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Background Many women affected by hidradenitis suppurativa (HS) are of childbearing age. To date, the literature is limited on pregnancy-related outcomes for women with HS. Objective To investigate maternal and obstetric outcomes and treatment utilization among women with HS. Methods This retrospective analysis used the IBM MarketScan Commercial Claims Database. Pregnant women with HS (n = 998) and 5:1 age-matched pregnant women without HS (n = 5065) were identified and information on claims related to diagnoses, procedures, and medications were analyzed. Results Compared to women without HS, pregnant women with HS had significantly lower odds of having a live birth (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.39-0.51) and significantly higher odds of having elective terminations (OR, 2.51; 95% CI, 2.13-2.96), gestational hypertension (OR, 1.44; 95% CI, 1.12-1.84), and cesarean deliveries (OR, 1.28; 95% CI, 1.06-1.55), and of receiving HS designated treatment during pregnancy (OR, 4.41; 95% CI, 3.56-5.46). Limitations Retrospective and convenience sampling and absence of clinical information to correlate HS severity and outcomes. Conclusion Pregnant women with HS have an increased probability of select complicated maternal and obstetric outcomes. Women planning for pregnancy or who are currently pregnant may benefit from coordinated care by dermatologists and obstetric providers.

Background Nearly half of patients with hidradenitis suppurativa (HS) report dissatisfaction with their treatment. However, factors related to treatment satisfaction have not been explored. Objectives To measure associations between treatment satisfaction and clinical and treatment-related characteristics among patients with HS. Methods Treatment satisfaction was evaluated utilizing data from a cross-sectional global survey of patients with HS recruited from 27 institutions, mainly HS referral centres, in 14 different countries from October 2017 to July 2018. The primary outcome was patients’ self-reported overall satisfaction with their current treatments for HS, rated on a five-point scale from ‘very dissatisfied’ to ‘very satisfied’. Results The final analysis cohort comprised 1418 patients with HS, most of whom were European (55%, 780 of 1418) or North American (38%, 542 of 1418), and female (85%, 1210 of 1418). Overall, 45% (640 of 1418) of participants were either dissatisfied or very dissatisfied with their current medical treatment. In adjusted analysis, patients primarily treated by a dermatologist for HS had 1·99 [95% confidence interval (CI) 1·62–2·44, P < 0·001] times the odds of being satisfied with current treatment than participants not primarily treated by a dermatologist. Treatment with biologics was associated with higher satisfaction [odds ratio (OR) 2·36, 95% CI 1·74–3·19, P < 0·001] relative to treatment with nonbiologic systemic medications. Factors associated with lower treatment satisfaction included smoking (OR 0·78, 95% CI 0·62–0·99; active vs. never), depression (OR 0·69, 95% CI 0·54–0·87), increasing number of comorbidities (OR 0·88 per comorbidity, 95% CI 0·81–0·96) and increasing flare frequency. Conclusions There are several factors that appear to positively influence satisfaction with treatment among patients with HS, including treatment by a dermatologist and treatment with a biologic medication. Factors that appear to lower treatment satisfaction include active smoking, depression, accumulation of comorbid conditions and increasing flare frequency. Awareness of these factors may support partnered decision making with the goal of improving treatment outcomes. What is already known about this topic? Nearly half of patients with hidradenitis suppurativa report dissatisfaction with their treatments. What does this study add? Satisfaction with treatment is increased by receiving care from a dermatologist and treatment with biologics.Satisfaction with treatment is decreased by tobacco smoking, accumulation of comorbid conditions including depression, and higher flare frequency. What are the clinical implications of this work? Awareness of the identified factors associated with poor treatment satisfaction may support partnered decision making and improve treatment outcomes.

Background: A needs assessment for patients with hidradenitis suppurativa (HS) will support advancements in multidisciplinary care, treatment, research, advocacy, and philanthropy. Objective: To evaluate unmet needs from the perspective of HS patients. Methods: Prospective multinational survey of patients between October 2017 and July 2018. Results: Before receiving a formal HS diagnosis, 63.7% (n = 827) of patients visited a physician >= 5 times. Mean delay in diagnosis was 10.2 6 8.9 years. Patients experienced flare daily, weekly, or monthly in 23.0%, 29.8%, and 31.1%, respectively. Most (61.4% [n = 798]) rated recent HS-related pain as moderate or higher, and 4.5% described recent pain to be the worst possible. Access to dermatology was rated as difficult by 37.0% (n = 481). Patients reported visiting the emergency department and hospital >= 5 times for symptoms in 18.3% and 12.5%, respectively. An extreme impact on life was reported by 43.3% (n = 563), and 14.5% were disabled due to disease. Patients reported a high frequency of comorbidities, most commonly mood disorders. Patients were dissatisfied with medical or procedural treatments in 45.9% and 34.6%, respectively. Limitations: Data were self-reported. Patients with more severe disease may have been selected. Conclusion: HS patients have identified several critical unmet needs that will require stakeholder collaboration to meaningfully address.

Importance: Surgery is a mainstay in the management of hidradenitis suppurativa (HS). Adalimumab is the first drug approved for HS. Objective: To investigate the efficacy and safety of adalimumab in combination with wide-excision surgery followed by secondary intention healing. Design, Setting, and Participants: The Safety and Efficacy of Adalimumab for Hidradenitis Suppurativa Peri-Surgically (SHARPS) trial was a phase 4, randomized, double-blind, placebo-controlled study of adalimumab in conjunction with surgery. Patients were enrolled in 45 sites across 20 countries from July 18, 2016, to February 2, 2019, with the last patient visit on October 16, 2019. Eligible patients (aged 18-65 years) had moderate to severe HS that required radical surgery in an axillary or inguinal region and had 2 other anatomical regions affected, with 1 or more regions at Hurley stage II or III. Analysis was conducted in November 2019. Interventions: Patients were randomized 1:1 to receive continuous adalimumab, 40 mg, or placebo during presurgery (12 weeks), perioperative (2 weeks), and postoperative (10 weeks) periods. Main Outcomes and Measures: The primary end point was the proportion of patients achieving HS clinical response across all body regions at week 12. Results: Overall, 103 patients were randomized to adalimumab and 103 to matching placebo. Among all patients, 51% (n = 106) were women, 94% (n = 193) were White, and the mean (SD) age was 37.6 (11.3) years. At week 12, significantly more patients receiving adalimumab (49 of 103 [48%]) vs placebo (35 of 103 [34%]; P =.049) achieved HS clinical response across all body regions (treatment difference, 14% [95% CI, 0%-27%]). Treatment-emergent adverse events were reported in 74 of 103 patients (72%) and 69 of 103 patients (67%) in the adalimumab and placebo groups, respectively. No increased risk of postoperative wound infection, complication, or hemorrhage was observed with adalimumab vs placebo. Two deaths occurred in the adalimumab group; neither was considered as having a reasonable possibility of relationship to study drug. Conclusions and Relevance: Adalimumab was efficacious in conjunction with wide-excision surgery followed by secondary intention healing, with no need to interrupt treatment prior to surgery. These data support further investigation of adalimumab as an adjuvant therapy to surgery in patients with moderate to severe HS. Trial Registration: ClinicalTrials.gov Identifier: NCT02808975.

IMPORTANCE: Up to 50% of patients may have hidradenitis suppurativa (HS) onset between age 10 and 21 years. To our knowledge, little is known about how adolescents with HS utilize health care during their journey to receiving a diagnosis. OBJECTIVE: To assess the clinical characteristics and health care utilization patterns of pediatric vs adult patients with HS. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included adult and pediatric patients with HS claims from the MarketScan medical claims database during the study period, January 1, 2012, to December 31, 2016. The data were analyzed between March 1 and March 31, 2021. EXPOSURES: Clinical characteristics and health care utilization patterns of pediatric vs adult patients with HS. MAIN OUTCOMES AND MEASURES: Health care utilization patterns were examined and included concurrent diagnoses, outpatient care by discipline, and emergency/urgent care and inpatient claims. RESULTS: This study included 8727 members, comprising 1094 pediatric (155 male [14.2%] and 939 female patients [85.8%]; mean [SD] age, 14.3 [2.47] years) and 7633 adult patients (1748 men [22.9%] and 5885 women [77.1%]; mean [SD] age, 37.2 [12.99] years). Pediatric patients were likely to see pediatricians, dermatologists, emergency department (ED) staff, and family physicians before diagnosis and commonly received diagnoses of folliculitis and comedones. Pediatric patients with HS had high rates of comorbid skin and general medical conditions, including acne vulgaris (558 [51.0%]), acne conglobata (503 [45.9%]), obesity (369 [33.7%]), and anxiety disorders (367 [33.6%]). A higher percentage of pediatric than adult patients had HS-specific claims for services rendered by emergency and urgent care physicians (35.6% vs 28.2%; P

Background Dermatomyositis (DM) is associated with malignancy and interstitial lung disease. Many malignancies associated with DM occur in organs not routinely screened by national guidelines; thus, best screening practices are still debated. Positron emission tomography (PET) has been suggested as a single study alternative to more complex screening panels and may also be valuable in detecting interstitial lung disease progression. Criticisms of PET screening exams have focused on cost and radiation exposure. Objective To compare the cost of PET and its variants to conventional malignancy screening panels, and to review concerns regarding radiation exposure in PET. Methods Four variants of PET and PET-CT were included in the study. The conventional screening panel was defined as CT of the abdomen and pelvis without contrast, CT of the thorax without contrast, CEA, CA 19.9, PSA (men), mammography (women), transvaginal ultrasound (women), cytopathology (women), and CA 125 (women). The MarketScan® Commercial Claims and Encounters database, a collection of private insurance claims data from 53 million Americans, was queried for every instance of each test from 2005 to 2014 and the mean inflation-adjusted cost of each was recorded. The mean total cost to insurance companies and the mean out-of-pocket costs to patients for PET variants were compared to the costs for conventional panels. Additionally, the cost of pulmonary function tests (PFT) from the same period was evaluated. Results From 2005–2014, the mean inflation-adjusted costs of PET have trended downward, but the mean cost of PET-CT have trended upward. The mean total cost to insurance companies for PET-CT whole body was $730.70 and $537.62 greater than the cost of conventional panels for men and women, respectively. The out-of-pocket patient costs for PET-CT whole body was $109.82 and $111.33 less than the cost of conventional panels for men and women, respectively. The mean total cost of PFT was $205.02. Conclusions The cost of PET-CT whole body was greater than conventional panels for insurance companies, but patient out-of-pocket costs were lower. PET-CT may also have added value in detecting and monitoring interstitial lung disease progression in DM patients. More data are needed on the efficacy of PET-CT in detecting malignancy in DM patients; however, the cost difference is less than expected, suggesting the single scan could be a reasonable alternative to the conventional screening panel in some patients.

Background There is an opportunity to explore alternate payment models in dermatology. Objective To pilot 2 bundled payment models for actinic keratosis (AK) management. Methods A prospective cohort study was conducted during September 2013-June 2016. Consecutive patients were recruited from clinics of 5 dermatologists. Patients had to be adults, have ≥1 year of care at the department, and have a history of AK. A bundled payment strategy was prospectively piloted for 1 year and compared with costs in the prior year. Results Overall, 400 participants were enrolled, and complete data was collected for 254 participants. During the year of bundled payments, actual total annual spending on claims was $70,557, whereas model 1 and model 2 bundled payment models would have totaled $67,310 and $74,422, respectively, for the patient cohort. Patient satisfaction surveys showed no difference in the quality of care. Limitations Single-center study and limited sample size. International Classification of Diseases 9 and 10 codes were used to identify claims and might be inaccurate. Costs were modeled rather than fully implemented. Conclusion Dermatologists should be aware of bundled payment models. More work is needed to elucidate the optimal formulation of a bundled payment for AK management, including the services covered, time delimitation, and risk stratification factors.

IMPORTANCE: Hidradenitis suppurativa (HS) is a chronic autoinflammatory disease that is highly associated with affective disorders such as depression and anxiety. Recent studies have shown that patients with HS may also endorse high levels of internalized skin bias (ISB). This redirection of skin disease−related social stigma toward oneself may also play an important role in the associations between adverse psychopathology (eg, depression, anxiety) and health-related quality of life (HRQOL). OBJECTIVES: To evaluate the associations of ISB with other core outcomes in HS and to determine if ISB may mediate the associations between adverse psychopathological outcomes and impaired HRQOL. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of adult patients with HS recruited from 1 academic medical center as well as through virtual social and recruitment networks. Eligible participants completed an online survey comprised of 4 survey instruments along with demographic and disease history information from April 1, 2021, to July 15, 2021. MAIN OUTCOMES AND MEASURES: Measures included the Internalized Skin Bias Questionnaire (ISBQ), Burns Anxiety Inventory, the Beck Depression Inventory−II, the Hidradenitis Suppurativa Quality of Life (HiSQOL) instrument, along with demographic and disease history information. The primary outcome was HRQOL as measured by the HiSQOL. Data were analyzed in July through August 2021. RESULTS: The survey was completed by 230 of 279 patients (82.4%; mean [SD] age, 39.2 [11.2] years; 209 [90.9%] identified as female, 203 [88.7%] as not Hispanic, 178 [77.7%] as White). Depression and anxiety were shown to be a substantial burden in this sample, with 56.5% of participants’ scores qualifying for moderate or greater anxiety and 45.7% moderate or greater depression. The mean (SD) HRQOL scores were moderately high at 34.5 (16.7), indicating strong levels of impairment. There was a moderate correlation between ISBQ score and depression (r = 0.67); and fair correlations with HRQOL (r = 0.52) and anxiety (r = 0.56). Therefore, ISB appears to positively mediate the associations between depression and anxiety (estimated proportions of total effect that were mediated, 38.7% and 24.9%, respectively) and HRQOL. After controlling for age, disease severity, and disease duration, both ISB and anxiety were positive predictors of impaired HRQOL. CONCLUSIONS AND RELEVANCE: This cross-sectional study found that ISB was associated with adverse psychopathology and impaired HRQOL in patients with HS. Furthermore, ISB appears to mediate the associations of depression and anxiety with HRQOL. Future studies are needed to design interventions targeted at addressing adverse psychopathology associated with ISB and improving HRQOL and well-being for patients with HS.

Background Hidradenitis suppurativa (HS) is associated with comorbidities that contribute to poor health, impaired life quality, and mortality risk. Objective To provide evidence-based screening recommendations for comorbidities linked to HS. Methods Systematic reviews were performed to summarize evidence on the prevalence and incidence of 30 comorbidities in patients with HS relative to the general population. The screening recommendation for each comorbidity was informed by the consistency and quality of existing studies, disease prevalence, and magnitude of association, as well as benefits, harms, and feasibility of screening. The level of evidence and strength of corresponding screening recommendation were graded by using the Strength of Recommendation Taxonomy (SORT) criteria. Results Screening is recommended for the following comorbidities: acne, dissecting cellulitis of the scalp, pilonidal disease, pyoderma gangrenosum, depression, generalized anxiety disorder, suicide, smoking, substance use disorder, polycystic ovary syndrome, obesity, dyslipidemia, diabetes mellitus, metabolic syndrome, hypertension, cardiovascular disease, inflammatory bowel disease, spondyloarthritis, and sexual dysfunction. It is also recommended to screen patients with Down syndrome for HS. The decision to screen for specific comorbidities may vary with patient risk factors. The role of the dermatologist in screening varies according to comorbidity. Limitations Screening recommendations represent one component of a comprehensive care strategy. Conclusions Dermatologists should support screening efforts to identify comorbid conditions in HS.

Background: A clinical decision support tool may improve recognition of hidradenitis suppurativa (HS) and reduce diagnosis delay. Objective: To develop and initially validate a clinical decision support to predict diagnosis of HS and distinguish it from cutaneous abscess of the axilla, groin, perineum, and buttock. Methods: This was a retrospective, cross-sectional analysis between January 2012 and June 2017 (development set) and July 2017 and March 2019 (validation set). We used an electronic records sample of 56 million patients from the Explorys database to identify patients with an ambulatory visit associated with either HS or cutaneous of the axilla, groin, perineum, and buttock. The outcome was predicted probability of HS diagnosis. Results: Development set included 7,974 patients with mean age of 41.4 years, who were predominantly female (66%) and white (62%). Validation set included 1,560 patients with similar demographic composition. Factors which were stronger independent predictors of HS included female sex (OR 2.17 [95% CI 1.96–2.40]); African American race (1.28 [95% CI 1.15–1.44]); increasing BMI (OR 1.05 [95% CI 1.05–1.06)]; history of acne (OR 3.46 [95% CI 2.83–4.23]); Down syndrome (OR 5.35 [95% CI 2.03–14.12]); and prescription for at least 7 opioid medications in the past year (OR 1.05 [95% CI 0.83–1.33]). Up to age 45 years, increasing age was a stronger predictor of HS diagnosis. The simplified model showed good discrimination (c-statistic 0.746 [SE 0.013]) and moderate calibration (calibration intercept –0.260 [SE 0.055]; calibration slope 1.142 [SE 0.076]). Conclusion: This clinical decision support tool shows good performance in predicting diagnosis of HS and distinguishing it from cutaneous abscess that involves the axilla, groin, perineum, and buttock.

IMPORTANCE: Generalized pustular psoriasis (GPP) is a chronic, orphan disease with limited epidemiological data. OBJECTIVE: To describe the clinical characteristics, treatments, longitudinal disease course, and disease-specific health care utilization among patients with GPP across the United States. DESIGN, SETTING, AND PARTICIPANTS: A retrospective longitudinal case series involving 95 adults who met the European Rare and Severe Psoriasis Expert Network consensus definition for GPP and were treated at 20 US academic dermatology practices between January 1, 2007, and December 31, 2018. MAIN OUTCOMES AND MEASURES: The primary outcome is to describe the patient characteristics, associated medical comorbidities, treatment patterns complications, and GPP–specific health care utilization. RESULTS: Sixty-seven of 95 patients (70.5%) were women (mean age, 50.3 years [SD, 16.1 years]). In the initial encounter, 35 patients (36.8%) were hospitalized and 64 (67.4%) were treated with systemic therapies. In total, more than 20 different systemic therapies were tried. During the follow-up period, 19 patients (35.8%) reported hospitalizations at a median rate of 0.5 hospitalizations per year (IQR, 0.4-1.6). Women had a decreased risk of an emergency department or hospital encounter (odds ratio, 0.19; 95% CI, 0.04-0.83). CONCLUSIONS AND RELEVANCE: Generalized pustular psoriasis is a rare, chronic disease without standard treatment and is associated with continued health care utilization over time.

Background: People with hidradenitis suppurativa (HS) are interested in dietary alterations to manage the condition. However, there are few data on the prevalence of this or the impact on HS activity. The objective of this study was to investigate the prevalence and impact of dietary alterations made by people with HS. Methods: A cross-sectional survey was sent to people with HS through multiple sources. Participants reported food alterations in the prior 6 months. ­Results: Overall, 242 complete surveys were included in this analysis; the mean age was 35.8 years, and most (87.5%) were women. The majority (75.8%, n = 182) altered at least one food from their diet. Within this group, 154 (84.6%) made changes to multiple food groups. The top 5 food groups that were altered were gluten (48.8%), dairy (44.2%), refined sugars (40.0%), tomatoes (36.7%), and alcohol (37.1%). Smoking was eliminated in 27.5% of participants. Some participants (30.9%) reported the change made the HS “much better.” Conclusions: Dietary alteration to manage HS was common among participants in this study. Some people reported improvement in HS activity, but some noted worsening. Additional research is needed to evaluate the efficacy of dietary alteration to manage HS and to better understand the underlying pathomechanisms.

Background Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease with a large impact on patients' health-related quality of life. However, reliable and consistent outcome measures to assess body surface area (BSA) of HS have not been established. Objectives To develop and assess the reliability and validity of a novel outcome instrument for assessment of HS BSA in a clinical trial setting. Methods Qualitative interviews and focus groups were conducted from July to August 2015 and October 2017 to January 2018. Evaluation of the measurement was assessed during a single-day grading session with patients in April 2018. Participants, who included clinicians or patients, were recruited from academic medical centres in the U.S. mid-Atlantic region. Results Concept elicitation included input from 10 providers, of which 60% (n = 6) were female, 80% (n = 8) dermatology specialists and 20% (n = 2) gynaecology specialists. Cognitive debriefing was conducted with 11 providers, of which 82% (n = 9) were dermatologists and 18% (n = 2) gynaecologists. The evaluation stage included 10 clinicians and 23 patients. The intraclass correlation coefficient (ICC) for inter-rater reliability was 0·60 [95% confidence interval (CI) 0·44-0·74]. The ICC for intrarater reliability was 0·98 (95% CI 0·94-1·00). Transformation of the BSA score resulted in an increase in inter-rater reliability to 0·75 (95% CI 0·62-0·85) or 0·76 (95% CI 0·62-0·85). Scores all demonstrated concurrent validity, with statistically significant correlations with extant scoring methods. Conclusions This novel scale is a reliable and valid HS outcome instrument and may capture a wide range of patients by assessing BSA. Future research is necessary to demonstrate its responsiveness. What's already known about this topic? The major HS disease activity scales rely on lesions counts and have moderate-to-good reliability. Body surface area (BSA) is one of the physical signs included in the Core Outcome Set for HS, but is not a part of existing HS disease activity scales. What does this study add? A novel disease severity scale, the Severity and Area Score for Hidradenitis (SASH), was developed and the psychometric properties assessed. There was high inter-rater reliability of 0·75 and 0·76 when BSA was scored on an ordinal scale, and an excellent intrarater reliability of 0·98. The SASH score also demonstrated convergent validity with extant instruments. What are the clinical implications of this work? The ability of clinicians to accurately assess disease status will be improved. Implementation of the SASH score will help guide and assess the effectiveness of appropriate treatment choice.

Background: Hidradenitis suppurativa (HS) is a chronic skin disorder with adverse impacts on both physical and psychosocial well-being. There is presently no validated HS-specific quality-of-life (QoL) measure. Objective: The objective of this study is to develop a QoL instrument for HS (HS-QoL) in accordance with recommended standards. Methods: Patient interviews (concept elicitation) and expert input were used to develop the conceptual framework for outcomes perceived important to patients with HS. A HS-QoL-v1 measure was developed, and cognitive interviews with patients were conducted for pilot testing. Results: Concept elicitation interviews with patients with HS (n = 21) generated 12 themes. Most frequently reported were impacts on daily activities and symptoms due to HS. These themes, along with literature review and input from clinical experts, informed development of the HS-QoL-v1. Nine cognitive interviews were conducted in a pilot test and resulted in the HS-QoL-v2 measure. Conclusion: The HS-QoL-v2 is a preliminary QoL instrument for which further psychometric validation and establishment of clinimetric properties will be undertaken.

Background Laboratory monitoring for adverse effects to isotretinoin occurs with variability. Standardization of laboratory monitoring practices represents an opportunity to improve quality of care. Objective We sought to develop an evidence-based approach to laboratory monitoring of patients receiving isotretinoin therapy for acne. Methods We reviewed laboratory data from 515 patients with acne undergoing 574 courses of isotretinoin from March 2003 to July 2011. Frequency, timing, and severity of abnormalities were determined. Results Clinically insignificant leukopenia or thrombocytopenia occurred in 1.4% and 0.9% of patients, respectively. Elevated liver transaminases were detected infrequently and not significantly increased compared with baseline detection rates (1.9% vs 1.6% at baseline). Significant elevations occurred with triglyceride (19.3%) and cholesterol (22.8%) levels. The most severe abnormalities were grade 2 (moderate). Mean duration of treatment before abnormalities were detected was 56.3 days for hypertriglyceridemia, 61.9 days for alanine transaminitis, and 50.1 days for hypercholesterolemia. Limitations This was a single-center experience examining variable isotretinoin laboratory monitoring practices. Conclusions In healthy patients with normal baseline lipid panel and liver function test results, repeated studies should be performed after 2 months of isotretinoin therapy. If findings are normal, no further testing may be required. Routine complete blood cell count monitoring is not recommended.

Systemic antibiotics are often used to treat rosacea and tetracyclines are the most common antibiotic prescribed; however, there is ambiguity among clinical guideline suggestions. Importantly, there is an increasing call to all clinicians to curtail antibiotic use.To investigate the utilization and cost of long-term oral antibiotic use for the treatment of rosacea, including ocular rosacea.This was a retrospective cohort study of MarketScanThe sample included 72,411 patients. The mean (SD) duration of long-term antibiotic treatment was 87.68 (145.99) days and for patients with ocular rosacea was slightly longer, 108.34 (176.74) days [p .0001]. The majority of antibiotic courses were shorter than 3 months (80.04%) for the entire sample and the subset with ocular rosacea (53.64% [p = .007]).Patient adherence is uncertain and database lacks information on rosacea severity and clinical outcomes.The majority of oral antibiotic course durations follow guidelines. Costs of antibiotic therapy were lower for shorter courses and those utilizing generic medications; the cost-effectiveness of these modifications has not been investigated.

Background The duration of oral antibiotic acne therapy for adolescents compared with guidelines was recently investigated; however it was uncertain if duration of antibiotics for adult acne therapy differed. Objective This study aimed to evaluate duration of oral antibiotics for adult acne compared with guidelines and determine possible cost-savings. Methods This was a retrospective cohort study of MarketScan Commercial Claims and Encounters database that incorporated claims data to determine duration and costs of antibiotic treatment among adults ages 21 years and older. Results Of 17,448 courses, 84.5% (14,737) aligned with duration guidelines, although 12,040 (69.0%) courses did not include concomitant topical retinoid therapy. Mean savings of $592.26 per person could result if prolonged courses met guidelines. Mean (median) costs of generic and branded formulations for the most frequent course duration (90-179 days) were $103.77 ($54.27) and $1421.61 ($1462.25), respectively. Limitations Actual patient prescription adherence is uncertain and database lacks information regarding acne severity, patient physical characteristics, and clinical outcomes. Conclusions The majority of oral antibiotic course durations follow guidelines, although topical retinoids are underused. Costs of antibiotic therapy were lower for shorter courses and those using generic medications; the cost-effectiveness of these modifications has not been investigated.

Hidradenitis suppurativa (HS) places a significant burden on the health-related quality of life (HRQOL) of patients, many of whom have depression. Resilience can play a role in mitigating the negative stressors, such as the symptoms of HS, on patients' mental health.To investigate the correlation among resilience, depression, and HRQOL for patients with HS.This cross-sectional survey study of 154 patients from 2 referral centers in the United States and in Denmark was conducted from June 1, 2016, to March 31, 2017. Patients were considered eligible if they were 18 years or older and had a visit for HS at 1 of the 2 referral centers in the past 2 years (from January 1, 2014, through December 31, 2016). Patients were excluded if they declined to participate, could not read or write in English or Danish, or had a cognitive disability that would preclude their understanding of the survey questions.The survey instrument included 4 questionnaires: (1) a sociodemographic and clinical characteristics questionnaire, (2) the Brief Resilient Coping Scale, (3) the Hospital Anxiety and Depression Scale, and (4) the Dermatology Life Quality Index. The main outcome of interest was the HRQOL as measured by the Dermatology Life Quality Index.All 154 patients submitted a completed survey. The mean (SD) age of the participants was 40.93 (13.5) years; most participants were women (130 [84.4%]), and most participants self-identified as white (139 [90.2%]). The rate of depression among the patients in this study was comparable to those reported in previous studies; 55 patients (35.7%) were classified as having depression, and 32 patients (20.8%) had borderline depressive symptoms. Patient-rated HS severity and the depression score each independently estimated 27% and 10% of variation in HRQOL, respectively. The interaction term for resilience and depression was significant, indicating that resilience moderates depression. Analysis of the mediation effects of resilience was not significant, indicating that resilience did not mediate the association between depressive symptoms and HRQOL. The resilience score was significantly associated with depressive symptoms (regression coefficient a = -0.21; P .001), and the depressive symptoms score (c = 0.637; P .001) was significantly associated with lower HRQOL (c' = 0.644; P .001). However, both the direct association (b = 0.033; P = .86) and the indirect association (a × b = 0.007; P = .87) of resilience with HRQOL were not significant.Patients with higher resilience levels experienced a smaller decrease in HRQOL as depressive symptoms increased. Because the findings suggest that resilience can be taught, there is an opportunity to develop a resiliency training program and investigate its role in stress levels and depressive symptoms, as well as in HRQOL and disease activity.

The true prevalence of hidradenitis suppurativa (HS) is unknown.To establish standardized overall and group-specific prevalence estimates for HS in the United States.This retrospective analysis included a demographically heterogeneous population-based sample of more than 48 million unique patients across all US census regions. As of October 27, 2016, a total of 47 690 patients with HS were identified using electronic health record data.Standardized overall point prevalence for HS and sex-, age-, and race-specific prevalence estimates of HS in the general US population.Of the 47 690 patients with HS (26.2% men and 73.8% women), the overall HS prevalence in the US population sample was 0.10%, or 98 per 100 000 persons (95% CI, 97-99 per 100 000 persons). The adjusted prevalence in women was 137 per 100 000 (95% CI, 136-139 per 100 000), more than twice that of men (58 per 100 000; 95% CI, 57-59 per 100 000; P .001). The prevalence of HS was highest among patients aged 30 to 39 years (172 per 100 000; 95% CI, 169-275 per 100 000) compared with all other age groups (range, 15-150 per 100 000; P .001). Adjusted HS prevalences among African American (296 per 100 000; 95% CI, 291-300 per 100 000) and biracial (218 per 100 000; 95% CI, 202-235 per 100 000) patients were more than 3-fold and 2-fold greater, respectively, than that among white patients (95 per 100 000; 95% CI, 94-96 per 100 000; P .001).Hidradenitis suppurativa is an uncommon, but not rare, disease in the United States that disproportionately affects female patients, young adults, and African American and biracial patients.

Background Duration of oral antibiotic therapy in acne has not been widely studied. Recent guidelines suggest it should be limited to 3 to 6 months. Objective We sought to compare the duration of oral antibiotic use with recent guidelines and determine the potential cost-savings related to shortened durations. Methods This is a retrospective cohort study from the MarketScan Commercial Claims and Encounters database. Claims data were used to determine duration and costs of antibiotic therapy. Results The mean course duration was 129 days. The majority (93%) of courses were less than 9 months. Among the 31,634 courses, 18,280 (57.8%) did not include concomitant topical retinoid therapy. The mean (95% confidence interval) duration with and without topical retinoid use was 133 (131.5-134.7) days and 127 (125.4-127.9) days, respectively. The mean excess direct cost of antibiotic treatment for longer than 6 months was $580.99/person. Limitations Claims cannot be attributed to a specific diagnosis or provider. The database does not provide information on acne severity. Conclusions Duration of antibiotic use is decreasing when compared with previous data. However, 5547 (17.53%) courses exceeded 6 months, highlighting an opportunity for reduced antibiotic use. If courses greater than 6 months were shortened to 6 months, savings would be $580.99/person.

Importance Recent legislation encourages alternative payment models, such as bundled payments. There are no clear recommendations on bundled payment design, and research on bundled payments for dermatologic care is limited. Objective To investigate several methods to develop bundled payment models for actinic keratosis (AK) management and the likely effect on the cost of AK management. Design, Setting, and Participants Cohort cost identification study using claims from Highmark Insurance and the MarketScan Commercial Claims and Encounters databases. Patients with claims for AK during the study period, January 2010 to December 2012, were included (N = 118 129). Utilization measures, such as visits and procedures, and direct costs were calculated and 8 bundled payment models were developed. Indirect costs were not included. Main Outcomes and Measures The actual health care costs and theoretical cost differences for the bundled payments. Costs are reported in 2012 US dollars and were adjusted for inflation. The proportion of patients and clinicians with annual AK claim costs less than or equal to the bundled payments were calculated. Results Eight bundled payment models were developed and 2, based on the 75th percentile payment, did not result in theoretical savings for any of the patient samples (increased annual spending of $1.04 million to $6.88 million). The median-based payment without adjustments resulted in the largest theoretical savings (decreased spending of $2.22 million to $6.43 million). In contrast, the mean-based payment with adjustments resulted in the smallest theoretical savings. The median-based with indirect payment (65.2% for patients and 62.0% for clinicians) and mean-based adjusted payments, with (68.9% and 66.2%) and without (68.1% and 65.6%) discount, were equal to or greater than the actual health care costs for similar proportions of patients and clinicians, respectively. In addition, both resulted in a decrease in overall health care costs for the patient cohort. Conclusions and Relevance It is important to consider alternative payment models, such as bundled payments, in preparation for payment reform. The dermatology profession needs to understand disease management in dollar terms to advocate on behalf of clinicians and patients for fair and reasonable reimbursement, regardless of payment type.

Importance Nurse practitioners (NPs) and physician assistants (PAs) are nonphysician clinicians (NPCs) who can deliver dermatology services. Many of these services are provided independently. Little is known about the types of services provided or where NPCs provide independent care. Objective To examine characteristics of dermatology care for Medicare enrollees billed independently by NPCs. Design, Setting, and Participants Retrospective review of the 2014 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File, which reflects fee-for-service payments to clinicians for services rendered to Medicare beneficiaries. Clinician location was matched with county-level demographic data from the American Community Survey, US Census Bureau. Clinicians identified using National Provider Identifier as NPs or PAs with at least 11 claims for common dermatology-associated Healthcare Common Procedure Coding System procedure codes were included. Main Outcomes and Measures Total services provided by service type category, density of dermatologists and nondermatologists who perform dermatology-related services, and geographic location by county. Results Among the cohort of NPCs were 824 NPs (770 [93.5%] female) and 2083 PAs (1602 [76.9%] female) who independently billed Medicare $59 438 802 and $171 645 943, respectively. Dermatologists were affiliated with 2667 (92%) independently billing NPCs. Most payments were for non–evaluation and management services including destruction of premalignant lesions, biopsies, excisions of skin cancer, surgical repairs, flaps/grafts, and interpretation of pathologic analysis. Nurse practitioners and PAs billed for a similar distribution of service categories overall. A total of 2062 (70.9%) NPCs practiced in counties with dermatologist density of greater than 4 per 100 000 population. Only 3.0% (86) of independently billing NPCs practiced in counties without a dermatologist. Both dermatologists and NPCs were less likely to be in rural counties than in urban counties. Conclusions and Relevance Nonphysician clinicians independently billed for a wide variety of complex dermatologic procedures. Most independently billing NPCs practice in counties with higher dermatologist densities, and nearly all these NPCs were affiliated with dermatologists. Further study of NPC training and integration with the dermatology discipline is an important part of addressing the changing US dermatology workforce.

Hidradenitis suppurativa (HS) is a chronic cutaneous disease with acutely painful flares that require appropriate and timely treatment.To assess how individuals with HS utilize medical care, especially emergency department (ED) care, a high-cost setting, and to describe the health care costs for this group.Cohort cost-identification study of 150 493 individuals with claims from the MarketScan medical claims database. Patients with claims for HS and psoriasis (16 736 and 110 266, respectively) and a control group with neither condition (23 491) during the study period, January 2008 to December 2010, were included.An HS cohort was formed from all the patients who had 2 or more claims for HS (International Classification of Diseases, Ninth Revision [ICD-9] code 705.83) during the 3-year period. A psoriasis cohort was used as a comparison group, since it is another chronic inflammatory condition with prominent skin findings. This group included randomly selected patients who had 2 or more claims for psoriasis (ICD-9 code 696.1) during the 3-year period. A second control group included randomly selected patients who had no claims for either condition during the 3-year period. From these cohorts only patients that were continuously enrolled for the 3-year period were included.Health care utilization measures including inpatient length of stay, emergency department and outpatient visits, and number of days supplied of prescription medication were investigated. Cost variables were also investigated and included inpatient, outpatient, emergency department, prescription drug, and total all-cause health care expenditures, which were adjusted for inflation and reported in 2010 US dollars.The largest component of the total 3-year cost for the HS group was inpatient cost (37.4%). In contrast, for the psoriasis group this was drug costs (46.5%) and for the control group, inpatient costs (40.9%). The proportion of people who were hospitalized in the HS cohort (15.8%) was higher than the psoriasis (10.8%) or control (8.6%) groups (P .001). The proportion of patients who used the ED over the 3-year period was higher in the HS cohort (27.1%) than the psoriasis (17.4%) or control groups (17.2%) (P .001). Similarly, the mean (SD) 3-year ED cost for the HS group was $2002 ($6632) and was higher than both comparison groups (P .001). After adjustment for age, sex, and comorbidities, ED utilization remained higher in the HS group compared with the control (P .001) and psoriasis (P = .02) cohorts.Hidradenitis suppurativa affects a younger, predominantly female population of patients. High-cost settings, such as ED and inpatient care, are used more frequently for patients with HS. Both patients and clinicians should be aware of this finding, and further research is needed to investigate the impact of health care utilization on patient outcomes.

Riehl melanosis is a rare cause of skin hyperpigmentation that typically occurs on the face and neck and is characterized by the rapid onset of gray-brown reticular pigmentation. It is theorized to be a pigmented contact dermatitis or a lichenoid immune reaction that may be caused by intrinsic as well as extrinsic factors. Treatment is challenging; laser and intense pulsed light (IPL) therapy is a common treatment for other pigmented skin conditions. IPL has been reported twice for the treatment of Riehl melanosis and we report a case of Riehl melanosis successfully treated with q-switched Nd:YAG after proving recalcitrant to IPL treatment.

Intense, intermittent exposure, the kind of exposure associated with attending an amusement park for example, is correlated with the development of basal cell carcinoma and melanoma. The goals of this study were to assess the use of the station by visitors and to identify opportunities to increase the utilization of the sunscreen station.The study was a descriptive observational study of attendees at an amusement park in Pennsylvania. The study included a paper survey and observation of the station for frequency of use.The station was very infrequently used; observation showed that 0.9% (8/879) of attendees in proximity used the station. There were numerous suggestions from attendees about increased utilization by improved station signage and locations as well as station advertising. Surveys were collected from 283 attendees and 59% (n=165) had used sunscreen on the day of the study and 29% (n=81) reported typical sunscreen use as 'Never' or 'Rarely' used. Once visitors were made aware of the station, 76% (201/263) reported that they would utilize it.This study showed that sunscreen use at an amusement park can be improved, especially among men and young adults. Therefore, men and younger visitors need to be purposefully encouraged in advertising and marketing the sunscreen stations.

Intralesional chemotherapy for nonmelanoma skin cancer has existed for more than 5 decades. However, it is used so infrequently that recent consensus guidelines for the treatment of basal cell and squamous cell carcinoma do not include intralesional chemotherapy. Barriers to the use of intralesional chemotherapy include the off-label use of these agents, absence of therapeutic guidelines, a relatively small number of patients treated, and a lack of large, well-designed trials with long-term follow-up. Surgical intervention remains the gold standard for the treatment of nonmelanoma skin cancer; however, intralesional chemotherapy remains an option for well-selected patients who cannot or will not undergo surgery. The objectives of this article are to determine response rates and suggest reasonable treatment guidelines for the treatment of squamous cell carcinoma, keratoacanthoma, and basal cell carcinoma with the most widely available intralesional agents (methotrexate, 5-fluorouracil, bleomycin, and interferon).