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IMPORTANCE: Autoimmune bullous diseases (AIBDs) are chronic relapsing-remitting conditions with significant morbidity. Skin-related quality of life (SRQL) may vary by AIBD subtype and disease type. Disease severity and flare severity can be difficult to define; SRQL can offer a key insight. OBJECTIVES: To investigate the Skindex-16 score as an SRQL measure in AIBD subtypes during flare and nonflare states and to evaluate Skindex-16 construct validity. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study was conducted from September 1, 2016, to February 1, 2020, among 192 patients at the University of Utah Health autoimmune dermatology clinic with pemphigoid, pemphigus, dermatitis herpetiformis, and linear immunoglobulin A disease. Patients had an encounter-associated diagnosis, Skindex-16 scores, and self-reported flare status. Statistical analysis was performed from March 2022 to June 2023. EXPOSURE: Autoimmune bullous disease subtype and patient-reported flare status. MAIN OUTCOMES AND MEASURES: Skindex-16 domain scores (emotions, symptoms, and functioning; range, 0-100, where 0 indicates no effect on SRQL and 100 maximum effect) and individual item scores were described by disease and flare status. Flare scores were expected to be higher by at least the standard error of measurement (SEm). Convergent validity was assessed using Spearman correlation among Skindex-16 scores, serologic titers, and other patient-reported outcome measures. Floor or ceiling domain scores (<20% of sample scoring either lowest or highest possible domain scores, respectively) were assessed for Skindex-16. Structural validity was assessed using confirmatory factor analysis (CFA). RESULTS: The study included 192 patients with 212 visits (median age, 68 years [IQR, 58-76 years]; 123 of 212 women [58.0%]) with Skindex-16 scores (64 in flare state and 148 in nonflare state). Median Skindex-16 domain scores were higher for all disease categories among patients in the flare state compared with those in the nonflare state (pemphigoid [emotions: flare, 52.4 (IQR, 38.1-69.0); nonflare, 7 (IQR, 0-17); symptoms: flare, 37.5 (IQR, 29.2-58.0); nonflare, 13 (IQR, 0-25); functioning: flare, 26.7 (IQR, 10.0-56.7); nonflare, 0 (IQR, 0-3)]; pemphigus [emotions: flare, 54.8 (IQR, 31.0-81.0; nonflare, 0 (IQR, 0-19); symptoms: flare, 58.3 (IQR, 41.7-70.8); nonflare, 4 (IQR, 0-12.5); functioning: flare, 26.7 (IQR, 13.3-83.3); nonflare, 0 (IQR, 0-3.33)]; dermatitis herpetiformis [emotions: flare, 72.6 (IQR, 34.7-90.5); nonflare, 14.3 (IQR, 2.4-26.2); symptoms: flare, 69 (IQR, 31.3-85.4); nonflare, 12.5 (IQR, 0-29.2); functioning: flare, 38.3 (IQR, 5.0-63.2); nonflare, 0 (IQR, 0-13.3)]. This difference exceeded SEm cut points. Cronbach α was greater than 0.80 for all domains and AIBDs. Moderate or low correlations were seen with desmoglein 1 and bullous pemphigoid 180 titers. Moderate correlation existed between Skindex-16 and Patient-Reported Outcomes Measurement Information System Depression scores (emotions: ρ = 0.40; symptoms: ρ = 0.41; functioning: ρ = 0.48), and strong correlation existed between Skindex-16 and patient-reported disease severity (emotions: ρ = 0.71; symptoms: ρ = 0.73; functioning: ρ = 0.66). Floor domain scores greater than 20% were seen among patients in the nonflare state, but ceiling domain scores were rare (<10% for all domains); CFA model fit was poor. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, SRQL was highly associated with flare of AIBDs. Skin-related quality of life was worse during periods without flare among patients with pemphigoid and dermatitis herpetiformis compared with pemphigus, highlighting residual SRQL morbidity. Skindex-16 showed good construct validity, but the poor CFA model fit needs further research. Clinical measurement of SRQL in AIBDs can add critical disease-severity information.

Supplemental Digital Content is Available in the Text.Nevi of specialized sites (NOSS) occur on the scalp, ears, flexural, acral, and genital areas and display atypical clinical and histologic features. We assessed NOSS recurrence and progression to melanoma, management patterns, and associations between histologic features and treatment recommendations. We queried all histologic diagnoses of NOSS (n = 275) from 2012 to 2017 from a large U.S. academic medical center with reference dermatopathology laboratory and matched these to clinical records. A blinded panel of dermatopathologists re-evaluated lesions, catalogued histologic findings, and gave management recommendation. Associations with dermatopathologist decision and concordance between new and original recommendations were assessed. Of 117 cases with follow-up, 2 locally recurred (1.46%) and none eventuated in melanoma. Clinical features were not associated with original treatment recommendations. After histopathologic review, large melanocytes [odds ratio ratio (ORR) = 8.00, 95% CI, 1.35–47.4] and junctional mitotic figures (ORR = 65.0, 6.5–650) predicted excision recommendation. Likewise, accumulation of many (>9) high-risk features was associated with excision recommendation. Panel review changed treatment recommendation in 27% of cases. Fair concordance existed between original and panel recommendations (κ = 0.29, 0.15–0.44). The low rate of recurrence and lack of melanoma occurrence suggest that despite an atypical clinical and histopathologic appearance, these nevi have limited potential for malignant transformation. Histopathologic findings seem to be principal drivers behind the recommendation for excision in this analysis. Variability existed in treatment recommendations; the panel's consensus recommendation tended to downgrade treatment. This highlights the importance of further outcomes-based studies to identify true high-risk features and refine management guidelines.

OBJECTIVE--The incidence of type 1 diabetes complications appears to be decreasing, but relative contributions of risk factors are unclear. We thus estimated the effect of modifiable risk factors on the [...]

Survival in type 1 diabetes has improved, but the impact on life expectancy in the U.S. type 1 diabetes population is not well established. Our objective was to estimate the [...]

OBJECTIVE--Little is known concerning the primary cause(s) of mortality in type 1 diabetes responsible for the excess mortality seen in this population. RESEARCH DESIGN AND METHODS--The Allegheny County (Pennsylvania) childhood-onset (age RESULTS--Vital status for 1,043 (97%) participants was ascertained as of I January 2008, revealing 279 (26.0%) deaths overall (141 females and 138 males). Within the first 10 years after diagnosis, the leading cause of death was acute diabetes complications (73.6%), while during the next 10 years, deaths were nearly evenly attributed to acute (15%), cardiovascular (22%), renal (20%), or infectious (18%) causes. After 20 years' duration, chronic diabetes complications (cardiovascular, renal, or infectious) accounted for >70% of all deaths, with cardiovascular disease as the leading cause of death (40%). Women (P < 0.05) and African Americans (P < 0.001) have significantly higher diabetes-related mortality rates than men and Caucasians, respectively. Standardized mortality ratios (SMRs) for non-diabetes-related causes do not significantly differ from the general population (violent deaths: SMR 1.2, 95% CI 0.6-1.8; cancer: SMR 1.2, 0.5-2.0). CONCLUSIONS--The excess mortality seen in type 1 diabetes is almost entirely related to diabetes and its comorbidities but varies by duration of diabetes and particularly affects women and African Americans. Diabetes 59:3216-3222, 2010, Mortality rates for type 1 diabetes are much higher than in the general population in the U.S. and worldwide (1-3). Understanding the primary cause(s) of this excess mortality is essential [...]

OBJECTIVE--Although management of type 1 diabetes improved dramatically in the 1980s, the effect on mortality is not clear. RESEARCH DESIGN AND METHODS--We report trends in 30-year mortality using the Allegheny [...]

OBJECTIVE--To examine the relationship between cardiovascular autonomic neuropathy and pulse waveform analysis (PWA) measures of arterial stiffness in a childhood-onset type 1 diabetes population. RESEARCH DESIGN AND METHODS--Cardiac autonomic nerve function was measured in the baseline examination of the Pittsburgh Epidemiology of Diabetes Complications Study of childhood-onset type 1 diabetes by heart rate variability (R-R interval) during deep breathing and expressed as expiration-to-inspiration (E/I) ratio. Other cardiovascular and diabetes factors were also assessed. PWA was performed using SphgymoCor Px on 144 participants at the 18-year follow-up examination. Univariate and multivariate analyses for associations between baseline nerve function and other cardiovascular and diabetes-related factors were performed for augmentation index (AIx), augmentation pressure (AP), and subendocardial viability ratio (SEVR), a surrogate marker of myocardial perfusion. RESULTS--EB ratio correlated negatively with both AIx (r = - 0.18, P = 0.03) and AP (r = -0.32, P < 0.001) and positively with SEVR (r = 0.47, P < 0.001) univariately. Lower baseline EB ratio, HDL cholesterol, and a history of smoking were associated with higher follow-up (18 years later) Alx and AP and lower SEVR in multivariate analyses. Higher baseline [HbA.sub.1] was also associated with higher AP and lower SEVR multivariately. CONCLUSIONS--Cardiovascular autonomic neuropathy is associated with increased arterial stiffness measures and decreased estimated myocardial perfusion in those with type 1 diabetes some 18 years later. This association persists after adjustment for potential confounders as well as for baseline [HbA.sub.1], HDL cholesterol, and smoking history, which were also associated with these PWA measures., Cardiovascular disease occurs earlier and with greater frequency in people with diabetes, a finding particularly striking in women (1). These observations are especially true for young adults with type 1 [...]

Patient-reported outcomes (PROs) provide quantitative assessments of patients’ experiences with their skin diseases. PROs are usually much more comprehensive than what can be gleaned from a brief clinical history and more informative than what dermatologists can gather on clinical examination. Correlations between PROs and clinician assessments (e.g., investigator global assessment, PASI) are poor to moderate at best, and therefore data from each source are not redundant and can complement one another. PROs should serve as skin vital signs in dermatology. PROs can offer snapshots of the intensity of a symptom as well as the effects of symptoms, emotions, and functioning on a patient’s skin-related QOL. Just as clinicians obtain a baseline blood pressure before starting antihypertensives, dermatology-specific PROs serve as a baseline from which clinicians can monitor (even remotely) for improvement or side effects with treatment and for flares. Both PROs and conventional vital signs are usually normal. It is when they are abnormal or different than expected that they become informative. We conclude by offering a roadmap for investigators to conduct the next steps in PRO research necessary to establish guidelines for transitioning PROs from clinical research and trials to routine clinical use.

Background:Psoriasis is a chronic skin condition with significant effects on quality of life, including impacts on emotional health. However, these experiences are not always addressed in clinic visits, despite their potential for significant effects on daily life. This study is part of a larger project on the effects of psoriasis on quality of life. The current information was analyzed separately because the amount of information on emotional impacts mentioned by participants was so significant that it warranted a separate analysis to thoroughly assess these experiences. Objective:To describe emotional consequences of psoriasis for patients and their family members. Methods:This project was conducted at an academic medical center in Utah. Experiences were discussed in interviews and focus groups with 25 patients and 11 family members. Thematic analysis was used to determine themes and subthemes. Results:This study sheds light on the damaging effects of psoriasis on emotional well-being, illustrating the challenges patients face from internal conflict, consequences for family members trying to cope with psoriasis in a loved one, and judgment from others who do not understand psoriasis and its challenges. Conclusion:Living with psoriasis leads to emotional consequences that may be left unaddressed in clinic visits, yet these experiences contribute significantly to quality of life. The stories told through this study can help clinicians understand how to identify and address emotional concerns to improve care for psoriasis patients and, as a result, improve quality of life for both patients and their families.

Background:Patients with psoriasis commonly report experiencing severe sensory symptoms, and the burden of these symptoms can extend beyond unpleasant experiences to impair patients’ health-related quality of life (HRQL). However, the symptom of pain and its consequences are still poorly understood in psoriasis patients. Objective:To understand the quality and intensity of pain associated with psoriasis as well as its interference with daily function in patients with psoriasis. Methods:Three focus groups and four interviews with psoriasis patients were conducted (n = 25). A trained facilitator used a semi-structured interview guide based on a literature review and a theory-driven approach. Two researchers independently coded the narratives and reached a consensus on the major themes using NVivo 12 software. Results:Our analysis produced five main themes regarding pain. (1) Perception of pain was illustrated through intense descriptors. (2) Patients identified pain triggers, including self-inflicted triggers. (3) Patients found coping strategies to deal with pain, including suppression of sensory experience. (4) Emotional suffering was linked primarily to the compulsion to continue scratching despite repeated efforts to stop and the failure of physicians to acknowledge the burden of the pain, which led to inadequate pain management. (5) Pain led to an overt impact on HRQL in these patients through interference with daily activity, intimate relationships, and sleep. Conclusions:Pain can be a significant hardship for patients with psoriasis. We encourage clinicians to inquire about pain separate from pruritus and to consider HRQL impacts of their patients’ pain when determining treatments.

IMPORTANCE: Insurance companies use prior authorizations (PAs) to address inappropriate prescribing or unnecessary variations in care, most often for expensive medications. Prior authorizations negatively affect patient care and add costs and administrative burden to dermatology offices. OBJECTIVE: To quantify the administrative burden and costs of dermatology PAs. DESIGN, SETTING, AND PARTICIPANTS: The University of Utah Department of Dermatology employs 2 full-time and 8 part-time PA staff. In this cross-sectional study at a large academic department spanning 11 clinical locations, these staff itemized all PA-related encounters over a 30-day period in September 2016. Staff salary and benefits were publicly available. Data were analyzed between December 2018 and August 2019. MAIN OUTCOMES AND MEASURES: Proportion of visits requiring PAs, median administrative time to finalize a PA (either approval or denial after appeal), and median cost per PA type. RESULTS: In September 2016, 626 PAs were generated from 9512 patient encounters. Staff spent 169.7 hours directly handling PAs, costing a median of $6.72 per PA. Biologic PAs cost a median of $15.80 each and took as long as 31 business days to complete. The costliest PA equaled 106% of the associated visit’s Medicare reimbursement rate. Approval rates were 99.6% for procedures, 78.9% for biologics, and 58.2% for other medications. After appeal, 5 of 23 (21.7%) previously denied PAs were subsequently approved. CONCLUSIONS AND RELEVANCE: Prior authorizations are costly to dermatology practices and their value appears limited for some requests. Fewer unnecessary PAs and appeals might increase practice efficiency and improve patient outcomes.

IMPORTANCE: Acne is a common dermatologic condition and significantly affects psychosocial health and quality of life. An international task force recommended routine use of quality-of-life measures for clinic visits associated with acne management, but this has yet to translate into clinical practice. OBJECTIVE: To assess mean Skindex-16 scores over time among patients with moderate to severe acne receiving isotretinoin treatment. DESIGN, SETTING, AND PARTICIPANTS: A longitudinal, retrospective case series study of Skindex-16 data collected at monthly visits from 57 consecutive patients with acne receiving isotretinoin; data were collected and evaluated between November 23, 2016, and January 22, 2019. Continuous variables were compared using quantile regression. Multivariable linear mixed models evaluated mean (95% CI) score trajectory over time. MAIN OUTCOMES AND MEASURE: Skindex-16 scores, including normalized scores for the emotional, symptomatic, and functional aspects of having skin disease as well as an overall score. RESULTS: Fifty-seven patients (31 [54.4 %] males, with median [interquartile range] age of 17.2 [15.9-18.1] years) in this case series study completed the Skindex-16 at baseline and at least once during follow-up. Baseline Skindex-16 scores were similar by sex but worse with increasing age. Emotional impact was more bothersome to patients with acne requiring isotretinoin treatment than either symptoms or functioning. Improvements of greater than 50% in overall and Emotional domain scores were seen by month 2 of receiving isotretinoin treatment (eg, overall scores decreased from 39.4 to 17.5 by month 2; a decrease of 22.0; P &lt; .001). Qualitatively, Skindex-16 scores reached their nadir between months 3 and 5; at month 4, overall Skindex-16 scores showed a 4.4-fold improvement (from 39.4 at baseline to 8.9; P &lt; .001) and Emotional domain scores showed a 4.8-fold improvement (from 57.7 at baseline to 11.9; P &lt; .001). CONCLUSIONS AND RELEVANCE: The findings of this case series suggest that patients receiving isotretinoin treatment achieve greater than a 50% improvement in quality of life by month 2 and can expect approximately 4-fold to 5-fold improvements from baseline with a full course of isotretinoin. This study shows the potential of routine administration of quality of life measures to assess patient care in dermatology.

Importance: Patients with psoriasis are at an increased risk of hypertension, and when present, hypertension is more severe in patients with psoriasis. However, hypertension often goes underdiagnosed and undertreated in this population, which can contribute to increased overall morbidity and mortality.Objective: To review the relationship between psoriasis and hypertension and provide practical screening and treatment recommendations for dermatologists to address hypertension in patients with psoriasis.Evidence Review: PubMed and MEDLINE databases were searched for hypertensionand psoriasis. Consensus was reached by the authors based on published work and clinical experience for recommendations on screening, monitoring, diagnosis, and treatment of hypertension in patients with psoriasis.Findings: Hypertension is more prevalent, and often more severe, in the psoriasis population. This review summarizes recommendations for annual hypertension screening in patients with psoriasis, as well as diagnostic cutoffs and initial therapies for dermatologists to consider. Referral to primary care for continued hypertension management and additional referral recommendations based on comorbidities are described.Conclusions and Relevance: Psoriasis is a common dermatologic diagnosis in the United States. Dermatologists should be fully aware of appropriate screening, diagnosis, and initial management of hypertension in this population to help improve morbidity and mortality.

Purpose: Google Trends (GT) offers insights into public interests and behaviors and holds potential for guiding public health campaigns. We evaluated trends in US searches for sunscreen, sunburn, skin cancer, and melanoma and their relationships with melanoma outcomes.Design: Google Trends was queried for US search volumes from 2004 to 2017. Time-matched search term data were correlated with melanoma outcomes data from Surveillance Epidemiology and End Results Program and United States Cancer Statistics databases (2004-2014 and 2010-2014, respectively).Setting: Users of the Google search engine in the United States.Participants: Google search engine users in the United States. This represents approximately 65% of the population.Measures: Search volumes, melanoma outcomes.Analysis: Pearson correlations between search term volumes, time, and national melanoma outcomes. Spearman correlations between state-level search data and melanoma outcomes.Results: The terms “sunscreen,” “sunburn,” “skin cancer,” and “melanoma” were all highly correlated (P< .001), with sunscreen and sunburn having the greatest correlation (r= 0.95). Sunscreen/sunburn searches have increased over time, but skin cancer/melanoma searches have decreased (P< .05). Nationally, sunscreen, sunburn, and skin cancer were significantly correlated with melanoma incidence. At the state level, only sunscreen and melanoma searches were significantly correlated with melanoma incidence.Conclusions: We conclude that online skin cancer prevention campaigns should focus on the search terms “sunburn” and “sunscreen,” given the decreasing online searches for skin cancer and melanoma. This is reinforced by the finding that sunscreen searches are higher in areas with higher melanoma incidence.

IMPORTANCE: Physician assistants (PAs) are increasingly used in dermatology practices to diagnose skin cancers, although, to date, their diagnostic accuracy compared with board-certified dermatologists has not been well studied. OBJECTIVE: To compare diagnostic accuracy for skin cancer of PAs with that of dermatologists. DESIGN, SETTING, AND PARTICIPANTS: Medical record review of 33 647 skin cancer screening examinations in 20 270 unique patients who underwent screening at University of Pittsburgh Medical Center–affiliated dermatology offices from January 1, 2011, to December 31, 2015. International Classification of Diseases, Ninth Revision code V76.43 and International Classification of Diseases and Related Health Problems, Tenth Revision code Z12.83 were used to identify pathology reports from skin cancer screening examinations by dermatologists and PAs. EXPOSURE: Examination performed by a PA or dermatologist. MAIN OUTCOMES AND MEASURES: Number needed to biopsy (NNB) to diagnose skin cancer (nonmelanoma, invasive melanoma, or in situ melanoma). RESULTS: Of 20 270 unique patients, 12 722 (62.8%) were female, mean (SD) age at the first visit was 52.7 (17.4) years, and 19 515 patients (96.3%) self-reported their race/ethnicity as non-Hispanic white. To diagnose 1 case of skin cancer, the NNB was 3.9 for PAs and 3.3 for dermatologists (P &lt; .001). Per diagnosed melanoma, the NNB was 39.4 for PAs and 25.4 for dermatologists (P = .007). Patients screened by a PA were significantly less likely than those screened by a dermatologist to be diagnosed with melanoma in situ (0.2% vs 0.4% of visits, P = .04), but differences were not significant for invasive melanoma (0.2% vs 0.2% of visits, P > .99) or nonmelanoma skin cancer (6.1% vs 6.1% of visits, P = .98). CONCLUSIONS AND RELEVANCE: Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. Although the availability of PAs may help increase access to care and reduce waiting times for appointments, these findings have important implications for the training, appropriate scope of practice, and supervision of PAs and other nonphysician practitioners in dermatology.