES: Outcomes were specified before data collection. The difference in erythema between the treated and placebo side of each participant’s face was measured 60 minutes after drug application (primary outcome) and at 90 and 120 minutes after drug application (secondary outcomes). Participants were asked to rate their likelihood of using the medication again and their likelihood of recommending the medication to a friend on a scale of 0 to 10. RESULTS: The mean (SD) age of the 20 individuals enrolled in the study was 30.5 (8.4) years, and there were 10 women (50%). There was a significant difference in erythema at 60 minutes after drug application as measured by the difference in Clinician Erythema Assessment score (2.1; 95% CI, 1.5-2.71; P

IMPORTANCE: The US Food and Drug Administration (FDA) has provided guidance that sunscreen active ingredients with systemic absorption greater than 0.5 ng/mL or with safety concerns should undergo nonclinical toxicology assessment including systemic carcinogenicity and additional developmental and reproductive studies. OBJECTIVE: To determine whether the active ingredients (avobenzone, oxybenzone, octocrylene, and ecamsule) of 4 commercially available sunscreens are absorbed into systemic circulation. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial conducted at a phase 1 clinical pharmacology unit in the United States and enrolling 24 healthy volunteers. Enrollment started in July 2018 and ended in August 2018. INTERVENTIONS: Participants were randomized to 1 of 4 sunscreens: spray 1 (n = 6 participants), spray 2 (n = 6), a lotion (n = 6), and a cream (n = 6). Two milligrams of sunscreen per 1 cm(2) was applied to 75% of body surface area 4 times per day for 4 days, and 30 blood samples were collected over 7 days from each participant. MAIN OUTCOMES AND MEASURES: The primary outcome was the maximum plasma concentration of avobenzone. Secondary outcomes were the maximum plasma concentrations of oxybenzone, octocrylene, and ecamsule. RESULTS: Among 24 participants randomized (mean age, 35.5 [SD, 1.5] years; 12 (50%] women; 14 [58%] black or African American; 14 [58%]), 23 (96%) completed the trial. For avobenzone, geometric mean maximum plasma concentrations were 4.0 ng/mL (coefficient of variation, 6.9%) for spray 1; 3.4 ng/mL (coefficient of variation, 77.3%) for spray 2; 4.3 ng/mL (coefficient of variation, 46.1%) for lotion; and 1.8 ng/mL (coefficient of variation, 32.1%). For oxybenzone, the corresponding values were 209.6 ng/mL (66.8%) for spray 1, 194.9 ng/mL (52.4%) for spray 2, and 169.3 ng/mL (44.5%) for lotion; for octocrylene, 2.9 ng/mL (102%) for spray 1, 7.8 ng/mL (113.3%) for spray 2, 5.7 ng/mL (66.3%) for lotion, and 5.7 ng/mL (47.1%) for cream; and for ecamsule, 1.5 ng/mL (166.1%) for cream. Systemic concentrations greater than 0.5 ng/mL were reached for all 4 products after 4 applications on day 1. The most common adverse event was rash, which developed in 1 participant with each sunscreen. RESULTS: Among 24 participants randomized (mean age, 35.5 [SD, 10.5] years; 12 [50%] women; 14 [58%] black or African American), 23 (96%) completed the trial. Systemic concentrations greater than 0.5 ng/mL were reached for all 4 products after 4 applications on day 1. The most common adverse event was rash (1 participant with each sunscreen). [Table: see text] CONCLUSIONS AND RELEVANCE: In this preliminary study involving healthy volunteers, application of 4 commercially available sunscreens under maximal use conditions resulted in plasma concentrations that exceeded the threshold established by the FDA for potentially waiving some nonclinical toxicology studies for sunscreens. The systemic absorption of sunscreen ingredients supports the need for further studies to determine the clinical significance of these findings. These results do not indicate that individuals should refrain from the use of sunscreen. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03582215