Dermatology Weekly

Patients may be relying more on over-the-counter (OTC) skin care products during the current health crisis due to limited access to dermatologists. In this resident takeover, Dr. Daniel Mazori talks to Dr. Sophie Greenberg about selection of OTC topicals to avoid potential adverse effects. “I started looking into regulation and safety data and realized there’s a gap in formal treating on this topic, so I wanted to provide a guide to residents so they can be adequately informed,” Dr. Greenberg explains. They discuss how the Food and Drug Administration categorizes and regulates OTC products as well as resources to learn more about common ingredients in OTC topicals.

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We also bring you the latest in dermatology news and research:

• New rosacea clinical management guidelines focus on symptomology
• Dermatologists saw small income drop before pandemic
• Remdesivir shortens COVID-19 time to recover in published study

Things you will learn in this episode:

• Choosing the wrong OTC products can cause or exacerbate skin conditions, such as allergic contact dermatitis, eczema, and acne, or even result in systemic toxicity.
• The FDA categories for OTC products that are most relevant to dermatology include drugs (both prescription and nonprescription medications), cosmetics, soaps, and dietary supplements. Each category has its own unique set of regulations.
• Drugs include topical steroids, antibiotic ointments, acne treatments, antifungals, and sunscreens. “Most of these products were previously available by prescription only but became available over-the-counter after sufficient postmarketing safety information,” says Dr. Greenberg.
• Regulations for chemical sunscreens currently are in flux in light of data that demonstrate serum levels above the FDA limit for drugs that are exempt from further testing for carcinogenicity.
• The FDA prohibits use of 11 categories of ingredients in all cosmetics but does not require approval, testing, or disclosure of safety data prior to products going to market. “A lot of patients and lay public have expressed concerns over the safety of over-the-counter [cosmetics], especially since regulation varies across the world,” Dr. Greenberg notes.
• It is important to be vigilant and educate patients about imported cosmetics containing ingredients such as clobetasol that can be harmful if used incorrectly. “When we prescribe [products containing these ingredients], we have a chance to counsel patients on how to properly use [them], but the fact that people can purchase them over-the-counter is very scary,” Dr. Greenberg says.
• Soap is categorized independently by its ingredients and its intended purpose to be used as a cleansing agent.
• The FDA evaluates safety and labeling of dietary supplements before marketing but does not directly test these products. “Clinicians can refer patients to third-party agencies that verify ingredients and test for contaminants. ... since there have been reports of supplements not containing the ingredients that they said they contain or containing toxins or potential allergens,” Dr. Greenberg explains.
• The Environmental Working Group’s Healthy Living app allows users to scan a product’s barcode to see all of its ingredients and safety rating.
• Clinicians can scan pharmacy aisles to familiarize themselves with available OTC products and also try products on themselves to better understand and address patient concerns. “You can get samples at conferences or purchase different products each time you restock your own supply,” Dr. Greenberg recommends.

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Hosts: Nick Andrews; Daniel R. Mazori, MD (State University of New York, Brooklyn)

Guests: Sophie A. Greenberg, MD (Columbia University Medical Center, New York)

Disclosures: Dr. Mazori reports no conflicts of interest. Dr. Greenberg reports no conflicts of interest.

Show notes by: Alicia Sonners, Melissa Sears

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You can find more of our podcasts at http://www.mdedge.com/podcasts

Email the show: [email protected]

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How is dermatology handling this change in practice toward telehealth? Guest host Dr. Candrice Heath talks with Dr. George Han about how dermatologists can adapt their clinical practice to conduct quality teledermatology visits with their patients. “Last year ... I think overall in the health system we probably had about 2,000-3,000 telehealth visits ... by the end of March [this year], I think the numbers I saw [were] around 30,000, so it’s absolutely just kind of been a huge change in the way we practice medicine,” Dr. Han explained. They discuss potential use cases for teledermatology during the current health crisis and beyond as well as how to address technological barriers to care.

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We also bring you the latest in dermatology news and research:

1. Novel inflammatory syndrome in children possibly linked to COVID-19

2. Case reports illustrate heterogeneity of skin manifestations in COVID patients

3. COVID-19 Dermatology Registry

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Things you will learn in this episode:

• Despite recent HIPAA relaxations, dermatologists still should be aware of privacy and security issues when conducting telehealth visits with patients.
• Existing resources -- such as noninvasive tests that can be self-administered by patients -- may be useful for concerning lesions that are difficult to diagnose during video visits. “There’s this genomic test for melanoma. ... I hadn’t used it very much before the COVID pandemic because we could biopsy patients in the office. ... But now that the whole paradigm has changed, I’ve actually used it more than I ever did before,” Dr. Han explained.
• Common conditions such as psoriasis, acne, and eczema are relatively easy to triage via telemedicine. “We’re going to have to do a lot more experimentation, certainly, if there’s a lesion that’s scaly and erythematous. ... But I think as long as you’re up front with the patients, they understand it, too,” Dr. Han said.
• In most cases, total-body skin examinations and evaluation of pigmented or potentially cancerous lesions still warrant an in-person visit.
• Biologics often can be started in patients with psoriasis or atopic dermatitis without first seeing them in person. “If it’s a pretty clear case of psoriasis, I would say that your treatment options are not limited by the fact that we’re handling over telemedicine, and I think that’s really nice for our patients. There are a number of treatments out there that you don’t need laboratory screening for, so those are helpful to have on hand,” Dr. Han said.
• For older patients who may not have the necessary technology skills or devices to participate in video consultations, the Centers for Medicare & Medicaid Services recently issued a guidance that telephone visits will now be paid at the level of an established visit (levels 2–4). “The recognition is there that we’re still doing important work for our patients and you don’t necessarily need that video signal to be able to do this, and we certainly don’t want to create any artificial barriers to access to care,” Dr. Han said.
• Prior to COVID-19, telehealth services use was low because patients did not think of it as a legitimate option, but the marketplace will demand these services moving forward now that they are seeing the benefits. “I think it’s important as we go ahead in the next phase ... we use the lessons we’ve learned during this pandemic of just large numbers of people utilizing teledermatology services to help map out what makes sense for our specialty ... as well as technical requirements that we should be asking of our vendors providing these services,” Dr. Han advised.
• Beyond the parameters of the COVID-19 pandemic, teledermatology also provides access to care for patients in parts of the country with limited access to dermatologists, such as in rural areas.
• Dermatologists can use telehealth services for short hands-off visits, such as to counsel patients, check in before titrating doses, or follow-up after a cosmetic procedure. “Those are situations where you actually might improve your show rate by offering telemedicine services,” Dr. Han noted.
• A tip sheet is available online that provides information to help dermatologists adopt telehealth in their practice. It describes what you need, how to select a software platform, and how to monitor workflow.
• Patients should be asked to provide high-quality photographs before the visit via a HIPAA-secured chat or email. “We always recommend that you get a HIPAA-secured email server account if you can if ...

Body lice present an important public health concern due to the potential spread of infectious diseases. Dr. Vincent DeLeo talks with Dr. Dirk Elston about how to identify and manage human body lice infestations.

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We also bring you the latest in dermatology news and research:

1. Skin manifestations are emerging in the coronavirus pandemic 2. NCCN panel: Defer nonurgent skin cancer care during pandemic 3. iPLEDGE allows at-home pregnancy tests during pandemic

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Key takeaways from this episode:

• Human body lice are similar in appearance to head lice but can be differentiated based on the location of the infestation: “Body lice tend to lay their eggs in seams of clothing and on the fibers of hair in clothing rather than on the hairs on the head,” Dr. Elston notes.
• Body lice are transmitted through prolonged person-to-person contact associated with mass crowding, refugees, poverty, and homelessness.
• Patients with body lice typically present with generalized pruritus, maculated ceruleae, and hemosiderin deposits in the skin where the lice have fed, as well as lice and nits in the clothing.
• Body lice can be treated entirely with treatment of the clothing. “Pharmacologic intervention in the case of body lice is more for disease that the body louse may have spread,” Dr. Elston explains.
• Clinical signs and symptoms of body lice infestation include sepsis or more serious infection, typhus, eschar associated with other rickettsial-type diseases, endocarditis, cat scratch fever, acral splinter hemorrhages, and Osler-type nodes. “Most of these patients won’t present to us in clinic but more likely to [the] emergency department,” says Dr. Elston.
• Unlike body lice, head lice can be treated by shaving the head or other topical treatments. Combing through the hair has shown low efficacy rates. “Head lice are widespread. They know no economic or social boundaries. ... Fortunately, they are not known to be significant vectors of disease, but they are certainly a nuisance and something that carries a significant social stigma,” advises Dr. Elston.
• Transmission of lice is highly preventable. “[The] simple separation of clothing is the greatest intervention that we can do to prevent spread among schoolchildren, and it’s really a very simple and common-sense thing to do,” Dr. Elston says.
• If a patient has very coarse curly hair, pubic lice are more likely to infest the scalp than head lice. Pubic lice also are common in body hair, particularly in males, and are not just restricted to the pubic region.

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Hosts: Nick Andrews, Vincent A. DeLeo, MD (Keck School of Medicine of the University of Southern California, Los Angeles)

Guest: Dirk M. Elston, MD (Medical University of South Carolina, Charleston)

Disclosures: Dr. DeLeo is a consultant for Estée Lauder. Dr. Elston reports no conflicts of interest.

Show notes by: Alicia Sonners, Melissa Sears

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You can find more of our podcasts at http://www.mdedge.com/podcasts

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Failure to recognize rosacea in the skin of color population presents an important gap in dermatology practice. Beginning at 10:06, Dr. Vincent DeLeo talks with Dr. Susan Taylor about how dermatologists can improve diagnosis and treatment of rosacea in this patient population. “I think that rosacea is underrecognized because it’s often confused for other disorders that occur commonly in skin of color populations,” Dr. Taylor explains. She highlights various clinical clues distinguishing rosacea from mimickers such as connective tissue diseases, seborrheic dermatitis, cutaneous sarcoidosis, and acne vulgaris.

We also bring you the latest in dermatology news and research:

1. No increased risk of psychiatric problems tied to isotretinoin

Arash Mostaghimi, MD, of Brigham and Women's Hospital in Boston discusses the study's findings and their implications.

2. FDA warning letters fall on Trump’s watch

The Food and Drug Administration sent out one-third fewer warning letters to marketers of problematic drugs, devices, or food during the Trump administration's first 28 months.

Things you will learn in this episode:

• Overall, rosacea does not occur as commonly in skin of color patients as in white patients in the United States, but all types of rosacea can be observed in skin of color.
• The erythematotelangiectatic and papulopustular subtypes are most common in skin of color populations, with granulomatous rosacea occurring more frequently in black patients.
• Rosacea is underrecognized and underdiagnosed in skin of color patients because physicians often don’t appreciate that rosacea can and does occur in these populations. It also can be difficult to identify the erythema that is characteristic of rosacea in skin of color.
• Skin of color patients with rosacea often don’t present to dermatology for treatment because they have no awareness of the disease.
• Connective tissue diseases such as systemic lupus erythematosus and dermatomyositis can mimic rosacea in patients with skin of color.
• Seborrheic dermatitis and rosacea have similar clinical features and can occur concurrently in the same patient.
• Biopsy is needed to accurately distinguish between granulomatous rosacea and cutaneous sarcoidosis, as it can be a challenge to make the diagnosis clinically.
• Comedones, nodules, cysts, and postinflammatory hyperpigmentation are suggestive of acne vulgaris, as these findings are not observed in rosacea.
• Most of the same medications used in white patients with rosacea can be used for skin of color patients.
• The most important factor to keep in mind when treating rosacea in skin of color patients is that irritation from topical agents can lead to postinflammatory hyperpigmentation. “I don’t think you can go wrong being cautious and approaching therapy slowly in this patient population,” notes Dr. Taylor.
• Daily sunscreen use is important in all skin of color patients, particularly those with rosacea who may have facial skin that is more subject to burning or stinging or those who are photosensitive because of treatment with topical agents.
• Ultimately, dermatologists should rely on information garnered from patients when rosacea is suspected in skin of color. “I think the key here is you must think about rosacea when you see a skin of color patient who comes to you and complains of burning, tingling, stinging of the facial skin; sensitivity to products; redness of the skin; papules; and pustules. There are times when as clinicians you may not be able to appreciate the erythema, but rest assured that your patient can tell you if his or her facial skin is red.”

Hosts: Elizabeth Mechcatie; Terry Rudd; Vincent A. DeLeo, MD (Keck School of Medicine of the University of Southern California, Los Angeles)

Guest: Susan C. Taylor, MD (Perelman School of Medicine, University of Pennsylvania, Philadelphia)

References:

• Establishing the Diagnosis of Rosacea in Skin of Color Patients
• Article PDF

Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie.

You can find more of our podcasts at www.mdedge.com/podcasts

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