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INTRODUCTION: The environmental impact of holding in-person academic conferences and continuing medical education (CME) programs can be significant. In-person conferences provide a unique social and professional platform to engage in networking and foster professional development; however, there is an opportunity for hybrid and virtual platforms to provide CME for broader audiences looking to improve their clinical skills and strengthen their knowledge base. This study seeks to describe the reduction in carbon emissions associated with a webinar hosted by an online dermatology-focused medical education platform. METHODS: This cross-sectional study used the location of deidentified virtual attendees of a webinar to predict the carbon emissions produced if attendees had instead traveled to the location of the most recent Integrative Dermatology Symposium (Sacramento, CA). Following collection of each virtual attendees location, the mode of transportation was predicted on the basis of each participants distance to the conference. RESULTS: The estimated carbon emissions were calculated for 576 participants. The total estimated, unadjusted carbon emissions for both attendees predicted to fly or drive was 370,100 kg CO2. The emissions produced per participant from those expected to fly to an in-person CME after adjusting for all additional passengers on every flight were 4.5 kg CO2. The emissions produced per participant from those expected to drive were 42.7 kg CO2. CONCLUSION: The use of a virtual CME webinar led to a significant reduction in travel-related carbon dioxide emissions when compared to running the same program in-person event. When accounting for all passengers traveling via plane on any flight, driving to an event produced more emissions per participant than flying.

Climate change poses an increasing threat to human health, with well-documented impacts on dermatologic conditions. However, the U.S. healthcare sector is paradoxically a significant contributor to climate change-worsening greenhouse gas emissions. To address this negative externality, calls to action to decarbonize healthcare delivery have spurred research and initiatives around improving the environmental sustainability of medicine. Published sustainability recommendations for dermatologic practices have addressed themes such as renewable energy, single-use disposable materials, regulated medical waste, and clinician advocacy. Our current commentary provides an analysis of the potential of existing recommendations and outlines additional, novel, and actionable interventions. We highlight recently released decarbonization resources and regulatory changes. We emphasize the importance of reassessing procedure kits, minimizing medication waste, and implementing green procurement policies. We also address nuances in promoting environmentally-conscious transit, maximizing the efficient use of technology, supporting alternatives to single-use items, leveraging resources for patient education, assessing appropriate use of carbon credits, and bolstering community climate resilience.

Introduction Sarcoidosis remains a debilitating, and sometimes fatal, multiorgan inflammatory granulomatous disease that predominately affects the lung and skin. Patients struggle with fatigue, difficulty breathing, and pain in their joints, [...], Sarcoidosis is a multiorgan granulomatous disease that lacks diagnostic biomarkers and targeted treatments. Using blood and skin from patients with sarcoid and non-sarcoid skin granulomas, we discovered that skin granulomas from different diseases exhibit unique immune cell recruitment and molecular signatures. Sarcoid skin granulomas were specifically enriched for type 1 innate lymphoid cells (ILC1s) and B cells and exhibited molecular programs associated with formation of mature tertiary lymphoid structures (TLSs), including increased CXCL12/CXCR4 signaling. Lung sarcoidosis granulomas also displayed similar immune cell recruitment. Thus, granuloma formation was not a generic molecular response. In addition to tissue-specific effects, patients with sarcoidosis exhibited an 8-fold increase in circulating ILC1s, which correlated with treatment status. Multiple immune cell types induced CXCL12/CXCR4 signaling in sarcoidosis, including Th1 T cells, macrophages, and ILCs. Mechanistically, CXCR4 inhibition reduced sarcoidosis-activated immune cell migration, and targeting CXCR4 or total ILCs attenuated granuloma formation in a noninfectious mouse model. Taken together, our results show that ILC1s are a tissue and circulating biomarker that distinguishes sarcoidosis from other skin granulomatous diseases. Repurposing existing CXCR4 inhibitors may offer a new targeted treatment for this devastating disease.

Combined internal medicine and dermatology (med-derm) training programs were created to advance complex medical dermatology and inpatient dermatology care. A prior study demonstrated that compared to categorical dermatology residents, med-derm residents had less program satisfaction, yet indicated a stronger desire to pursue careers in academia. No follow-up data on practice patterns after training has been reported. We aimed to characterize differences in residency program satisfaction and practice patterns between physicians trained in categorical dermatology compared to med-derm residency programs. We surveyed physicians who graduated from combined med-derm programs along with their counterparts, from six institutions, that either currently or historically had a combined med-derm training, from 2008-2017. Fifty-five percent of med-derm and forty-one percent of categorical-trained physicians responded. The practice patterns between the two groups were similar. A quarter of med-derm physicians continued to provide general internal medicine services. Categorical trained physicians were significantly more satisfied with their training (P=0.03) and performed more excisions on the head/neck (P=0.02). The combined graduates had significantly greater confidence in multidisciplinary care (P=0.003), prescribed more biologic (P

We describe a patient with leukemia undergoing chemotherapy who developed painful purpuric nodules of the digits. These findings were concerning for endocarditis (clinically) and angiokeratomas on gross histology. After extensive evaluation, we report the development of painful purpuric nodules as a likely side effect of the patient's therapeutic regimen (hydroxyurea, danorubicin, cytarabine, and methotrexate).

As wearable devices play an increasing role in the management of health and disease, adverse skin reactions to wearables have become more common. However, the management of allergic contact dermatitis is challenging and new treatment options more compatible with wearable devices are needed. In a 40-year-old woman with contact dermatitis to a continuous glucose monitoring device, topical clobetasol propionate 0.05% spray proved to be an effective treatment that was compatible with the application of adhesive wearables. This case demonstrates that spray formulations of topical steroids are a good option for the treatment of dermatitis under wearable devices such as continuous glucose monitors or ostomy appliance.

Background: Lengthy wait times for dermatology appointments in the U.S. limit care access. The University of Pennsylvania's Department of Dermatology has established an urgent care clinic (UCC) and an intermediate care clinic (ICC) to expedite appointments for higher acuity patients.Objective: To describe our rapid access clinics' operations, referral patterns, and distributions of diagnoses. Methods: We performed a retrospective review of dermatology consult order and appointment data for UCC, ICC, and routine care to determine the number of orders, consult appointments, and follow-up appointments; appointment wait times; and frequencies of diagnoses in referring provider and consult appointments. Press Ganey patient satisfaction ratings were also analyzed.Results: The median (interquartile range) wait times for UCC, ICC, and routine care, appointments were 3 (1-8) days, 36 (15-64) days, and 45 (12-97) days, respectively (P

Introduction Individuals with Sweet syndrome (acute febrile neutrophilic dermatosis) present with fever, leukocytosis, and an eruption of erythematous plaques with a dense dermal neutrophilic infiltrate on histology (1, 2). Systemic [...], BACKGROUND. Acute febrile neutrophilic dermatosis (Sweet syndrome) is a potentially fatal multiorgan inflammatory disease characterized by fever, leukocytosis, and a rash with a neutrophilic infiltrate. The disease pathophysiology remains elusive, and current dogma suggests that Sweet syndrome is a process of reactivity to an unknown antigen. Corticosteroids and steroid-sparing agents remain frontline therapies, but refractory cases pose a clinical challenge. METHODS. A 51-year-old woman with multiorgan Sweet syndrome developed serious corticosteroid-related side effects and was refractory to steroid-sparing agents. Blood counts, liver enzymes, and skin histopathology supported the diagnosis. Whole-genome sequencing, transcriptomic profiling, and cellular assays of the patient's skin and neutrophils were performed. RESULTS. We identified elevated IL-1 signaling in lesional Sweet syndrome skin caused by a PIK3R1 gain-of-function mutation specifically found in neutrophils. This mutation increased neutrophil migration toward IL-1[beta] and neutrophil respiratory burst. Targeted treatment of the patient with an IL-1 receptor 1 antagonist resulted in a dramatic therapeutic response and enabled a tapering off of corticosteroids. CONCLUSION. Dysregulated PI3K/AKT signaling is the first signaling pathway linked to Sweet syndrome and suggests that this syndrome may be caused by acquired mutations that modulate neutrophil function. Moreover, integration of molecular data across multiple levels identified a distinct subtype within a heterogeneous disease that resulted in a rational and successful clinical intervention. Future patients will benefit from efforts to identify potential mutations. The ability to directly interrogate the diseased skin allows this method to be generalizable to other inflammatory diseases and demonstrates a potential personalized medicine approach for patients with clinically challenging disease. FUNDING SOURCES. Berstein Foundation, NIH, Veterans Affairs (VA) Administration, Moseley Foundation, and H.T. Leung Foundation.

Sarcoidosis and Crohn disease (CD) are granulomatous disorders of unknown etiology that are rarely seen together in one patient. We describe a woman in her 40s with well-established diagnoses of pulmonary and cutaneous sarcoidosis and CD involving the terminal ileum, whose skin and gastrointestinal symptoms improved dramatically with infliximab treatment (5mg/kg on weeks 0, 2, 6, then every 8 weeks). The concurrence of sarcoidosis and CD has only been reported in a handful of cases and a review of the literature reveals that the two diseases share many clinical and immunological features, suggesting the presence of an underlying connection. Further studies of patients with overlap syndromes may provide deeper insight into the clinical spectrum, and possibly the pathogenesis, of idiopathic granulomatous diseases.

Importance: In response to a perceived erosion of medical dermatology, combined internal medicine and dermatology programs (med/derm) programs have been developed that aim to train dermatologists who take care of medically complex patients. Despite the investment in these programs, there is currently no data with regards to the potential impact of these trainees on the dermatology workforce.Objective: To determine the experiences, motivations, and future plans of residents in combined med/derm residency programs.Design, Setting, and Participants: We surveyed residents at all United States institutions with both categorical and combined training programs in spring of 2012. Respondents used visual analog scales to rate clinical interests, self-assessed competency, career plans, and challenges.Main Outcomes and Measures: The primary study outcomes were comfort in taking care of patients with complex disease, future practice plans, and experience during residency.Results: Twenty-eight of 31 med/derm residents (87.5%) and 28 of 91 (31%) categorical residents responded (overall response rate 46%). No significant differences were seen in self-assessed dermatology competency, or comfort in performing inpatient consultations, cosmetic procedures, or prescribing systemic agents. A trend toward less comfort in general dermatology was seen among med/derm residents. Med/derm residents were more likely to indicate career preferences for performing inpatient consultation and taking care of medically complex patients. Categorical residents rated their programs and experiences more highly.Conclusions and Relevance: Med/derm residents have stronger interests in serving medically complex patients. Categorical residents are more likely to have a positive experience during residency. Future work will be needed to ascertain career choices among graduates once data are available.