Article

What are the American Academy of Dermatology’s (AAD’s) top advocacy priorities related to Medicare physician reimbursement?

Dr. Taylor: Medicare physician payment has failed to keep up with inflation, threatening the viability of medical practices. The AAD urges Congress to stabilize the Medicare payment system to ensure continued patient access to essential health care by cosponsoring the Medicare Patient Access and Practice Stabilization Act of 2025, which reverses the 2.83% cut and provides a positive inflationary adjustment for physician practices for 2025. In July 2025, Congress passed the One Big Beautiful Bill Act, which provides for a 1-year 2.5% increase to Medicare physician payment in 2026 to account for sustained cuts as Congress continues to work toward long-term payment reform. This short-term remedy is only applicable to 2026—a fix for 2025 as well as long-term reform still are needed. The AAD recently formed an ad-hoc task force on sustaining physician practices for senior citizen care that will continue to press for solutions to the Medicare payment crisis.

What is the AAD’s stance on transitioning from traditional fee-for-service to value-based care models in dermatology under Medicare?

Dr. Taylor: Current value-based programs are extremely burdensome, have not demonstrated improved patient care, and are not clinically relevant to physicians or patients. The AAD has serious concerns about the viability and effectiveness of the Quality Payment Program (QPP), especially the Merit-Based Incentive Payment System (MIPS). Numerous studies have highlighted persistent challenges associated with MIPS, including practices serving high-risk patients and those that are small or in rural areas. For instance, researchers examined whether MIPS disproportionately penalized surgeons who care for these patients and found a connection between caring for these patients, lower MIPS scores, and a higher likelihood of facing negative payment adjustments.

Additionally, the US Government Accountability Office was tasked with reviewing several aspects concerning small and rural practices in relation to Medicare payment incentive programs, including MIPS. Findings indicated that physician practices with 15 or fewer providers, whether located in rural or nonrural areas, had a higher likelihood of receiving negative payment adjustments in Medicare incentive programs compared to larger practices. To maximize participation and facilitate the best possible outcomes for dermatologists within the MIPS program, the AAD maintains that we must continue to develop and advocate that the Centers for Medicare and Medicaid Services approve dermatology-specific measures for MIPS reporting.

Does the AAD have plans to develop or expand dermatology-specific quality measures that are more clinically relevant and less administratively taxing?

Dr. Taylor: The AAD is committed to ensuring that dermatologists can be successful in the QPP and its MIPS Value Pathways and Advanced Alternative Payment Model programs. These payment pathways for QPP-eligible participants allow physicians to increase their future Medicare reimbursements but also penalize those who do not meet performance objectives. The AAD is constantly reviewing and proposing new dermatology-specific quality measures to the Centers for Medicare and Medicaid Services based on member feedback to reduce administrative burdens of MIPS reporting. All of our quality measures are developed by dermatologists for dermatologists.

How is the AAD supporting practices dealing with insurer-mandated switch policies that disrupt continuity of care and increase documentation burden?

Dr. Taylor: The AAD works with private payers to alleviate administrative burdens for dermatologists, maintain appropriate reimbursement for services provided, and ensure patients can access covered quality care by building and maintaining relationships with public and private payers. This critical collaboration addresses immediate needs affecting our members’ ability to deliver care, such as when policy changes affect claims and formulary coverage or payment. Our coordinated strategy ensures payer policies align with everyday practice for dermatologists so they can focus on treating patients. The AAD has resources and tools to guide dermatology practices in appropriate documentation and coding.

What initiatives is the AAD pursuing to specifically support independent or small dermatology practices in coping with administrative overload?

Dr. Taylor: The AAD is continuously advocating for our small and independent dermatology practices. In every comment letter we submit on proposed medical practice reporting regulation, we demand small practice exemptions. Moreover, the AAD has resources and practical tools for all types of practices to cope with administrative burdens, including MIPS reporting requirements. These resources and tools were created by dermatologists for dermatologists to take the guesswork out of administrative compliance. DataDerm is the AAD’s clinical data registry used for MIPS reporting. Since its launch in 2016, DataDerm has become dermatology’s largest clinical data registry, capturing information on more than 16 million unique patients and 69 million encounters. It supports the advancement of skin disease diagnosis and treatment, informs clinical practice, streamlines MIPS reporting, and drives clinically relevant research using real-world data.

What are the biggest contributors to physician burnout right now? What resources does AAD offer to support dermatologists in managing burnout?

Dr. Taylor: The biggest contributors to burnout that dermatologists are facing are demanding workloads, administrative burdens, and loss of autonomy. Dermatologists welcome medical challenges, but they face growing administrative and regulatory burdens that take time away from patient care and contribute to burnout. Taking a wellness-centered approach can help, which is why the AAD includes both practical tools to reduce burdens and strategies to sustain your practice in its online resources. The burnout and wellness section of the AAD website can help with administrative burdens, building a supportive work culture, recognizing drivers of burnout, reconnecting with your purpose, and more.

How is the AAD working to ensure that the expanding scope of practice does not compromise patient safety, particularly when it comes to diagnosis and treatment of complex skin cancers or prescribing systemic medications?

Dr. Taylor: The AAD advocates to ensure that each member of the care team is practicing at a level consistent with their training and education and opposes scope-of-practice expansions for physician assistants, nurse practitioners, and other nonphysician clinicians that threaten patient safety by allowing them to practice independently and advertise as skin experts. Each state has its own scope-of-practice laws governing what nonphysicians can do, whether supervision is required, and how they can represent their training, both in advertising and in a medical practice. The AAD supports appropriate safeguards to ensure patient safety and a focus on the highest-quality appropriate care as the nonphysician workforce expands. The AAD encourages patients to report adverse outcomes to the appropriate state licensing boards.

Is the AAD developing or recommending best practices for dermatologists who supervise NPs or PAs, especially in large practices or retail clinics where oversight can be inconsistent?

Dr. Taylor: The AAD firmly believes that the optimal quality of medical care is delivered when a qualified and licensed physician provides direct on-site supervision to all qualified nonphysician personnel. A medical director of a medical spa facility should be a physician licensed in the state where the facility is located and also should be clearly identified by state licensure and any state-recognized board certification as well as by medical specialty, training, and education. The individual also should be identified as the medical director in all marketing materials and on websites and social media accounts related to the medical spa facility. The AAD would like to see policies that would provide increased transparency in state licensure and specialty board certification including requiring disclosure that a physician is certified or eligible for certification by a private or public board, parent association, or multidisciplinary board or association; requiring disclosure of the certifying board or association with one’s field of study or specialty; requiring display of visible identification—including one’s state licensure, professional degree, field of study, and the use of clarifying titles—in facilities, in marketing materials, and on websites and social media; and requiring all personnel in private medical practices, hospitals, clinics, or other settings employing physicians and/or other personnel that offer medical, surgical, or aesthetic procedures to wear a photo identification name tag during all patient encounters.

What are the American Academy of Dermatology’s (AAD’s) top advocacy priorities related to Medicare physician reimbursement?

Dr. Taylor: Medicare physician payment has failed to keep up with inflation, threatening the viability of medical practices. The AAD urges Congress to stabilize the Medicare payment system to ensure continued patient access to essential health care by cosponsoring the Medicare Patient Access and Practice Stabilization Act of 2025, which reverses the 2.83% cut and provides a positive inflationary adjustment for physician practices for 2025. In July 2025, Congress passed the One Big Beautiful Bill Act, which provides for a 1-year 2.5% increase to Medicare physician payment in 2026 to account for sustained cuts as Congress continues to work toward long-term payment reform. This short-term remedy is only applicable to 2026—a fix for 2025 as well as long-term reform still are needed. The AAD recently formed an ad-hoc task force on sustaining physician practices for senior citizen care that will continue to press for solutions to the Medicare payment crisis.

What is the AAD’s stance on transitioning from traditional fee-for-service to value-based care models in dermatology under Medicare?

Dr. Taylor: Current value-based programs are extremely burdensome, have not demonstrated improved patient care, and are not clinically relevant to physicians or patients. The AAD has serious concerns about the viability and effectiveness of the Quality Payment Program (QPP), especially the Merit-Based Incentive Payment System (MIPS). Numerous studies have highlighted persistent challenges associated with MIPS, including practices serving high-risk patients and those that are small or in rural areas. For instance, researchers examined whether MIPS disproportionately penalized surgeons who care for these patients and found a connection between caring for these patients, lower MIPS scores, and a higher likelihood of facing negative payment adjustments.

Additionally, the US Government Accountability Office was tasked with reviewing several aspects concerning small and rural practices in relation to Medicare payment incentive programs, including MIPS. Findings indicated that physician practices with 15 or fewer providers, whether located in rural or nonrural areas, had a higher likelihood of receiving negative payment adjustments in Medicare incentive programs compared to larger practices. To maximize participation and facilitate the best possible outcomes for dermatologists within the MIPS program, the AAD maintains that we must continue to develop and advocate that the Centers for Medicare and Medicaid Services approve dermatology-specific measures for MIPS reporting.

Does the AAD have plans to develop or expand dermatology-specific quality measures that are more clinically relevant and less administratively taxing?

Dr. Taylor: The AAD is committed to ensuring that dermatologists can be successful in the QPP and its MIPS Value Pathways and Advanced Alternative Payment Model programs. These payment pathways for QPP-eligible participants allow physicians to increase their future Medicare reimbursements but also penalize those who do not meet performance objectives. The AAD is constantly reviewing and proposing new dermatology-specific quality measures to the Centers for Medicare and Medicaid Services based on member feedback to reduce administrative burdens of MIPS reporting. All of our quality measures are developed by dermatologists for dermatologists.

How is the AAD supporting practices dealing with insurer-mandated switch policies that disrupt continuity of care and increase documentation burden?

Dr. Taylor: The AAD works with private payers to alleviate administrative burdens for dermatologists, maintain appropriate reimbursement for services provided, and ensure patients can access covered quality care by building and maintaining relationships with public and private payers. This critical collaboration addresses immediate needs affecting our members’ ability to deliver care, such as when policy changes affect claims and formulary coverage or payment. Our coordinated strategy ensures payer policies align with everyday practice for dermatologists so they can focus on treating patients. The AAD has resources and tools to guide dermatology practices in appropriate documentation and coding.

What initiatives is the AAD pursuing to specifically support independent or small dermatology practices in coping with administrative overload?

Dr. Taylor: The AAD is continuously advocating for our small and independent dermatology practices. In every comment letter we submit on proposed medical practice reporting regulation, we demand small practice exemptions. Moreover, the AAD has resources and practical tools for all types of practices to cope with administrative burdens, including MIPS reporting requirements. These resources and tools were created by dermatologists for dermatologists to take the guesswork out of administrative compliance. DataDerm is the AAD’s clinical data registry used for MIPS reporting. Since its launch in 2016, DataDerm has become dermatology’s largest clinical data registry, capturing information on more than 16 million unique patients and 69 million encounters. It supports the advancement of skin disease diagnosis and treatment, informs clinical practice, streamlines MIPS reporting, and drives clinically relevant research using real-world data.

What are the biggest contributors to physician burnout right now? What resources does AAD offer to support dermatologists in managing burnout?

Dr. Taylor: The biggest contributors to burnout that dermatologists are facing are demanding workloads, administrative burdens, and loss of autonomy. Dermatologists welcome medical challenges, but they face growing administrative and regulatory burdens that take time away from patient care and contribute to burnout. Taking a wellness-centered approach can help, which is why the AAD includes both practical tools to reduce burdens and strategies to sustain your practice in its online resources. The burnout and wellness section of the AAD website can help with administrative burdens, building a supportive work culture, recognizing drivers of burnout, reconnecting with your purpose, and more.

How is the AAD working to ensure that the expanding scope of practice does not compromise patient safety, particularly when it comes to diagnosis and treatment of complex skin cancers or prescribing systemic medications?

Dr. Taylor: The AAD advocates to ensure that each member of the care team is practicing at a level consistent with their training and education and opposes scope-of-practice expansions for physician assistants, nurse practitioners, and other nonphysician clinicians that threaten patient safety by allowing them to practice independently and advertise as skin experts. Each state has its own scope-of-practice laws governing what nonphysicians can do, whether supervision is required, and how they can represent their training, both in advertising and in a medical practice. The AAD supports appropriate safeguards to ensure patient safety and a focus on the highest-quality appropriate care as the nonphysician workforce expands. The AAD encourages patients to report adverse outcomes to the appropriate state licensing boards.

Is the AAD developing or recommending best practices for dermatologists who supervise NPs or PAs, especially in large practices or retail clinics where oversight can be inconsistent?

Dr. Taylor: The AAD firmly believes that the optimal quality of medical care is delivered when a qualified and licensed physician provides direct on-site supervision to all qualified nonphysician personnel. A medical director of a medical spa facility should be a physician licensed in the state where the facility is located and also should be clearly identified by state licensure and any state-recognized board certification as well as by medical specialty, training, and education. The individual also should be identified as the medical director in all marketing materials and on websites and social media accounts related to the medical spa facility. The AAD would like to see policies that would provide increased transparency in state licensure and specialty board certification including requiring disclosure that a physician is certified or eligible for certification by a private or public board, parent association, or multidisciplinary board or association; requiring disclosure of the certifying board or association with one’s field of study or specialty; requiring display of visible identification—including one’s state licensure, professional degree, field of study, and the use of clarifying titles—in facilities, in marketing materials, and on websites and social media; and requiring all personnel in private medical practices, hospitals, clinics, or other settings employing physicians and/or other personnel that offer medical, surgical, or aesthetic procedures to wear a photo identification name tag during all patient encounters.

What are the American Academy of Dermatology’s (AAD’s) top advocacy priorities related to Medicare physician reimbursement?

Dr. Taylor: Medicare physician payment has failed to keep up with inflation, threatening the viability of medical practices. The AAD urges Congress to stabilize the Medicare payment system to ensure continued patient access to essential health care by cosponsoring the Medicare Patient Access and Practice Stabilization Act of 2025, which reverses the 2.83% cut and provides a positive inflationary adjustment for physician practices for 2025. In July 2025, Congress passed the One Big Beautiful Bill Act, which provides for a 1-year 2.5% increase to Medicare physician payment in 2026 to account for sustained cuts as Congress continues to work toward long-term payment reform. This short-term remedy is only applicable to 2026—a fix for 2025 as well as long-term reform still are needed. The AAD recently formed an ad-hoc task force on sustaining physician practices for senior citizen care that will continue to press for solutions to the Medicare payment crisis.

What is the AAD’s stance on transitioning from traditional fee-for-service to value-based care models in dermatology under Medicare?

Dr. Taylor: Current value-based programs are extremely burdensome, have not demonstrated improved patient care, and are not clinically relevant to physicians or patients. The AAD has serious concerns about the viability and effectiveness of the Quality Payment Program (QPP), especially the Merit-Based Incentive Payment System (MIPS). Numerous studies have highlighted persistent challenges associated with MIPS, including practices serving high-risk patients and those that are small or in rural areas. For instance, researchers examined whether MIPS disproportionately penalized surgeons who care for these patients and found a connection between caring for these patients, lower MIPS scores, and a higher likelihood of facing negative payment adjustments.

Additionally, the US Government Accountability Office was tasked with reviewing several aspects concerning small and rural practices in relation to Medicare payment incentive programs, including MIPS. Findings indicated that physician practices with 15 or fewer providers, whether located in rural or nonrural areas, had a higher likelihood of receiving negative payment adjustments in Medicare incentive programs compared to larger practices. To maximize participation and facilitate the best possible outcomes for dermatologists within the MIPS program, the AAD maintains that we must continue to develop and advocate that the Centers for Medicare and Medicaid Services approve dermatology-specific measures for MIPS reporting.

Does the AAD have plans to develop or expand dermatology-specific quality measures that are more clinically relevant and less administratively taxing?

Dr. Taylor: The AAD is committed to ensuring that dermatologists can be successful in the QPP and its MIPS Value Pathways and Advanced Alternative Payment Model programs. These payment pathways for QPP-eligible participants allow physicians to increase their future Medicare reimbursements but also penalize those who do not meet performance objectives. The AAD is constantly reviewing and proposing new dermatology-specific quality measures to the Centers for Medicare and Medicaid Services based on member feedback to reduce administrative burdens of MIPS reporting. All of our quality measures are developed by dermatologists for dermatologists.

How is the AAD supporting practices dealing with insurer-mandated switch policies that disrupt continuity of care and increase documentation burden?

Dr. Taylor: The AAD works with private payers to alleviate administrative burdens for dermatologists, maintain appropriate reimbursement for services provided, and ensure patients can access covered quality care by building and maintaining relationships with public and private payers. This critical collaboration addresses immediate needs affecting our members’ ability to deliver care, such as when policy changes affect claims and formulary coverage or payment. Our coordinated strategy ensures payer policies align with everyday practice for dermatologists so they can focus on treating patients. The AAD has resources and tools to guide dermatology practices in appropriate documentation and coding.

What initiatives is the AAD pursuing to specifically support independent or small dermatology practices in coping with administrative overload?

Dr. Taylor: The AAD is continuously advocating for our small and independent dermatology practices. In every comment letter we submit on proposed medical practice reporting regulation, we demand small practice exemptions. Moreover, the AAD has resources and practical tools for all types of practices to cope with administrative burdens, including MIPS reporting requirements. These resources and tools were created by dermatologists for dermatologists to take the guesswork out of administrative compliance. DataDerm is the AAD’s clinical data registry used for MIPS reporting. Since its launch in 2016, DataDerm has become dermatology’s largest clinical data registry, capturing information on more than 16 million unique patients and 69 million encounters. It supports the advancement of skin disease diagnosis and treatment, informs clinical practice, streamlines MIPS reporting, and drives clinically relevant research using real-world data.

What are the biggest contributors to physician burnout right now? What resources does AAD offer to support dermatologists in managing burnout?

Dr. Taylor: The biggest contributors to burnout that dermatologists are facing are demanding workloads, administrative burdens, and loss of autonomy. Dermatologists welcome medical challenges, but they face growing administrative and regulatory burdens that take time away from patient care and contribute to burnout. Taking a wellness-centered approach can help, which is why the AAD includes both practical tools to reduce burdens and strategies to sustain your practice in its online resources. The burnout and wellness section of the AAD website can help with administrative burdens, building a supportive work culture, recognizing drivers of burnout, reconnecting with your purpose, and more.

How is the AAD working to ensure that the expanding scope of practice does not compromise patient safety, particularly when it comes to diagnosis and treatment of complex skin cancers or prescribing systemic medications?

Dr. Taylor: The AAD advocates to ensure that each member of the care team is practicing at a level consistent with their training and education and opposes scope-of-practice expansions for physician assistants, nurse practitioners, and other nonphysician clinicians that threaten patient safety by allowing them to practice independently and advertise as skin experts. Each state has its own scope-of-practice laws governing what nonphysicians can do, whether supervision is required, and how they can represent their training, both in advertising and in a medical practice. The AAD supports appropriate safeguards to ensure patient safety and a focus on the highest-quality appropriate care as the nonphysician workforce expands. The AAD encourages patients to report adverse outcomes to the appropriate state licensing boards.

Is the AAD developing or recommending best practices for dermatologists who supervise NPs or PAs, especially in large practices or retail clinics where oversight can be inconsistent?

Dr. Taylor: The AAD firmly believes that the optimal quality of medical care is delivered when a qualified and licensed physician provides direct on-site supervision to all qualified nonphysician personnel. A medical director of a medical spa facility should be a physician licensed in the state where the facility is located and also should be clearly identified by state licensure and any state-recognized board certification as well as by medical specialty, training, and education. The individual also should be identified as the medical director in all marketing materials and on websites and social media accounts related to the medical spa facility. The AAD would like to see policies that would provide increased transparency in state licensure and specialty board certification including requiring disclosure that a physician is certified or eligible for certification by a private or public board, parent association, or multidisciplinary board or association; requiring disclosure of the certifying board or association with one’s field of study or specialty; requiring display of visible identification—including one’s state licensure, professional degree, field of study, and the use of clarifying titles—in facilities, in marketing materials, and on websites and social media; and requiring all personnel in private medical practices, hospitals, clinics, or other settings employing physicians and/or other personnel that offer medical, surgical, or aesthetic procedures to wear a photo identification name tag during all patient encounters.

Topical application or injection of cosmeceuticals in conjunction with procedures such as facial microneedling (MN) has been associated with local and systemic complications.¹  Microneedling is an increasingly popular minimally invasive therapeutic procedure that is used for a wide range of dermatologic purposes, including facial rejuvenation.² Other indications for MN include minimizing the appearance of acne scars, surgical scars, stretch marks, wrinkles, and other cosmetic skin concerns. This procedure can be performed both at home and in a clinical setting, but at-home devices differ from procedures performed in a dermatology office. Clinicians use medical-grade devices for deeper penetration of the skin, yielding more effective results. In contrast, at-home MN devices are designed to be safer and less powerful with milder outcomes.

Although at-home options may be more accessible and affordable for patients, they also increase the risk for improper use and subsequent infection. Additionally, the use of cosmeceuticals such as vitamin E oil in conjunction with MN to enhance the effects of the procedure can lead to further complications. We report the case of a 44-year-old woman who developed a necrotic ulcer on the chin following self-treatment with vitamin E oil and an at-home MN device. While MN has been reported to be relatively safe when performed by board-certified dermatologists, clinicians should be vigilant in correlating clinical history and recent cosmetic procedures with the histologic findings for timely diagnosis and treatment of unusual lesions on the face.

Case Report

A 44-year-old woman presented to the emergency department with a progressively enlarging, necrotic, ulcerative lesion on the midline chin of 4 months’ duration. The patient reported that the lesion started as redness that developed into a painful oozing ulcer following application of vitamin E oil in conjunction with an at-home MN device (Figure 1). She purchased the vitamin E oil and MN device online and performed the procedure herself, applying the vitamin E oil to her whole face before, during, and after using the MN device, which contained 0.25-mm titanium needles. She denied undergoing any other recent cosmetic procedures.

The lesion initially was treated by the patient’s primary care physician with oral doxycycline for 6 weeks, followed by oral cephalexin and clindamycin for 2 weeks. Although the redness stabilized, the lesion continued to enlarge, which prompted her initial visit to our hospital 1 month after seeing her primary care physician. During this visit, the patient was given penicillin, and the ulcer was debrided and biopsied; however, no clinical improvement was seen. 

A biopsy during her initial emergency department visit and a repeat biopsy after 1 month showed similar findings of diffuse lymphohistiocytic and eosinophilic inflammation in the dermis (Figure 2) with poorly defined granulomas and multinucleated giant cells containing nonpolarizable exogenous material (Figure 3). Similar detached exogenous materials also were identified adjacent to the tissue. Diffuse re-epithelialization was seen, featuring pseudoepitheliomatous hyperplasia in association with the inflammatory process and granulation tissue (Figures 3 and 4). A higher-power view of the dermis showed foci of sclerosing lipogranuloma (Figure 4). Periodic acid–Schiff, Grocott methenamine silver, acid-fast bacilli, Fite, and Wright-Giemsa stains all were negative for microorganisms, and pancytokeratin staining was negative for carcinoma. These findings supported the diagnosis of a foreign body granulomatous reaction to an exogenous material—in this case, the vitamin E oil. Subsequent treatment with intralesional triamcinolone 10 mg/mL injection over 18 months resulted in progressive and drastic improvement of the lesion (Figure 5). A scar excision was performed, which further improved the lesion’s cosmetic appearance.

Comment

Application of various topical cosmeceuticals before, during, or after MN to enhance the effects of the procedure can introduce particles into the dermis, resulting in local or systemic hypersensitivity reactions. The associated adverse events can be divided into 2 main categories: adverse reactions related to the topical product or to the materials of the MN device itself.

A study showed that topical application of vitamin E oil to wounds on the skin does not improve the cosmetic appearance of scars.³ Instead, it is associated with a high incidence of contact dermatitis. A similar case of vitamin E injection, although without the concurrent use of an MN device, complicated by a facial lipogranuloma has been described.⁴ Sclerodermoid reaction, subcutaneous nodules, persistent edema, and ulceration at the site of vitamin E injection also have been described following the injection.^5,6 Because vitamin E is a lipid-soluble vitamin, its absorption in the human body is dependent on the presence of lipid or oil-like substances. The reactions mentioned above are associated with the vitamin E oil, which acts as a helper vehicle for lipid-soluble vitamins to be absorbed.⁷ Other ingredients in topical vitamin E oil include a combination of D-alpha-tocopherol, D-alpha-tocopheryl acetate, D-alpha-tocopheryl succinate, or mixed tocopherols.⁸ These ester conjugate forms of vitamin E also may play a role in its immunogenic properties and possibly contribute to adverse effects such as dermatitis and erythema. Further research is needed to investigate the impact of ester conjugate forms on skin reactions and individual responses.⁷

Hyaluronic acid is a relatively safe and commonly used topical treatment that acts as a lubricant during MN procedures to help the needles glide across the skin and prevent dragging. It also can be applied after the procedure for hydration purposes. Other common alternatives include peptides, ceramides, and epidermal growth factors. Topical products to avoid before, during, and 48 hours after undergoing MN include retinoids, vitamin C, vitamin E, exfoliants, serums that contain acids (eg, alpha hydroxy acids, beta hydroxy acids, glycolic acid, and lactic acid), serums that contain fragrance, and oil-based serums because they are associated with similar adverse effects.^8-10 A granulomatous reaction after an MN procedure also has been reported with the use of vitamin C serum.¹¹

The US Food and Drug Administration has approved the use of MN devices, including for at-home use, to improve the appearance of facial acne scars and wrinkles as well as abdominal scars in patients aged 22 years or older; however, MN devices are not approved for delivery of cosmeceuticals or other topical products into the skin. Therefore, there is no universal list of approved topicals to be used in conjunction with MN.¹²

Most MN devices are made of nickel and various other metals. Cases of contact dermatitis and delayed-type hypersensitivity granulomatous reaction with systemic symptoms have been reported after MN procedures due to the material of the MN device.^1,13,14

Conclusion

Microneedling is a minimally invasive procedure that causes nominal damage to the epidermis and superficial papillary dermis, stimulating a wound-healing cascade for collagen production.^15,16 Although not approved by the US Food and Drug Administration, MN performed at dermatology offices sometimes can be used in conjunction with topical products to enhance their absorption; however, while vitamin E is known for its antioxidant properties and potential skin benefits, the lipid substance acting as the vehicle is not absorbable by the skin and may cause a granulomatous reaction as the body attempts to encapsulate and digest the foreign substance.^10,17 Although rarely reported, the use of topical vitamins with MN—through intradermal injection or combined with MN—can be associated with severe complications, including local, sometimes systemic, and life-threatening complications. Clinicians should be vigilant in order to correlate clinical background and history of recent cosmetic procedures with the histologic findings for prompt diagnosis and timely treatment.

Topical application or injection of cosmeceuticals in conjunction with procedures such as facial microneedling (MN) has been associated with local and systemic complications.¹  Microneedling is an increasingly popular minimally invasive therapeutic procedure that is used for a wide range of dermatologic purposes, including facial rejuvenation.² Other indications for MN include minimizing the appearance of acne scars, surgical scars, stretch marks, wrinkles, and other cosmetic skin concerns. This procedure can be performed both at home and in a clinical setting, but at-home devices differ from procedures performed in a dermatology office. Clinicians use medical-grade devices for deeper penetration of the skin, yielding more effective results. In contrast, at-home MN devices are designed to be safer and less powerful with milder outcomes.

Although at-home options may be more accessible and affordable for patients, they also increase the risk for improper use and subsequent infection. Additionally, the use of cosmeceuticals such as vitamin E oil in conjunction with MN to enhance the effects of the procedure can lead to further complications. We report the case of a 44-year-old woman who developed a necrotic ulcer on the chin following self-treatment with vitamin E oil and an at-home MN device. While MN has been reported to be relatively safe when performed by board-certified dermatologists, clinicians should be vigilant in correlating clinical history and recent cosmetic procedures with the histologic findings for timely diagnosis and treatment of unusual lesions on the face.

Case Report

A 44-year-old woman presented to the emergency department with a progressively enlarging, necrotic, ulcerative lesion on the midline chin of 4 months’ duration. The patient reported that the lesion started as redness that developed into a painful oozing ulcer following application of vitamin E oil in conjunction with an at-home MN device (Figure 1). She purchased the vitamin E oil and MN device online and performed the procedure herself, applying the vitamin E oil to her whole face before, during, and after using the MN device, which contained 0.25-mm titanium needles. She denied undergoing any other recent cosmetic procedures.

The lesion initially was treated by the patient’s primary care physician with oral doxycycline for 6 weeks, followed by oral cephalexin and clindamycin for 2 weeks. Although the redness stabilized, the lesion continued to enlarge, which prompted her initial visit to our hospital 1 month after seeing her primary care physician. During this visit, the patient was given penicillin, and the ulcer was debrided and biopsied; however, no clinical improvement was seen. 

A biopsy during her initial emergency department visit and a repeat biopsy after 1 month showed similar findings of diffuse lymphohistiocytic and eosinophilic inflammation in the dermis (Figure 2) with poorly defined granulomas and multinucleated giant cells containing nonpolarizable exogenous material (Figure 3). Similar detached exogenous materials also were identified adjacent to the tissue. Diffuse re-epithelialization was seen, featuring pseudoepitheliomatous hyperplasia in association with the inflammatory process and granulation tissue (Figures 3 and 4). A higher-power view of the dermis showed foci of sclerosing lipogranuloma (Figure 4). Periodic acid–Schiff, Grocott methenamine silver, acid-fast bacilli, Fite, and Wright-Giemsa stains all were negative for microorganisms, and pancytokeratin staining was negative for carcinoma. These findings supported the diagnosis of a foreign body granulomatous reaction to an exogenous material—in this case, the vitamin E oil. Subsequent treatment with intralesional triamcinolone 10 mg/mL injection over 18 months resulted in progressive and drastic improvement of the lesion (Figure 5). A scar excision was performed, which further improved the lesion’s cosmetic appearance.

Comment

Application of various topical cosmeceuticals before, during, or after MN to enhance the effects of the procedure can introduce particles into the dermis, resulting in local or systemic hypersensitivity reactions. The associated adverse events can be divided into 2 main categories: adverse reactions related to the topical product or to the materials of the MN device itself.

A study showed that topical application of vitamin E oil to wounds on the skin does not improve the cosmetic appearance of scars.³ Instead, it is associated with a high incidence of contact dermatitis. A similar case of vitamin E injection, although without the concurrent use of an MN device, complicated by a facial lipogranuloma has been described.⁴ Sclerodermoid reaction, subcutaneous nodules, persistent edema, and ulceration at the site of vitamin E injection also have been described following the injection.^5,6 Because vitamin E is a lipid-soluble vitamin, its absorption in the human body is dependent on the presence of lipid or oil-like substances. The reactions mentioned above are associated with the vitamin E oil, which acts as a helper vehicle for lipid-soluble vitamins to be absorbed.⁷ Other ingredients in topical vitamin E oil include a combination of D-alpha-tocopherol, D-alpha-tocopheryl acetate, D-alpha-tocopheryl succinate, or mixed tocopherols.⁸ These ester conjugate forms of vitamin E also may play a role in its immunogenic properties and possibly contribute to adverse effects such as dermatitis and erythema. Further research is needed to investigate the impact of ester conjugate forms on skin reactions and individual responses.⁷

Hyaluronic acid is a relatively safe and commonly used topical treatment that acts as a lubricant during MN procedures to help the needles glide across the skin and prevent dragging. It also can be applied after the procedure for hydration purposes. Other common alternatives include peptides, ceramides, and epidermal growth factors. Topical products to avoid before, during, and 48 hours after undergoing MN include retinoids, vitamin C, vitamin E, exfoliants, serums that contain acids (eg, alpha hydroxy acids, beta hydroxy acids, glycolic acid, and lactic acid), serums that contain fragrance, and oil-based serums because they are associated with similar adverse effects.^8-10 A granulomatous reaction after an MN procedure also has been reported with the use of vitamin C serum.¹¹

The US Food and Drug Administration has approved the use of MN devices, including for at-home use, to improve the appearance of facial acne scars and wrinkles as well as abdominal scars in patients aged 22 years or older; however, MN devices are not approved for delivery of cosmeceuticals or other topical products into the skin. Therefore, there is no universal list of approved topicals to be used in conjunction with MN.¹²

Most MN devices are made of nickel and various other metals. Cases of contact dermatitis and delayed-type hypersensitivity granulomatous reaction with systemic symptoms have been reported after MN procedures due to the material of the MN device.^1,13,14

Conclusion

Microneedling is a minimally invasive procedure that causes nominal damage to the epidermis and superficial papillary dermis, stimulating a wound-healing cascade for collagen production.^15,16 Although not approved by the US Food and Drug Administration, MN performed at dermatology offices sometimes can be used in conjunction with topical products to enhance their absorption; however, while vitamin E is known for its antioxidant properties and potential skin benefits, the lipid substance acting as the vehicle is not absorbable by the skin and may cause a granulomatous reaction as the body attempts to encapsulate and digest the foreign substance.^10,17 Although rarely reported, the use of topical vitamins with MN—through intradermal injection or combined with MN—can be associated with severe complications, including local, sometimes systemic, and life-threatening complications. Clinicians should be vigilant in order to correlate clinical background and history of recent cosmetic procedures with the histologic findings for prompt diagnosis and timely treatment.

Topical application or injection of cosmeceuticals in conjunction with procedures such as facial microneedling (MN) has been associated with local and systemic complications.¹  Microneedling is an increasingly popular minimally invasive therapeutic procedure that is used for a wide range of dermatologic purposes, including facial rejuvenation.² Other indications for MN include minimizing the appearance of acne scars, surgical scars, stretch marks, wrinkles, and other cosmetic skin concerns. This procedure can be performed both at home and in a clinical setting, but at-home devices differ from procedures performed in a dermatology office. Clinicians use medical-grade devices for deeper penetration of the skin, yielding more effective results. In contrast, at-home MN devices are designed to be safer and less powerful with milder outcomes.

Although at-home options may be more accessible and affordable for patients, they also increase the risk for improper use and subsequent infection. Additionally, the use of cosmeceuticals such as vitamin E oil in conjunction with MN to enhance the effects of the procedure can lead to further complications. We report the case of a 44-year-old woman who developed a necrotic ulcer on the chin following self-treatment with vitamin E oil and an at-home MN device. While MN has been reported to be relatively safe when performed by board-certified dermatologists, clinicians should be vigilant in correlating clinical history and recent cosmetic procedures with the histologic findings for timely diagnosis and treatment of unusual lesions on the face.

Case Report

A 44-year-old woman presented to the emergency department with a progressively enlarging, necrotic, ulcerative lesion on the midline chin of 4 months’ duration. The patient reported that the lesion started as redness that developed into a painful oozing ulcer following application of vitamin E oil in conjunction with an at-home MN device (Figure 1). She purchased the vitamin E oil and MN device online and performed the procedure herself, applying the vitamin E oil to her whole face before, during, and after using the MN device, which contained 0.25-mm titanium needles. She denied undergoing any other recent cosmetic procedures.

The lesion initially was treated by the patient’s primary care physician with oral doxycycline for 6 weeks, followed by oral cephalexin and clindamycin for 2 weeks. Although the redness stabilized, the lesion continued to enlarge, which prompted her initial visit to our hospital 1 month after seeing her primary care physician. During this visit, the patient was given penicillin, and the ulcer was debrided and biopsied; however, no clinical improvement was seen. 

A biopsy during her initial emergency department visit and a repeat biopsy after 1 month showed similar findings of diffuse lymphohistiocytic and eosinophilic inflammation in the dermis (Figure 2) with poorly defined granulomas and multinucleated giant cells containing nonpolarizable exogenous material (Figure 3). Similar detached exogenous materials also were identified adjacent to the tissue. Diffuse re-epithelialization was seen, featuring pseudoepitheliomatous hyperplasia in association with the inflammatory process and granulation tissue (Figures 3 and 4). A higher-power view of the dermis showed foci of sclerosing lipogranuloma (Figure 4). Periodic acid–Schiff, Grocott methenamine silver, acid-fast bacilli, Fite, and Wright-Giemsa stains all were negative for microorganisms, and pancytokeratin staining was negative for carcinoma. These findings supported the diagnosis of a foreign body granulomatous reaction to an exogenous material—in this case, the vitamin E oil. Subsequent treatment with intralesional triamcinolone 10 mg/mL injection over 18 months resulted in progressive and drastic improvement of the lesion (Figure 5). A scar excision was performed, which further improved the lesion’s cosmetic appearance.

Comment

Application of various topical cosmeceuticals before, during, or after MN to enhance the effects of the procedure can introduce particles into the dermis, resulting in local or systemic hypersensitivity reactions. The associated adverse events can be divided into 2 main categories: adverse reactions related to the topical product or to the materials of the MN device itself.

A study showed that topical application of vitamin E oil to wounds on the skin does not improve the cosmetic appearance of scars.³ Instead, it is associated with a high incidence of contact dermatitis. A similar case of vitamin E injection, although without the concurrent use of an MN device, complicated by a facial lipogranuloma has been described.⁴ Sclerodermoid reaction, subcutaneous nodules, persistent edema, and ulceration at the site of vitamin E injection also have been described following the injection.^5,6 Because vitamin E is a lipid-soluble vitamin, its absorption in the human body is dependent on the presence of lipid or oil-like substances. The reactions mentioned above are associated with the vitamin E oil, which acts as a helper vehicle for lipid-soluble vitamins to be absorbed.⁷ Other ingredients in topical vitamin E oil include a combination of D-alpha-tocopherol, D-alpha-tocopheryl acetate, D-alpha-tocopheryl succinate, or mixed tocopherols.⁸ These ester conjugate forms of vitamin E also may play a role in its immunogenic properties and possibly contribute to adverse effects such as dermatitis and erythema. Further research is needed to investigate the impact of ester conjugate forms on skin reactions and individual responses.⁷

Hyaluronic acid is a relatively safe and commonly used topical treatment that acts as a lubricant during MN procedures to help the needles glide across the skin and prevent dragging. It also can be applied after the procedure for hydration purposes. Other common alternatives include peptides, ceramides, and epidermal growth factors. Topical products to avoid before, during, and 48 hours after undergoing MN include retinoids, vitamin C, vitamin E, exfoliants, serums that contain acids (eg, alpha hydroxy acids, beta hydroxy acids, glycolic acid, and lactic acid), serums that contain fragrance, and oil-based serums because they are associated with similar adverse effects.^8-10 A granulomatous reaction after an MN procedure also has been reported with the use of vitamin C serum.¹¹

The US Food and Drug Administration has approved the use of MN devices, including for at-home use, to improve the appearance of facial acne scars and wrinkles as well as abdominal scars in patients aged 22 years or older; however, MN devices are not approved for delivery of cosmeceuticals or other topical products into the skin. Therefore, there is no universal list of approved topicals to be used in conjunction with MN.¹²

Most MN devices are made of nickel and various other metals. Cases of contact dermatitis and delayed-type hypersensitivity granulomatous reaction with systemic symptoms have been reported after MN procedures due to the material of the MN device.^1,13,14

Conclusion

Microneedling is a minimally invasive procedure that causes nominal damage to the epidermis and superficial papillary dermis, stimulating a wound-healing cascade for collagen production.^15,16 Although not approved by the US Food and Drug Administration, MN performed at dermatology offices sometimes can be used in conjunction with topical products to enhance their absorption; however, while vitamin E is known for its antioxidant properties and potential skin benefits, the lipid substance acting as the vehicle is not absorbable by the skin and may cause a granulomatous reaction as the body attempts to encapsulate and digest the foreign substance.^10,17 Although rarely reported, the use of topical vitamins with MN—through intradermal injection or combined with MN—can be associated with severe complications, including local, sometimes systemic, and life-threatening complications. Clinicians should be vigilant in order to correlate clinical background and history of recent cosmetic procedures with the histologic findings for prompt diagnosis and timely treatment.

Intravascular large B-cell lymphoma (IVBCL) is an exceedingly rare aggressive form of non-Hodgkin lymphoma with tumor cells growing selectively in vascular lumina.¹ The annual incidence of IVBCL is fewer than 0.5 cases per 1,000,000 individuals worldwide.² Only about 500 known cases of IVBCL have been recorded in the literature,³ and it accounts for less than 1% of all lymphomas. It generally affects middle-aged to elderly individuals, with an average age at diagnosis of 70 years.² It has a predilection for men and commonly develops in individuals who are immunosuppressed.^3,4

Multiple variants of IVBCL have been described in the literature, with central nervous system and cutaneous involvement being the most classic findings.⁵ Bone marrow involvement with hepatosplenomegaly also has been noted in the literature.^6,7 Diagnosis of IVBCL and its variants requires a high index of suspicion, as the clinical manifestations and tissues involved typically are nonspecific and highly variable. Even in the classic variant of IVBCL, skin involvement is only reported in approximately half of cases.³ When present, cutaneous manifestations can range from nodules and violaceous plaques to induration and telangiectasias.³ Lymphadenopathy and lymphoma (leukemic) cells are not seen on a peripheral blood smear.^2,8,9

The lack of lymphadenopathy or identifiable leukemic cells in the peripheral blood presents a diagnostic dilemma, as sufficient information for accurate diagnosis must be obtained while minimizing invasive procedures and resource expenditure. Because IVBCL cells can reside in the vascular lumina of various organs, numerous biopsy sites have been proposed for diagnosis of lymphoma, including the bone marrow, skin, prostate, adrenal gland, brain, liver, and kidneys.¹⁰ While some studies have reported that the optimal diagnostic site is the bone marrow, skin biopsies are more routinely carried out, as they represent a convenient and cost-effective alternative to other more invasive techniques.^6,7,10 Studies have shown biopsy sensitivity values ranging from 77.8% to 83.3% for detection of IVBCL in normal-appearing skin, which is comparable to the sensitivities of a bone marrow biopsy.^7,8 Although skin biopsy of random sites has shown diagnostic efficacy, some studies have proposed that biopsies taken from hemangiomas and other hypervascular lesions can further improve diagnostic yield, as lymphoma cells often are present in capillaries of subcutaneous adipose tissue.^6,10,11 However, no obvious clinicopathologic differences were observed between IVBCL with and without involvement of a cutaneous hemangioma.¹¹

The purpose of this study was to determine the diagnostic efficacy of skin biopsies for detecting IVBCL at various body sites and to establish whether biopsies from hemangiomas yield higher diagnostic value.

Methods

A 66-year-old man recently died at our institution secondary to IVBCL. His disease course was characterized by multiple hospital admissions in a 6-month period for fever of unknown origin and tachycardia unresponsive to broad-spectrum antibiotics and systemic steroids. The patient declined over the course of 3 to 4 weeks with findings suggestive of lymphoma and tumor lysis syndrome, and he eventually developed shock, hypoxic respiratory failure, and acute renal failure. As imaging studies and examinations had not shown lymphadenopathy, bone marrow biopsy was performed, and dermatology was consulted to perform skin biopsies to evaluate for IVBCL. Both bone marrow biopsies and random skin biopsies from the abdomen showed large and atypical CD20+ B cells within select vascular lumina (Figure). No extravascular lymphoma cells were seen. Based on the bone marrow and skin biopsies, a diagnosis of IVBCL was made. Unfortunately, no progress was made clinically, and the patient was transitioned to comfort measures. Upon the patient’s death, his family expressed interest in participating in IVBCL research and agreed to a limited autopsy consisting of numerous skin biopsies to evaluate different body sites and biopsy types (normal skin vs hemangiomas) to ascertain whether diagnostic yield could be increased by performing selective biopsies of hemangiomas if IVBCL was suspected.

Twenty-four postmortem 4-mm punch biopsies containing subcutaneous adipose tissue were taken within 24 hours of the death of the patient before embalming. The biopsies were taken from all regions of the body except the head and neck for cosmetic preservation of the decedent. Eighteen of the biopsies were taken from random sites of normal-appearing skin; the remaining 6 were taken from clinically identifiable cherry hemangiomas (5 on the trunk and 1 on the thigh). There was a variable degree of livor mortis in the dependent areas of the body, which was included in the random biopsies from the back to ensure any pooling of dependent blood would not alter the findings.

A histopathologic examination by a board-certified dermatopathologist (M.P.) on a single hematoxylin-eosin–stained level was performed to evaluate each biopsy for superficial involvement and deep involvement by IVBCL. Superficial involvement was defined as dermal involvement at or above the level of the eccrine sweat glands; deep involvement was defined as dermal involvement beneath the eccrine sweat glands and all subcutaneous fat present. Skin and bone marrow biopsies used to make the original diagnosis prior to the patient’s death were reviewed, including CD20 immunohistochemistry for morphologic comparison to the study slides. Involvement was graded as 0 to 3+ (eTable).

Results

Results from all 24 biopsies are shown in the eTable. Twenty-two (91.7%) biopsies showed at least focal involvement by IVBCL. Nine (37.5%) biopsies showed more deep vs superficial involvement of the same site. On average, the 6 biopsies from clinically detected hemangiomas showed more involvement by IVBCL than the random biopsies (eFigures 1 and 2A). The superficial involvement of skin with a hemangioma showed an average score of 2.33 v 0.78 when compared with the superficial aspect of the random biopsies; the deep involvement of skin with a hemangioma showed an average score of 2.67 vs 1.16 when compared with the deep aspect of the random biopsies (eFigure 2B).

Comment

Intravascular large B-cell lymphoma is an aggressive malignancy that traditionally is difficult to diagnose. Many efforts have been made to improve detection and early diagnosis. As cutaneous involvement is common and sometimes the only sign of disease, dermatologists may be called upon to evaluate and biopsy patients with this suspected diagnosis. The purpose of our study was to improve diagnostic efficacy by methodically performing numerous biopsies and assessing the level of involvement of the superficial and deep skin as well as involvement of hemangiomas. The goal of this meticulous approach was to identify the highest-yield areas for biopsy with minimal impact on the patient. Our results showed that random skin biopsies are an effective way to identify IVBCL. Twenty-two (91.7%) biopsies contained at least focal lymphoma cells. Although the 2 biopsies that showed no tumor cells at all happened to both be from the left arm, this is believed to be coincidental. No discernable pattern was identified regarding involvement and anatomic region. Even though 20 (83.3%) biopsies showed superficial involvement, deep biopsy is essential, as 9 (37.5%) biopsies showed increased deep involvement compared to superficial involvement. Therefore, a deep punch biopsy is essential for maximum sensitivity.

Hemangiomas provide a potential target that could increase the sensitivity of a biopsy in the absence of clinical findings, when the disease in question is exclusively intravascular. The data gathered in this study support this idea, as biopsies from hemangiomas showed increased involvement compared to random biopsies, both superficially and deep (2.33 vs 0.78 and 2.67 vs 1.16, respectively). Interestingly, the hemangioma biopsy sites showed increased deep and superficial involvement, despite these typical cherry hemangiomas only involving the superficial dermis. One possible explanation for this is that the hemangiomas have larger-caliber feeder vessels with increased blood flow beneath them. It would then follow that this increased vasculature would increase the chances of identifying intravascular lymphoma cells. This finding further accentuates the need for a deep punch biopsy containing subcutaneous fat. 

Completing the study in the setting of an autopsy provided the advantage of being able to take numerous biopsies without increased harm to the patient. This extensive set of biopsies would not be reasonable to complete on a living patient. This study also has limitations. Although this patient did fall within the typical demographics for patients with IVBCL, the data were still limited to 1 patient. This autopsy format (on a patient whose cause of death was indeed IVBCL) also implies terminal disease, which may mean the patient had a larger disease burden than a living patient who would typically be biopsied. Although this increased disease burden may have increased the sensitivity of finding IVBCL in the biopsies of this study, this further emphasizes the importance of trying to determine any factors that could increase sensitivity in a living patient with a lower disease burden.

Conclusion

Skin biopsies can provide a sensitive, low-cost, and low-morbidity method to assess a patient for IVBCL. Though random skin biopsies can yield valuable information, deep, 4-mm punch biopsies of clinically identifiable hemangiomas may provide the highest sensitivity for IVBCL.

Intravascular large B-cell lymphoma (IVBCL) is an exceedingly rare aggressive form of non-Hodgkin lymphoma with tumor cells growing selectively in vascular lumina.¹ The annual incidence of IVBCL is fewer than 0.5 cases per 1,000,000 individuals worldwide.² Only about 500 known cases of IVBCL have been recorded in the literature,³ and it accounts for less than 1% of all lymphomas. It generally affects middle-aged to elderly individuals, with an average age at diagnosis of 70 years.² It has a predilection for men and commonly develops in individuals who are immunosuppressed.^3,4

Multiple variants of IVBCL have been described in the literature, with central nervous system and cutaneous involvement being the most classic findings.⁵ Bone marrow involvement with hepatosplenomegaly also has been noted in the literature.^6,7 Diagnosis of IVBCL and its variants requires a high index of suspicion, as the clinical manifestations and tissues involved typically are nonspecific and highly variable. Even in the classic variant of IVBCL, skin involvement is only reported in approximately half of cases.³ When present, cutaneous manifestations can range from nodules and violaceous plaques to induration and telangiectasias.³ Lymphadenopathy and lymphoma (leukemic) cells are not seen on a peripheral blood smear.^2,8,9

The lack of lymphadenopathy or identifiable leukemic cells in the peripheral blood presents a diagnostic dilemma, as sufficient information for accurate diagnosis must be obtained while minimizing invasive procedures and resource expenditure. Because IVBCL cells can reside in the vascular lumina of various organs, numerous biopsy sites have been proposed for diagnosis of lymphoma, including the bone marrow, skin, prostate, adrenal gland, brain, liver, and kidneys.¹⁰ While some studies have reported that the optimal diagnostic site is the bone marrow, skin biopsies are more routinely carried out, as they represent a convenient and cost-effective alternative to other more invasive techniques.^6,7,10 Studies have shown biopsy sensitivity values ranging from 77.8% to 83.3% for detection of IVBCL in normal-appearing skin, which is comparable to the sensitivities of a bone marrow biopsy.^7,8 Although skin biopsy of random sites has shown diagnostic efficacy, some studies have proposed that biopsies taken from hemangiomas and other hypervascular lesions can further improve diagnostic yield, as lymphoma cells often are present in capillaries of subcutaneous adipose tissue.^6,10,11 However, no obvious clinicopathologic differences were observed between IVBCL with and without involvement of a cutaneous hemangioma.¹¹

The purpose of this study was to determine the diagnostic efficacy of skin biopsies for detecting IVBCL at various body sites and to establish whether biopsies from hemangiomas yield higher diagnostic value.

Methods

A 66-year-old man recently died at our institution secondary to IVBCL. His disease course was characterized by multiple hospital admissions in a 6-month period for fever of unknown origin and tachycardia unresponsive to broad-spectrum antibiotics and systemic steroids. The patient declined over the course of 3 to 4 weeks with findings suggestive of lymphoma and tumor lysis syndrome, and he eventually developed shock, hypoxic respiratory failure, and acute renal failure. As imaging studies and examinations had not shown lymphadenopathy, bone marrow biopsy was performed, and dermatology was consulted to perform skin biopsies to evaluate for IVBCL. Both bone marrow biopsies and random skin biopsies from the abdomen showed large and atypical CD20+ B cells within select vascular lumina (Figure). No extravascular lymphoma cells were seen. Based on the bone marrow and skin biopsies, a diagnosis of IVBCL was made. Unfortunately, no progress was made clinically, and the patient was transitioned to comfort measures. Upon the patient’s death, his family expressed interest in participating in IVBCL research and agreed to a limited autopsy consisting of numerous skin biopsies to evaluate different body sites and biopsy types (normal skin vs hemangiomas) to ascertain whether diagnostic yield could be increased by performing selective biopsies of hemangiomas if IVBCL was suspected.

Twenty-four postmortem 4-mm punch biopsies containing subcutaneous adipose tissue were taken within 24 hours of the death of the patient before embalming. The biopsies were taken from all regions of the body except the head and neck for cosmetic preservation of the decedent. Eighteen of the biopsies were taken from random sites of normal-appearing skin; the remaining 6 were taken from clinically identifiable cherry hemangiomas (5 on the trunk and 1 on the thigh). There was a variable degree of livor mortis in the dependent areas of the body, which was included in the random biopsies from the back to ensure any pooling of dependent blood would not alter the findings.

A histopathologic examination by a board-certified dermatopathologist (M.P.) on a single hematoxylin-eosin–stained level was performed to evaluate each biopsy for superficial involvement and deep involvement by IVBCL. Superficial involvement was defined as dermal involvement at or above the level of the eccrine sweat glands; deep involvement was defined as dermal involvement beneath the eccrine sweat glands and all subcutaneous fat present. Skin and bone marrow biopsies used to make the original diagnosis prior to the patient’s death were reviewed, including CD20 immunohistochemistry for morphologic comparison to the study slides. Involvement was graded as 0 to 3+ (eTable).

Results

Results from all 24 biopsies are shown in the eTable. Twenty-two (91.7%) biopsies showed at least focal involvement by IVBCL. Nine (37.5%) biopsies showed more deep vs superficial involvement of the same site. On average, the 6 biopsies from clinically detected hemangiomas showed more involvement by IVBCL than the random biopsies (eFigures 1 and 2A). The superficial involvement of skin with a hemangioma showed an average score of 2.33 v 0.78 when compared with the superficial aspect of the random biopsies; the deep involvement of skin with a hemangioma showed an average score of 2.67 vs 1.16 when compared with the deep aspect of the random biopsies (eFigure 2B).

Comment

Intravascular large B-cell lymphoma is an aggressive malignancy that traditionally is difficult to diagnose. Many efforts have been made to improve detection and early diagnosis. As cutaneous involvement is common and sometimes the only sign of disease, dermatologists may be called upon to evaluate and biopsy patients with this suspected diagnosis. The purpose of our study was to improve diagnostic efficacy by methodically performing numerous biopsies and assessing the level of involvement of the superficial and deep skin as well as involvement of hemangiomas. The goal of this meticulous approach was to identify the highest-yield areas for biopsy with minimal impact on the patient. Our results showed that random skin biopsies are an effective way to identify IVBCL. Twenty-two (91.7%) biopsies contained at least focal lymphoma cells. Although the 2 biopsies that showed no tumor cells at all happened to both be from the left arm, this is believed to be coincidental. No discernable pattern was identified regarding involvement and anatomic region. Even though 20 (83.3%) biopsies showed superficial involvement, deep biopsy is essential, as 9 (37.5%) biopsies showed increased deep involvement compared to superficial involvement. Therefore, a deep punch biopsy is essential for maximum sensitivity.

Hemangiomas provide a potential target that could increase the sensitivity of a biopsy in the absence of clinical findings, when the disease in question is exclusively intravascular. The data gathered in this study support this idea, as biopsies from hemangiomas showed increased involvement compared to random biopsies, both superficially and deep (2.33 vs 0.78 and 2.67 vs 1.16, respectively). Interestingly, the hemangioma biopsy sites showed increased deep and superficial involvement, despite these typical cherry hemangiomas only involving the superficial dermis. One possible explanation for this is that the hemangiomas have larger-caliber feeder vessels with increased blood flow beneath them. It would then follow that this increased vasculature would increase the chances of identifying intravascular lymphoma cells. This finding further accentuates the need for a deep punch biopsy containing subcutaneous fat. 

Completing the study in the setting of an autopsy provided the advantage of being able to take numerous biopsies without increased harm to the patient. This extensive set of biopsies would not be reasonable to complete on a living patient. This study also has limitations. Although this patient did fall within the typical demographics for patients with IVBCL, the data were still limited to 1 patient. This autopsy format (on a patient whose cause of death was indeed IVBCL) also implies terminal disease, which may mean the patient had a larger disease burden than a living patient who would typically be biopsied. Although this increased disease burden may have increased the sensitivity of finding IVBCL in the biopsies of this study, this further emphasizes the importance of trying to determine any factors that could increase sensitivity in a living patient with a lower disease burden.

Conclusion

Skin biopsies can provide a sensitive, low-cost, and low-morbidity method to assess a patient for IVBCL. Though random skin biopsies can yield valuable information, deep, 4-mm punch biopsies of clinically identifiable hemangiomas may provide the highest sensitivity for IVBCL.

Intravascular large B-cell lymphoma (IVBCL) is an exceedingly rare aggressive form of non-Hodgkin lymphoma with tumor cells growing selectively in vascular lumina.¹ The annual incidence of IVBCL is fewer than 0.5 cases per 1,000,000 individuals worldwide.² Only about 500 known cases of IVBCL have been recorded in the literature,³ and it accounts for less than 1% of all lymphomas. It generally affects middle-aged to elderly individuals, with an average age at diagnosis of 70 years.² It has a predilection for men and commonly develops in individuals who are immunosuppressed.^3,4

Multiple variants of IVBCL have been described in the literature, with central nervous system and cutaneous involvement being the most classic findings.⁵ Bone marrow involvement with hepatosplenomegaly also has been noted in the literature.^6,7 Diagnosis of IVBCL and its variants requires a high index of suspicion, as the clinical manifestations and tissues involved typically are nonspecific and highly variable. Even in the classic variant of IVBCL, skin involvement is only reported in approximately half of cases.³ When present, cutaneous manifestations can range from nodules and violaceous plaques to induration and telangiectasias.³ Lymphadenopathy and lymphoma (leukemic) cells are not seen on a peripheral blood smear.^2,8,9

The lack of lymphadenopathy or identifiable leukemic cells in the peripheral blood presents a diagnostic dilemma, as sufficient information for accurate diagnosis must be obtained while minimizing invasive procedures and resource expenditure. Because IVBCL cells can reside in the vascular lumina of various organs, numerous biopsy sites have been proposed for diagnosis of lymphoma, including the bone marrow, skin, prostate, adrenal gland, brain, liver, and kidneys.¹⁰ While some studies have reported that the optimal diagnostic site is the bone marrow, skin biopsies are more routinely carried out, as they represent a convenient and cost-effective alternative to other more invasive techniques.^6,7,10 Studies have shown biopsy sensitivity values ranging from 77.8% to 83.3% for detection of IVBCL in normal-appearing skin, which is comparable to the sensitivities of a bone marrow biopsy.^7,8 Although skin biopsy of random sites has shown diagnostic efficacy, some studies have proposed that biopsies taken from hemangiomas and other hypervascular lesions can further improve diagnostic yield, as lymphoma cells often are present in capillaries of subcutaneous adipose tissue.^6,10,11 However, no obvious clinicopathologic differences were observed between IVBCL with and without involvement of a cutaneous hemangioma.¹¹

The purpose of this study was to determine the diagnostic efficacy of skin biopsies for detecting IVBCL at various body sites and to establish whether biopsies from hemangiomas yield higher diagnostic value.

Methods

A 66-year-old man recently died at our institution secondary to IVBCL. His disease course was characterized by multiple hospital admissions in a 6-month period for fever of unknown origin and tachycardia unresponsive to broad-spectrum antibiotics and systemic steroids. The patient declined over the course of 3 to 4 weeks with findings suggestive of lymphoma and tumor lysis syndrome, and he eventually developed shock, hypoxic respiratory failure, and acute renal failure. As imaging studies and examinations had not shown lymphadenopathy, bone marrow biopsy was performed, and dermatology was consulted to perform skin biopsies to evaluate for IVBCL. Both bone marrow biopsies and random skin biopsies from the abdomen showed large and atypical CD20+ B cells within select vascular lumina (Figure). No extravascular lymphoma cells were seen. Based on the bone marrow and skin biopsies, a diagnosis of IVBCL was made. Unfortunately, no progress was made clinically, and the patient was transitioned to comfort measures. Upon the patient’s death, his family expressed interest in participating in IVBCL research and agreed to a limited autopsy consisting of numerous skin biopsies to evaluate different body sites and biopsy types (normal skin vs hemangiomas) to ascertain whether diagnostic yield could be increased by performing selective biopsies of hemangiomas if IVBCL was suspected.

Twenty-four postmortem 4-mm punch biopsies containing subcutaneous adipose tissue were taken within 24 hours of the death of the patient before embalming. The biopsies were taken from all regions of the body except the head and neck for cosmetic preservation of the decedent. Eighteen of the biopsies were taken from random sites of normal-appearing skin; the remaining 6 were taken from clinically identifiable cherry hemangiomas (5 on the trunk and 1 on the thigh). There was a variable degree of livor mortis in the dependent areas of the body, which was included in the random biopsies from the back to ensure any pooling of dependent blood would not alter the findings.

A histopathologic examination by a board-certified dermatopathologist (M.P.) on a single hematoxylin-eosin–stained level was performed to evaluate each biopsy for superficial involvement and deep involvement by IVBCL. Superficial involvement was defined as dermal involvement at or above the level of the eccrine sweat glands; deep involvement was defined as dermal involvement beneath the eccrine sweat glands and all subcutaneous fat present. Skin and bone marrow biopsies used to make the original diagnosis prior to the patient’s death were reviewed, including CD20 immunohistochemistry for morphologic comparison to the study slides. Involvement was graded as 0 to 3+ (eTable).

Results

Results from all 24 biopsies are shown in the eTable. Twenty-two (91.7%) biopsies showed at least focal involvement by IVBCL. Nine (37.5%) biopsies showed more deep vs superficial involvement of the same site. On average, the 6 biopsies from clinically detected hemangiomas showed more involvement by IVBCL than the random biopsies (eFigures 1 and 2A). The superficial involvement of skin with a hemangioma showed an average score of 2.33 v 0.78 when compared with the superficial aspect of the random biopsies; the deep involvement of skin with a hemangioma showed an average score of 2.67 vs 1.16 when compared with the deep aspect of the random biopsies (eFigure 2B).

Comment

Intravascular large B-cell lymphoma is an aggressive malignancy that traditionally is difficult to diagnose. Many efforts have been made to improve detection and early diagnosis. As cutaneous involvement is common and sometimes the only sign of disease, dermatologists may be called upon to evaluate and biopsy patients with this suspected diagnosis. The purpose of our study was to improve diagnostic efficacy by methodically performing numerous biopsies and assessing the level of involvement of the superficial and deep skin as well as involvement of hemangiomas. The goal of this meticulous approach was to identify the highest-yield areas for biopsy with minimal impact on the patient. Our results showed that random skin biopsies are an effective way to identify IVBCL. Twenty-two (91.7%) biopsies contained at least focal lymphoma cells. Although the 2 biopsies that showed no tumor cells at all happened to both be from the left arm, this is believed to be coincidental. No discernable pattern was identified regarding involvement and anatomic region. Even though 20 (83.3%) biopsies showed superficial involvement, deep biopsy is essential, as 9 (37.5%) biopsies showed increased deep involvement compared to superficial involvement. Therefore, a deep punch biopsy is essential for maximum sensitivity.

Hemangiomas provide a potential target that could increase the sensitivity of a biopsy in the absence of clinical findings, when the disease in question is exclusively intravascular. The data gathered in this study support this idea, as biopsies from hemangiomas showed increased involvement compared to random biopsies, both superficially and deep (2.33 vs 0.78 and 2.67 vs 1.16, respectively). Interestingly, the hemangioma biopsy sites showed increased deep and superficial involvement, despite these typical cherry hemangiomas only involving the superficial dermis. One possible explanation for this is that the hemangiomas have larger-caliber feeder vessels with increased blood flow beneath them. It would then follow that this increased vasculature would increase the chances of identifying intravascular lymphoma cells. This finding further accentuates the need for a deep punch biopsy containing subcutaneous fat. 

Completing the study in the setting of an autopsy provided the advantage of being able to take numerous biopsies without increased harm to the patient. This extensive set of biopsies would not be reasonable to complete on a living patient. This study also has limitations. Although this patient did fall within the typical demographics for patients with IVBCL, the data were still limited to 1 patient. This autopsy format (on a patient whose cause of death was indeed IVBCL) also implies terminal disease, which may mean the patient had a larger disease burden than a living patient who would typically be biopsied. Although this increased disease burden may have increased the sensitivity of finding IVBCL in the biopsies of this study, this further emphasizes the importance of trying to determine any factors that could increase sensitivity in a living patient with a lower disease burden.

Conclusion

Skin biopsies can provide a sensitive, low-cost, and low-morbidity method to assess a patient for IVBCL. Though random skin biopsies can yield valuable information, deep, 4-mm punch biopsies of clinically identifiable hemangiomas may provide the highest sensitivity for IVBCL.

Practice Gap

Hyperhidrosis poses a considerable challenge for many amputees who use prosthetic devices, particularly at the interface between the residual limb and the prosthetic socket. The enclosed environment of the socket often leads to excessive sweating, which can compromise suction fit and increase the risk for skin chafing, irritation, and slippage. Persistent moisture also promotes bacterial and fungal growth, raising the likelihood of infections and foul odors within the socket. Research has shown that skin complications are highly prevalent among amputees, affecting up to 73.9% of this population in the United States.¹ Commonly reported complications include wounds, abscesses, and blisters, many of which can be triggered or worsened by hyperhidrosis.² Current treatment options for residual limb sweating include topical antiperspirants, botulinum toxin (BTX) injections, iontophoresis, and liner-liner socks.

While BTX commonly is used to treat hyperhidrosis in areas such as the palms and axillae, it typically is not considered as a first-line therapy for residual limb sweating; however, both BTX type A and type B have shown safety and effectiveness in managing hyperhidrosis in amputees, enhancing prosthetic use, and improving overall quality of life.³ Despite these benefits, BTX remains relatively underutilized for residual limb sweating, particularly among dermatologists who may not routinely treat individuals with acquired limb loss. This presents an opportunity for dermatologists to expand their scope and address the unique needs of amputees. We propose a technique for administering BTX injections to treat residual limb hyperhidrosis.

Tools and Techniques

A 64-year-old man initially presented to our dermatology clinic after undergoing an above-the-knee amputation of the left leg 1 year prior. The amputation had been performed due to chronic prosthetic joint infections with Escherichia coli. He reported persistent sweating of the residual limb, which severely limited his use of a prosthesis and led to frequent falls.

During the initial visit, treatment options for primary hyperhidrosis including topical and injectable therapies were discussed. Due to a fear of needles, the patient chose topical treatment, with the option to pursue BTX injections later if better control was needed. An aluminum chloride hexahydrate prosthetic antiperspirant was prescribed for nightly application on the anterior and posterior residual limb along with an over-the-counter prosthetic antiperspirant simultaneously. Although the over-the-counter prosthetic antiperspirant provided partial relief, the symptoms persisted, preventing the patient from returning to work. Unfortunately, the prescription antiperspirant was prohibitively expensive and not covered by the patient’s insurance. As a result, BTX injections were initiated at 1-month follow-up.

Botulinum toxin injections were administered in a grid-like pattern across the surface area where the residual limb made contact with the prosthetic. Using a surgical marker, the patient assisted the medical team in identifying the areas where sweating occurred most frequently. The area was divided into 4 equal sections, with each section treated per weekly interval sequentially over 4 weeks. The targeted areas included the left anterior (extending from the anterior tensor fasciae latae band to the lateral thigh) and left posterior residual limb (Figure 1 and eFigure 1, respectively).

The treated section was cleaned with an alcohol wipe prior to each injection, and 50 units of BTX (diluted to 2.5 units per 0.1 mL in bacteriostatic saline) were injected intradermally into each section (Figure 2 and eFigure 2). The injections were administered in rows, with the needle inserted at evenly spaced intervals approximately 1 inch apart. A total of 100 units were administered per section at each weekly appointment. The patient tolerated the procedure well, and no complications were observed.

Practice Implications

This staged approach to administering BTX ensures even distribution of the injections, optimizes hyperhidrosis control, minimizes the risk for complications, and allows for precise targeting of the affected areas to maximize therapeutic benefit. Following the initial procedure, our patient was scheduled for follow-ups approximately every 3 to 4 months starting from the first set of injections for each area. Over 9 months, the patient successfully completed 3 treatment sessions using this method. The patient reported improved quality of life after starting the BTX injections.

After evaluating the initial treatment outcomes with 100 units per section, the dosage was increased to 200 units per section to reduce the number of visits from 4 every 3 months to cover the entire area to 2 visits every 3 months. This adjustment aimed to optimize results and better manage the patient’s ongoing symptoms. At about 1 to 2 weeks after beginning treatment, the patient noticed decreased sweating and discomfort during his daily activities and reduced friction with his prosthetic leg. No adverse effects were noted with the increased dosage during a clinical visit. 

Our case highlights the importance of ensuring equitable access to hyperhidrosis treatment. Dermatologists should prioritize patient-centered care by factoring in financial constraints when recommending therapies. In this patient’s case, offering a range of options including over-the-counter antiperspirants and prescription treatments allowed for a management plan tailored to his individual needs and circumstances.

DaxibotulinumtoxinA, known for its longer duration of action compared to other BTX formulations, presents a promising alternative for treating hyperhidrosis.⁴ However, a gap in care emerged for our patient when prescription antiperspirant was not covered by his insurance, and daxibotulinumtoxinA, which could have offered a more durable solution, was not yet available at our clinic for hyperhidrosis management. Expanding insurance coverage for effective prescription treatments and improving access to newer treatment options are crucial for enhancing patient outcomes and ensuring more equitable care.

Focusing dermatologic care on amputees presents distinct challenges and opportunities for improving their care and decreasing discomfort. Amputees, particularly those with residual limb hyperhidrosis, often experience additional discomfort and difficulty while using prosthetics, as excessive sweating can interfere with fit and function.^5,6 Dermatologists should proactively address these specific needs by tailoring treatment accordingly. Incorporating targeted therapies, such as BTX injections, in addition to education on lifestyle modifications and managing treatment expectations, ensures comprehensive care that enhances both quality of life and functional outcomes. Engaging patients in discussions about all available options, including emerging therapies, is essential for improving care for this underserved population.

Practice Gap

Hyperhidrosis poses a considerable challenge for many amputees who use prosthetic devices, particularly at the interface between the residual limb and the prosthetic socket. The enclosed environment of the socket often leads to excessive sweating, which can compromise suction fit and increase the risk for skin chafing, irritation, and slippage. Persistent moisture also promotes bacterial and fungal growth, raising the likelihood of infections and foul odors within the socket. Research has shown that skin complications are highly prevalent among amputees, affecting up to 73.9% of this population in the United States.¹ Commonly reported complications include wounds, abscesses, and blisters, many of which can be triggered or worsened by hyperhidrosis.² Current treatment options for residual limb sweating include topical antiperspirants, botulinum toxin (BTX) injections, iontophoresis, and liner-liner socks.

While BTX commonly is used to treat hyperhidrosis in areas such as the palms and axillae, it typically is not considered as a first-line therapy for residual limb sweating; however, both BTX type A and type B have shown safety and effectiveness in managing hyperhidrosis in amputees, enhancing prosthetic use, and improving overall quality of life.³ Despite these benefits, BTX remains relatively underutilized for residual limb sweating, particularly among dermatologists who may not routinely treat individuals with acquired limb loss. This presents an opportunity for dermatologists to expand their scope and address the unique needs of amputees. We propose a technique for administering BTX injections to treat residual limb hyperhidrosis.

Tools and Techniques

A 64-year-old man initially presented to our dermatology clinic after undergoing an above-the-knee amputation of the left leg 1 year prior. The amputation had been performed due to chronic prosthetic joint infections with Escherichia coli. He reported persistent sweating of the residual limb, which severely limited his use of a prosthesis and led to frequent falls.

During the initial visit, treatment options for primary hyperhidrosis including topical and injectable therapies were discussed. Due to a fear of needles, the patient chose topical treatment, with the option to pursue BTX injections later if better control was needed. An aluminum chloride hexahydrate prosthetic antiperspirant was prescribed for nightly application on the anterior and posterior residual limb along with an over-the-counter prosthetic antiperspirant simultaneously. Although the over-the-counter prosthetic antiperspirant provided partial relief, the symptoms persisted, preventing the patient from returning to work. Unfortunately, the prescription antiperspirant was prohibitively expensive and not covered by the patient’s insurance. As a result, BTX injections were initiated at 1-month follow-up.

Botulinum toxin injections were administered in a grid-like pattern across the surface area where the residual limb made contact with the prosthetic. Using a surgical marker, the patient assisted the medical team in identifying the areas where sweating occurred most frequently. The area was divided into 4 equal sections, with each section treated per weekly interval sequentially over 4 weeks. The targeted areas included the left anterior (extending from the anterior tensor fasciae latae band to the lateral thigh) and left posterior residual limb (Figure 1 and eFigure 1, respectively).

The treated section was cleaned with an alcohol wipe prior to each injection, and 50 units of BTX (diluted to 2.5 units per 0.1 mL in bacteriostatic saline) were injected intradermally into each section (Figure 2 and eFigure 2). The injections were administered in rows, with the needle inserted at evenly spaced intervals approximately 1 inch apart. A total of 100 units were administered per section at each weekly appointment. The patient tolerated the procedure well, and no complications were observed.

Practice Implications

This staged approach to administering BTX ensures even distribution of the injections, optimizes hyperhidrosis control, minimizes the risk for complications, and allows for precise targeting of the affected areas to maximize therapeutic benefit. Following the initial procedure, our patient was scheduled for follow-ups approximately every 3 to 4 months starting from the first set of injections for each area. Over 9 months, the patient successfully completed 3 treatment sessions using this method. The patient reported improved quality of life after starting the BTX injections.

After evaluating the initial treatment outcomes with 100 units per section, the dosage was increased to 200 units per section to reduce the number of visits from 4 every 3 months to cover the entire area to 2 visits every 3 months. This adjustment aimed to optimize results and better manage the patient’s ongoing symptoms. At about 1 to 2 weeks after beginning treatment, the patient noticed decreased sweating and discomfort during his daily activities and reduced friction with his prosthetic leg. No adverse effects were noted with the increased dosage during a clinical visit. 

Our case highlights the importance of ensuring equitable access to hyperhidrosis treatment. Dermatologists should prioritize patient-centered care by factoring in financial constraints when recommending therapies. In this patient’s case, offering a range of options including over-the-counter antiperspirants and prescription treatments allowed for a management plan tailored to his individual needs and circumstances.

DaxibotulinumtoxinA, known for its longer duration of action compared to other BTX formulations, presents a promising alternative for treating hyperhidrosis.⁴ However, a gap in care emerged for our patient when prescription antiperspirant was not covered by his insurance, and daxibotulinumtoxinA, which could have offered a more durable solution, was not yet available at our clinic for hyperhidrosis management. Expanding insurance coverage for effective prescription treatments and improving access to newer treatment options are crucial for enhancing patient outcomes and ensuring more equitable care.

Focusing dermatologic care on amputees presents distinct challenges and opportunities for improving their care and decreasing discomfort. Amputees, particularly those with residual limb hyperhidrosis, often experience additional discomfort and difficulty while using prosthetics, as excessive sweating can interfere with fit and function.^5,6 Dermatologists should proactively address these specific needs by tailoring treatment accordingly. Incorporating targeted therapies, such as BTX injections, in addition to education on lifestyle modifications and managing treatment expectations, ensures comprehensive care that enhances both quality of life and functional outcomes. Engaging patients in discussions about all available options, including emerging therapies, is essential for improving care for this underserved population.

Practice Gap

Hyperhidrosis poses a considerable challenge for many amputees who use prosthetic devices, particularly at the interface between the residual limb and the prosthetic socket. The enclosed environment of the socket often leads to excessive sweating, which can compromise suction fit and increase the risk for skin chafing, irritation, and slippage. Persistent moisture also promotes bacterial and fungal growth, raising the likelihood of infections and foul odors within the socket. Research has shown that skin complications are highly prevalent among amputees, affecting up to 73.9% of this population in the United States.¹ Commonly reported complications include wounds, abscesses, and blisters, many of which can be triggered or worsened by hyperhidrosis.² Current treatment options for residual limb sweating include topical antiperspirants, botulinum toxin (BTX) injections, iontophoresis, and liner-liner socks.

While BTX commonly is used to treat hyperhidrosis in areas such as the palms and axillae, it typically is not considered as a first-line therapy for residual limb sweating; however, both BTX type A and type B have shown safety and effectiveness in managing hyperhidrosis in amputees, enhancing prosthetic use, and improving overall quality of life.³ Despite these benefits, BTX remains relatively underutilized for residual limb sweating, particularly among dermatologists who may not routinely treat individuals with acquired limb loss. This presents an opportunity for dermatologists to expand their scope and address the unique needs of amputees. We propose a technique for administering BTX injections to treat residual limb hyperhidrosis.

Tools and Techniques

A 64-year-old man initially presented to our dermatology clinic after undergoing an above-the-knee amputation of the left leg 1 year prior. The amputation had been performed due to chronic prosthetic joint infections with Escherichia coli. He reported persistent sweating of the residual limb, which severely limited his use of a prosthesis and led to frequent falls.

During the initial visit, treatment options for primary hyperhidrosis including topical and injectable therapies were discussed. Due to a fear of needles, the patient chose topical treatment, with the option to pursue BTX injections later if better control was needed. An aluminum chloride hexahydrate prosthetic antiperspirant was prescribed for nightly application on the anterior and posterior residual limb along with an over-the-counter prosthetic antiperspirant simultaneously. Although the over-the-counter prosthetic antiperspirant provided partial relief, the symptoms persisted, preventing the patient from returning to work. Unfortunately, the prescription antiperspirant was prohibitively expensive and not covered by the patient’s insurance. As a result, BTX injections were initiated at 1-month follow-up.

Botulinum toxin injections were administered in a grid-like pattern across the surface area where the residual limb made contact with the prosthetic. Using a surgical marker, the patient assisted the medical team in identifying the areas where sweating occurred most frequently. The area was divided into 4 equal sections, with each section treated per weekly interval sequentially over 4 weeks. The targeted areas included the left anterior (extending from the anterior tensor fasciae latae band to the lateral thigh) and left posterior residual limb (Figure 1 and eFigure 1, respectively).

The treated section was cleaned with an alcohol wipe prior to each injection, and 50 units of BTX (diluted to 2.5 units per 0.1 mL in bacteriostatic saline) were injected intradermally into each section (Figure 2 and eFigure 2). The injections were administered in rows, with the needle inserted at evenly spaced intervals approximately 1 inch apart. A total of 100 units were administered per section at each weekly appointment. The patient tolerated the procedure well, and no complications were observed.

Practice Implications

This staged approach to administering BTX ensures even distribution of the injections, optimizes hyperhidrosis control, minimizes the risk for complications, and allows for precise targeting of the affected areas to maximize therapeutic benefit. Following the initial procedure, our patient was scheduled for follow-ups approximately every 3 to 4 months starting from the first set of injections for each area. Over 9 months, the patient successfully completed 3 treatment sessions using this method. The patient reported improved quality of life after starting the BTX injections.

After evaluating the initial treatment outcomes with 100 units per section, the dosage was increased to 200 units per section to reduce the number of visits from 4 every 3 months to cover the entire area to 2 visits every 3 months. This adjustment aimed to optimize results and better manage the patient’s ongoing symptoms. At about 1 to 2 weeks after beginning treatment, the patient noticed decreased sweating and discomfort during his daily activities and reduced friction with his prosthetic leg. No adverse effects were noted with the increased dosage during a clinical visit. 

Our case highlights the importance of ensuring equitable access to hyperhidrosis treatment. Dermatologists should prioritize patient-centered care by factoring in financial constraints when recommending therapies. In this patient’s case, offering a range of options including over-the-counter antiperspirants and prescription treatments allowed for a management plan tailored to his individual needs and circumstances.

DaxibotulinumtoxinA, known for its longer duration of action compared to other BTX formulations, presents a promising alternative for treating hyperhidrosis.⁴ However, a gap in care emerged for our patient when prescription antiperspirant was not covered by his insurance, and daxibotulinumtoxinA, which could have offered a more durable solution, was not yet available at our clinic for hyperhidrosis management. Expanding insurance coverage for effective prescription treatments and improving access to newer treatment options are crucial for enhancing patient outcomes and ensuring more equitable care.

Focusing dermatologic care on amputees presents distinct challenges and opportunities for improving their care and decreasing discomfort. Amputees, particularly those with residual limb hyperhidrosis, often experience additional discomfort and difficulty while using prosthetics, as excessive sweating can interfere with fit and function.^5,6 Dermatologists should proactively address these specific needs by tailoring treatment accordingly. Incorporating targeted therapies, such as BTX injections, in addition to education on lifestyle modifications and managing treatment expectations, ensures comprehensive care that enhances both quality of life and functional outcomes. Engaging patients in discussions about all available options, including emerging therapies, is essential for improving care for this underserved population.

Emergency departments (EDs) and immediate care (IC) facilities often do not have prompt dermatologic care available for triage and treatment. Many EDs do not have staff dermatologists on call, instead relying on input from other specialists or quick outpatient dermatology appointments. It can be challenging to obtain a prompt appointment with a board-certified dermatologist, which is preferred for complex cases such as severe drug reactions or infection. In the United States, there are few well-established IC centers equipped to address dermatologic needs. The orthopedic specialty has modeled a concept that has led to the establishment of orthopedic urgent care/IC in many larger institutions,¹ and many private practice clinics serve their communities as well. We present a rationale for why a similar IC concept for dermatology would be beneficial, particularly within a large institution or health system.

Dermatology Consultation Changes Disease Management

There is diagnostic and therapeutic utility in dermatology evaluation. In a prospective study of 591 patients who were either hospitalized or evaluated in an ED/urgent care setting, treatment was changed in more than 60% of cases when dermatology consultation was utilized.² In another prospective review of 691 cases on an inpatient service, dermatology consultation resulted in treatment changes more than 80% of the time.³

Cellulitis has been a particularly well-studied diagnosis. Dermatologists often change the diagnosis of cellulitis in the hospital setting and reduce antibiotic exposure. In a prospective cohort study of 116 patients, 33.6% had their diagnosis of cellulitis changed to pseudocellulitis following evaluation by the dermatologist; of 34 patients who had started antibiotic therapy, 82.4% were recommended to discontinue the treatment, and all 39 patients with pseudocellulitis had a proven stable clinical course at 1-month follow-up.⁴ In another trial, 175 patients with presumed cellulitis were given standard management (provided by the medicine inpatient team) either alone or with the addition of dermatology consultation. Duration of antibiotic treatment (including intravenous therapy) was reduced when dermatology was consulted. Two weeks after discharge, patients who had dermatology consultations demonstrated greater clinical improvement.⁵

Improving ED and IC Access to Dermatology

Emergency department and IC teams across the United States work tirelessly to meet the demands of patients presenting with medically urgent conditions. In a study examining 861 ED cases, dermatology made up only 9.5% of specialist consultations, and in the opinion of the on-call dermatology resident, 51.0% (439/861) of cases warranted ED-level care.⁶

Data from the 2021 National Hospital Ambulatory Medical Care Survey showed that the mean wait time to see a physician, nurse, or physician assistant in an ED was 37.5 minutes, but wait times could range from less than 15 minutes to more than 6 hours.⁷ According to a study of 35,849 ED visits at nonfederal hospitals in the United States, only 47.7% of EDs admitted more than 90% of their patients within 6 hours.⁸ Moreover, perceived wait times in the ED have been shown to greatly impact patient satisfaction. Two predictors of perceived wait time include appropriate assessment of emergency level and the feeling of being forgotten.⁹ In a study of 2377 ED visits with primary dermatologic diagnoses, only 5.5% led to admission.¹⁰ This suggests many patients who come to the ED for dermatologic needs do not require inpatient hospital care. In these cases, patients with primary dermatologic concerns may experience longer ED wait times, as higher acuity or emergency cases take precedence. Studies also have shown that more vulnerable populations are utilizing ED visits most for primary dermatologic concerns.^10,11 This includes individuals of lower income and/or those with Medicaid/Medicare or those without insurance.¹¹ Predictors of high ED use for dermatologic concerns include prior frequent use of the ED (for nondermatologic concerns) instead of outpatient care, income below the poverty level, and lack of insurance; older individuals (>65 years) also were found to use the ED more frequently for dermatologic concerns when compared to younger individuals.¹⁰

Importantly, there is a great need for urgent dermatology consultation for pediatric patients. A single-institution study showed that over a 36-month period, there were 347 pediatric dermatology consultations from the pediatric ED mostly for children aged 0 days to 5 years; nearly half of these consultations required outpatient clinic follow-up.¹² However, dermatology outpatient follow-up can be difficult to obtain, especially for vulnerable groups. In a study of 611 dermatology clinics, patients with Medicaid were shown to have longer wait times and less success in obtaining dermatology appointments compared to those with Medicare or private insurance.¹³ Only about 30% of private dermatology practices accept Medicaid patients, likely pushing these patients toward utilization of emergency services for dermatologic concerns.^13,14

There is a clear role for a dermatology IC in our health care system, and the concept already has been identified and trialed in several institutions. At Oregon Health and Science University (Portland, Oregon), a retrospective chart review of patients with diagnoses of Morgellons disease and neurotic excoriations seen in dermatology urgent care between 2018 and 2020 showed an 88% decrease in annual rates of health care visits and a 77% decrease in ED visits after dermatology services were engaged compared to before the opening of the dermatology urgent care.¹⁵ Another study showed that uninsured or self-pay patients were more than 14 times more likely to access dermatology urgent care than to schedule a routine clinic appointment, suggesting that there is a barrier to making outpatient dermatologic appointments for uninsured patients. An urgent access model may facilitate the ability of underinsured patients to access care.¹⁶

Improving Dermatology Access for Other Specialties

Needs for dermatologic care are encountered in many other specialties. Having direct access to immediate dermatologic treatment is best for patients and may avoid inpatient care and trips to the ED for consultation access. Ideally, a dermatology IC would allow direct care to be provided alongside the oncology outpatient team. New immunologic therapies (cytotoxic T-lymphocyte–associated protein 4 and programmed cell death protein 1/programmed death-ligand 1 treatments) can cause dermatologic reactions in more than 40% of patients.¹⁷ Paraneoplastic syndromes can manifest with cutaneous symptoms, as can acute graft-vs-host-disease.¹⁸ In a study at Memorial Sloan Kettering (New York, New York) analyzing 426 same-day outpatient dermatology consultations, 17% of patients experienced interruptions in their cancer therapy, but 83% responded quickly to dermatologic treatment and resumed oncologic therapy—19% of them at a reduced dose.¹⁹ This is an important demonstration of prompt dermatologic consultation in an outpatient setting reducing interruptions to anticancer therapy. The heterogeneity of the cutaneous reactions seen from oncologic and immunomodulatory medications is profound, with more than 140 different types of skin-specific reactions.²⁰

Solid-organ transplant recipients also could benefit from urgent access to dermatology services. These patients are at a much higher risk for skin cancers, and a study showed that those who receive referrals to dermatology are seen sooner after transplantation (5.6 years) than those who self-refer (7.2 years). Importantly, annual skin cancer screenings are recommended to begin 1 year after transplantation.²¹

Direct access to dermatology care could benefit patients with complicated rheumatologic conditions who present with skin findings; for example, patients with lupus erythematosus or dermatomyositis can have a spectrum of disease ranging from skin-predominant to systemic manifestations. Identification and treatment of such diseases require collaboration between dermatologists and rheumatologists.²² Likewise, a study of a joint rheumatology-dermatology clinic for psoriatic arthritis showed that a multidisciplinary approach to management leads to decreased time for patients to obtain proper rheumatologic and dermatologic examination and a faster time to diagnosis; however, such multidisciplinary clinic models and approaches to care often are found only at large university-based hospitals.²³ In a patient population for whom time to diagnosis is crucial to avoid permanent changes such as joint destruction, a dermatology IC could fill this role in community hospitals and clinics. A dermatology IC also can serve patients with specific diagnoses who would benefit from more direct access to care; for example, in 2017 there were 131,430 ED visits for hidradenitis suppurativa (HS) in the United States. While HS is not uncommon, it usually is underdiagnosed because it can be challenging to differentiate from an uncomplicated abscess. Emergency department visits often are utilized for first-time presentations as well as flares of HS. In these situations, ED doctors can provide palliative treatment, but prompt referrals to dermatologists should be made for disease management to decrease recurrence.²⁴

Final Thoughts

A huge caveat to the dermatology urgent care system is determining what is deemed “urgent.” We propose starting with a referral-based system only from other physicians (including IC and urgent care) rather than having patients walk in directly. Ideally, as support and staff increases, the availability can increase as well. In our institution, we suggested half-day clinics staffed by varying physicians, with compensation models similar to an ED or IC physician rather than by productivity. Each group considering this kind of addition to patient care will need to assess these points in building an IC for dermatology. The University of Pennsylvania’s (Philadelphia, Pennsylvania) system of rapid-access clinics to facilitate access to care for patients requiring urgent appointments may function as a model for future similar clinics.²⁵ Creating a specialized IC/urgent care is not a novel concept. Orthopedic urgent care centers have increased greatly in the past decade, reducing ED burden for musculoskeletal complaints. In a study evaluating the utility of orthopedic urgent care settings, time to see an orthopedic specialist and cost were both greatly reduced with this system.¹ The same has been shown in same-day access ophthalmology clinics, which are organized similarly to an urgent care.²⁶

In 2021, there were 107.4 million treat-and-release visits to the ED in the United States for a total cost of $80.3 billion.²⁷ This emphasizes the need to consider care models that not only provide excellent clinical care and treat the most acute diagnoses promptly and accurately but also reduce overall costs. While this may be convoluted for other specialties given the difficulty of having patients self-triage, dermatologic concerns are similar to orthopedic concerns for the patient to decipher the etiology of the concern. As in orthopedics, a dermatology IC could function similarly, increasing access, decreasing ED and IC wait times, saving overall health care spending, and allowing underserved and publicly insured individuals to have improved, prompt care.

Emergency departments (EDs) and immediate care (IC) facilities often do not have prompt dermatologic care available for triage and treatment. Many EDs do not have staff dermatologists on call, instead relying on input from other specialists or quick outpatient dermatology appointments. It can be challenging to obtain a prompt appointment with a board-certified dermatologist, which is preferred for complex cases such as severe drug reactions or infection. In the United States, there are few well-established IC centers equipped to address dermatologic needs. The orthopedic specialty has modeled a concept that has led to the establishment of orthopedic urgent care/IC in many larger institutions,¹ and many private practice clinics serve their communities as well. We present a rationale for why a similar IC concept for dermatology would be beneficial, particularly within a large institution or health system.

Dermatology Consultation Changes Disease Management

There is diagnostic and therapeutic utility in dermatology evaluation. In a prospective study of 591 patients who were either hospitalized or evaluated in an ED/urgent care setting, treatment was changed in more than 60% of cases when dermatology consultation was utilized.² In another prospective review of 691 cases on an inpatient service, dermatology consultation resulted in treatment changes more than 80% of the time.³

Cellulitis has been a particularly well-studied diagnosis. Dermatologists often change the diagnosis of cellulitis in the hospital setting and reduce antibiotic exposure. In a prospective cohort study of 116 patients, 33.6% had their diagnosis of cellulitis changed to pseudocellulitis following evaluation by the dermatologist; of 34 patients who had started antibiotic therapy, 82.4% were recommended to discontinue the treatment, and all 39 patients with pseudocellulitis had a proven stable clinical course at 1-month follow-up.⁴ In another trial, 175 patients with presumed cellulitis were given standard management (provided by the medicine inpatient team) either alone or with the addition of dermatology consultation. Duration of antibiotic treatment (including intravenous therapy) was reduced when dermatology was consulted. Two weeks after discharge, patients who had dermatology consultations demonstrated greater clinical improvement.⁵

Improving ED and IC Access to Dermatology

Emergency department and IC teams across the United States work tirelessly to meet the demands of patients presenting with medically urgent conditions. In a study examining 861 ED cases, dermatology made up only 9.5% of specialist consultations, and in the opinion of the on-call dermatology resident, 51.0% (439/861) of cases warranted ED-level care.⁶

Data from the 2021 National Hospital Ambulatory Medical Care Survey showed that the mean wait time to see a physician, nurse, or physician assistant in an ED was 37.5 minutes, but wait times could range from less than 15 minutes to more than 6 hours.⁷ According to a study of 35,849 ED visits at nonfederal hospitals in the United States, only 47.7% of EDs admitted more than 90% of their patients within 6 hours.⁸ Moreover, perceived wait times in the ED have been shown to greatly impact patient satisfaction. Two predictors of perceived wait time include appropriate assessment of emergency level and the feeling of being forgotten.⁹ In a study of 2377 ED visits with primary dermatologic diagnoses, only 5.5% led to admission.¹⁰ This suggests many patients who come to the ED for dermatologic needs do not require inpatient hospital care. In these cases, patients with primary dermatologic concerns may experience longer ED wait times, as higher acuity or emergency cases take precedence. Studies also have shown that more vulnerable populations are utilizing ED visits most for primary dermatologic concerns.^10,11 This includes individuals of lower income and/or those with Medicaid/Medicare or those without insurance.¹¹ Predictors of high ED use for dermatologic concerns include prior frequent use of the ED (for nondermatologic concerns) instead of outpatient care, income below the poverty level, and lack of insurance; older individuals (>65 years) also were found to use the ED more frequently for dermatologic concerns when compared to younger individuals.¹⁰

Importantly, there is a great need for urgent dermatology consultation for pediatric patients. A single-institution study showed that over a 36-month period, there were 347 pediatric dermatology consultations from the pediatric ED mostly for children aged 0 days to 5 years; nearly half of these consultations required outpatient clinic follow-up.¹² However, dermatology outpatient follow-up can be difficult to obtain, especially for vulnerable groups. In a study of 611 dermatology clinics, patients with Medicaid were shown to have longer wait times and less success in obtaining dermatology appointments compared to those with Medicare or private insurance.¹³ Only about 30% of private dermatology practices accept Medicaid patients, likely pushing these patients toward utilization of emergency services for dermatologic concerns.^13,14

There is a clear role for a dermatology IC in our health care system, and the concept already has been identified and trialed in several institutions. At Oregon Health and Science University (Portland, Oregon), a retrospective chart review of patients with diagnoses of Morgellons disease and neurotic excoriations seen in dermatology urgent care between 2018 and 2020 showed an 88% decrease in annual rates of health care visits and a 77% decrease in ED visits after dermatology services were engaged compared to before the opening of the dermatology urgent care.¹⁵ Another study showed that uninsured or self-pay patients were more than 14 times more likely to access dermatology urgent care than to schedule a routine clinic appointment, suggesting that there is a barrier to making outpatient dermatologic appointments for uninsured patients. An urgent access model may facilitate the ability of underinsured patients to access care.¹⁶

Improving Dermatology Access for Other Specialties

Needs for dermatologic care are encountered in many other specialties. Having direct access to immediate dermatologic treatment is best for patients and may avoid inpatient care and trips to the ED for consultation access. Ideally, a dermatology IC would allow direct care to be provided alongside the oncology outpatient team. New immunologic therapies (cytotoxic T-lymphocyte–associated protein 4 and programmed cell death protein 1/programmed death-ligand 1 treatments) can cause dermatologic reactions in more than 40% of patients.¹⁷ Paraneoplastic syndromes can manifest with cutaneous symptoms, as can acute graft-vs-host-disease.¹⁸ In a study at Memorial Sloan Kettering (New York, New York) analyzing 426 same-day outpatient dermatology consultations, 17% of patients experienced interruptions in their cancer therapy, but 83% responded quickly to dermatologic treatment and resumed oncologic therapy—19% of them at a reduced dose.¹⁹ This is an important demonstration of prompt dermatologic consultation in an outpatient setting reducing interruptions to anticancer therapy. The heterogeneity of the cutaneous reactions seen from oncologic and immunomodulatory medications is profound, with more than 140 different types of skin-specific reactions.²⁰

Solid-organ transplant recipients also could benefit from urgent access to dermatology services. These patients are at a much higher risk for skin cancers, and a study showed that those who receive referrals to dermatology are seen sooner after transplantation (5.6 years) than those who self-refer (7.2 years). Importantly, annual skin cancer screenings are recommended to begin 1 year after transplantation.²¹

Direct access to dermatology care could benefit patients with complicated rheumatologic conditions who present with skin findings; for example, patients with lupus erythematosus or dermatomyositis can have a spectrum of disease ranging from skin-predominant to systemic manifestations. Identification and treatment of such diseases require collaboration between dermatologists and rheumatologists.²² Likewise, a study of a joint rheumatology-dermatology clinic for psoriatic arthritis showed that a multidisciplinary approach to management leads to decreased time for patients to obtain proper rheumatologic and dermatologic examination and a faster time to diagnosis; however, such multidisciplinary clinic models and approaches to care often are found only at large university-based hospitals.²³ In a patient population for whom time to diagnosis is crucial to avoid permanent changes such as joint destruction, a dermatology IC could fill this role in community hospitals and clinics. A dermatology IC also can serve patients with specific diagnoses who would benefit from more direct access to care; for example, in 2017 there were 131,430 ED visits for hidradenitis suppurativa (HS) in the United States. While HS is not uncommon, it usually is underdiagnosed because it can be challenging to differentiate from an uncomplicated abscess. Emergency department visits often are utilized for first-time presentations as well as flares of HS. In these situations, ED doctors can provide palliative treatment, but prompt referrals to dermatologists should be made for disease management to decrease recurrence.²⁴

Final Thoughts

A huge caveat to the dermatology urgent care system is determining what is deemed “urgent.” We propose starting with a referral-based system only from other physicians (including IC and urgent care) rather than having patients walk in directly. Ideally, as support and staff increases, the availability can increase as well. In our institution, we suggested half-day clinics staffed by varying physicians, with compensation models similar to an ED or IC physician rather than by productivity. Each group considering this kind of addition to patient care will need to assess these points in building an IC for dermatology. The University of Pennsylvania’s (Philadelphia, Pennsylvania) system of rapid-access clinics to facilitate access to care for patients requiring urgent appointments may function as a model for future similar clinics.²⁵ Creating a specialized IC/urgent care is not a novel concept. Orthopedic urgent care centers have increased greatly in the past decade, reducing ED burden for musculoskeletal complaints. In a study evaluating the utility of orthopedic urgent care settings, time to see an orthopedic specialist and cost were both greatly reduced with this system.¹ The same has been shown in same-day access ophthalmology clinics, which are organized similarly to an urgent care.²⁶

In 2021, there were 107.4 million treat-and-release visits to the ED in the United States for a total cost of $80.3 billion.²⁷ This emphasizes the need to consider care models that not only provide excellent clinical care and treat the most acute diagnoses promptly and accurately but also reduce overall costs. While this may be convoluted for other specialties given the difficulty of having patients self-triage, dermatologic concerns are similar to orthopedic concerns for the patient to decipher the etiology of the concern. As in orthopedics, a dermatology IC could function similarly, increasing access, decreasing ED and IC wait times, saving overall health care spending, and allowing underserved and publicly insured individuals to have improved, prompt care.

Emergency departments (EDs) and immediate care (IC) facilities often do not have prompt dermatologic care available for triage and treatment. Many EDs do not have staff dermatologists on call, instead relying on input from other specialists or quick outpatient dermatology appointments. It can be challenging to obtain a prompt appointment with a board-certified dermatologist, which is preferred for complex cases such as severe drug reactions or infection. In the United States, there are few well-established IC centers equipped to address dermatologic needs. The orthopedic specialty has modeled a concept that has led to the establishment of orthopedic urgent care/IC in many larger institutions,¹ and many private practice clinics serve their communities as well. We present a rationale for why a similar IC concept for dermatology would be beneficial, particularly within a large institution or health system.

Dermatology Consultation Changes Disease Management

There is diagnostic and therapeutic utility in dermatology evaluation. In a prospective study of 591 patients who were either hospitalized or evaluated in an ED/urgent care setting, treatment was changed in more than 60% of cases when dermatology consultation was utilized.² In another prospective review of 691 cases on an inpatient service, dermatology consultation resulted in treatment changes more than 80% of the time.³

Cellulitis has been a particularly well-studied diagnosis. Dermatologists often change the diagnosis of cellulitis in the hospital setting and reduce antibiotic exposure. In a prospective cohort study of 116 patients, 33.6% had their diagnosis of cellulitis changed to pseudocellulitis following evaluation by the dermatologist; of 34 patients who had started antibiotic therapy, 82.4% were recommended to discontinue the treatment, and all 39 patients with pseudocellulitis had a proven stable clinical course at 1-month follow-up.⁴ In another trial, 175 patients with presumed cellulitis were given standard management (provided by the medicine inpatient team) either alone or with the addition of dermatology consultation. Duration of antibiotic treatment (including intravenous therapy) was reduced when dermatology was consulted. Two weeks after discharge, patients who had dermatology consultations demonstrated greater clinical improvement.⁵

Improving ED and IC Access to Dermatology

Emergency department and IC teams across the United States work tirelessly to meet the demands of patients presenting with medically urgent conditions. In a study examining 861 ED cases, dermatology made up only 9.5% of specialist consultations, and in the opinion of the on-call dermatology resident, 51.0% (439/861) of cases warranted ED-level care.⁶

Data from the 2021 National Hospital Ambulatory Medical Care Survey showed that the mean wait time to see a physician, nurse, or physician assistant in an ED was 37.5 minutes, but wait times could range from less than 15 minutes to more than 6 hours.⁷ According to a study of 35,849 ED visits at nonfederal hospitals in the United States, only 47.7% of EDs admitted more than 90% of their patients within 6 hours.⁸ Moreover, perceived wait times in the ED have been shown to greatly impact patient satisfaction. Two predictors of perceived wait time include appropriate assessment of emergency level and the feeling of being forgotten.⁹ In a study of 2377 ED visits with primary dermatologic diagnoses, only 5.5% led to admission.¹⁰ This suggests many patients who come to the ED for dermatologic needs do not require inpatient hospital care. In these cases, patients with primary dermatologic concerns may experience longer ED wait times, as higher acuity or emergency cases take precedence. Studies also have shown that more vulnerable populations are utilizing ED visits most for primary dermatologic concerns.^10,11 This includes individuals of lower income and/or those with Medicaid/Medicare or those without insurance.¹¹ Predictors of high ED use for dermatologic concerns include prior frequent use of the ED (for nondermatologic concerns) instead of outpatient care, income below the poverty level, and lack of insurance; older individuals (>65 years) also were found to use the ED more frequently for dermatologic concerns when compared to younger individuals.¹⁰

Importantly, there is a great need for urgent dermatology consultation for pediatric patients. A single-institution study showed that over a 36-month period, there were 347 pediatric dermatology consultations from the pediatric ED mostly for children aged 0 days to 5 years; nearly half of these consultations required outpatient clinic follow-up.¹² However, dermatology outpatient follow-up can be difficult to obtain, especially for vulnerable groups. In a study of 611 dermatology clinics, patients with Medicaid were shown to have longer wait times and less success in obtaining dermatology appointments compared to those with Medicare or private insurance.¹³ Only about 30% of private dermatology practices accept Medicaid patients, likely pushing these patients toward utilization of emergency services for dermatologic concerns.^13,14

There is a clear role for a dermatology IC in our health care system, and the concept already has been identified and trialed in several institutions. At Oregon Health and Science University (Portland, Oregon), a retrospective chart review of patients with diagnoses of Morgellons disease and neurotic excoriations seen in dermatology urgent care between 2018 and 2020 showed an 88% decrease in annual rates of health care visits and a 77% decrease in ED visits after dermatology services were engaged compared to before the opening of the dermatology urgent care.¹⁵ Another study showed that uninsured or self-pay patients were more than 14 times more likely to access dermatology urgent care than to schedule a routine clinic appointment, suggesting that there is a barrier to making outpatient dermatologic appointments for uninsured patients. An urgent access model may facilitate the ability of underinsured patients to access care.¹⁶

Improving Dermatology Access for Other Specialties

Needs for dermatologic care are encountered in many other specialties. Having direct access to immediate dermatologic treatment is best for patients and may avoid inpatient care and trips to the ED for consultation access. Ideally, a dermatology IC would allow direct care to be provided alongside the oncology outpatient team. New immunologic therapies (cytotoxic T-lymphocyte–associated protein 4 and programmed cell death protein 1/programmed death-ligand 1 treatments) can cause dermatologic reactions in more than 40% of patients.¹⁷ Paraneoplastic syndromes can manifest with cutaneous symptoms, as can acute graft-vs-host-disease.¹⁸ In a study at Memorial Sloan Kettering (New York, New York) analyzing 426 same-day outpatient dermatology consultations, 17% of patients experienced interruptions in their cancer therapy, but 83% responded quickly to dermatologic treatment and resumed oncologic therapy—19% of them at a reduced dose.¹⁹ This is an important demonstration of prompt dermatologic consultation in an outpatient setting reducing interruptions to anticancer therapy. The heterogeneity of the cutaneous reactions seen from oncologic and immunomodulatory medications is profound, with more than 140 different types of skin-specific reactions.²⁰

Solid-organ transplant recipients also could benefit from urgent access to dermatology services. These patients are at a much higher risk for skin cancers, and a study showed that those who receive referrals to dermatology are seen sooner after transplantation (5.6 years) than those who self-refer (7.2 years). Importantly, annual skin cancer screenings are recommended to begin 1 year after transplantation.²¹

Direct access to dermatology care could benefit patients with complicated rheumatologic conditions who present with skin findings; for example, patients with lupus erythematosus or dermatomyositis can have a spectrum of disease ranging from skin-predominant to systemic manifestations. Identification and treatment of such diseases require collaboration between dermatologists and rheumatologists.²² Likewise, a study of a joint rheumatology-dermatology clinic for psoriatic arthritis showed that a multidisciplinary approach to management leads to decreased time for patients to obtain proper rheumatologic and dermatologic examination and a faster time to diagnosis; however, such multidisciplinary clinic models and approaches to care often are found only at large university-based hospitals.²³ In a patient population for whom time to diagnosis is crucial to avoid permanent changes such as joint destruction, a dermatology IC could fill this role in community hospitals and clinics. A dermatology IC also can serve patients with specific diagnoses who would benefit from more direct access to care; for example, in 2017 there were 131,430 ED visits for hidradenitis suppurativa (HS) in the United States. While HS is not uncommon, it usually is underdiagnosed because it can be challenging to differentiate from an uncomplicated abscess. Emergency department visits often are utilized for first-time presentations as well as flares of HS. In these situations, ED doctors can provide palliative treatment, but prompt referrals to dermatologists should be made for disease management to decrease recurrence.²⁴

Final Thoughts

A huge caveat to the dermatology urgent care system is determining what is deemed “urgent.” We propose starting with a referral-based system only from other physicians (including IC and urgent care) rather than having patients walk in directly. Ideally, as support and staff increases, the availability can increase as well. In our institution, we suggested half-day clinics staffed by varying physicians, with compensation models similar to an ED or IC physician rather than by productivity. Each group considering this kind of addition to patient care will need to assess these points in building an IC for dermatology. The University of Pennsylvania’s (Philadelphia, Pennsylvania) system of rapid-access clinics to facilitate access to care for patients requiring urgent appointments may function as a model for future similar clinics.²⁵ Creating a specialized IC/urgent care is not a novel concept. Orthopedic urgent care centers have increased greatly in the past decade, reducing ED burden for musculoskeletal complaints. In a study evaluating the utility of orthopedic urgent care settings, time to see an orthopedic specialist and cost were both greatly reduced with this system.¹ The same has been shown in same-day access ophthalmology clinics, which are organized similarly to an urgent care.²⁶

In 2021, there were 107.4 million treat-and-release visits to the ED in the United States for a total cost of $80.3 billion.²⁷ This emphasizes the need to consider care models that not only provide excellent clinical care and treat the most acute diagnoses promptly and accurately but also reduce overall costs. While this may be convoluted for other specialties given the difficulty of having patients self-triage, dermatologic concerns are similar to orthopedic concerns for the patient to decipher the etiology of the concern. As in orthopedics, a dermatology IC could function similarly, increasing access, decreasing ED and IC wait times, saving overall health care spending, and allowing underserved and publicly insured individuals to have improved, prompt care.

The impact of pseudofolliculitis barbae (PFB) on military service members and other uniformed professionals has been a topic of recent interest due to the announcement of the US Army’s new shaving rule in July 2025.¹ The policy prohibits permanent shaving waivers, requires medical re-evaluation of shaving profiles within 90 days, and allows for administrative separation if a service member accumulates shaving exceptions totaling more than 12 months over a 24-month period.² A common skin condition triggered or worsened by shaving, PFB causes painful bumps, pustules, and hyperpigmentation most often in the beard and cheek areas and negatively impacts quality of life. It disproportionately affects 45% to 83% of men in the United States, particularly those of African, Hispanic, or Middle Eastern descent.^3,4 Genetic factors, particularly tightly coiled or coarse curly hair, can predispose individuals to PFB. The most successful treatment for PFB is to stop shaving, but this conflicts with military shaving standards and interferes with the use of protective equipment (eg, masks). Herein, we highlight the adverse impact of PFB on military career progression and provide context for clinicians who treat patients with PFB, especially as policies recently have shifted to allow nonmilitary clinicians to evaluate PFB in service members.⁵

Shaving Waivers and Advancement

Pseudofolliculitis barbae disproportionately prolongs the time to advancement of many service members, and those with PFB also are overburdened by policy changes related to shaving.⁶ In the US military, nearly 18% of the active-duty force is Black,⁷ a population that is more susceptible to PFB. Military personnel may request PFB-related accommodations, including medical shaving waivers that vary by branch. Through a formal documentation process, waivers allow service members to maintain facial hair up to one-quarter inch in length.⁵ Previously, waivers could be temporary (eg, up to 90 days) or permanent as subjectively determined based on clinician-documented disease severity. Almost 65% of US Air Force medical shaving waivers are held by Black men, and PFB is one of the most common reasons.⁶ Notably, the US Navy discontinued permanent shaving waivers in October 2019.⁸ A US Marine Corps policy issued in March 2025 now allows administrative separation of service members with PFB if symptoms do not improve after a 1-year medical shaving waiver due to “incompatibility with service.”⁹ This change reversed a 2022 policy that protected Marines from separation based on PFB.¹⁰ A Marine Corps spokesperson stated that this change aims to clarify how medical conditions can impact uniform compliance and standardize medical condition management while prioritizing compliance and duty readiness.¹

Even in the absence of policy changes, obtaining a medical shaving waiver for PFB can be challenging. Service members may have little to no access to military dermatologists who specialize in management of PFB and experience long wait times for civilian network deferment. Service members seen in civilian clinics may have restricted treatment options due to limited insurance coverage for laser hair reduction, even in the most difficult-to-manage areas (eg, neck, jawline). Expanding access to military dermatologists, civilian dermatologists who are experienced with PFB and understand the impact and necessity of military waivers, and teledermatology services could help improve and streamline care. Other challenges include the subjective nature of documenting PFB disease severity, the need for validated assessment tools, a lack of standardized policies across military branches, and stigma. A standardized approach to documentation may reduce variability in how shaving waivers are evaluated across service branches, but at a minimum, clinicians should document the diagnosis, clinical findings, severity of PFB, and the treatment used. Having a waiver would help these service members focus on mastering critical skillsets and performing duties without the time pressures, angst, and expense dedicated to caring for and managing PFB.

Clinical and Policy Barriers

Unfortunately, service members with PFB or shaving waivers often face stigma that can hinder career advancement.⁶ In a recent analysis of 9339 US Air Force personnel, those with shaving waivers experienced longer times to promotion compared to those without waivers: in the waiver group, 94.47% were enlisted and 5.53% were officers; in the nonwaiver group, 72.11% were enlisted and 27.89% were officers (P=.0003).⁶ While delays in promotion were consistent across racial groups, most of the waiver holders identified as Black (64.8%), despite this demographic group representing only a small portion of the overall cohort (12.9%).⁶ Promotion delays may be linked to perceptions of unprofessionalism and exclusion from high-profile assignments, which notably require “the highest standards of military appearance and professional conduct.”¹¹ The burden of career-limiting shaving policies falls disproportionately on military personnel with PFB who self-identify as Black. Perceptions about unprofessional appearance or job readiness often unintentionally introduce bias, unjustly restricting career advancement.⁶

Safety Equipment and Shaving Standards

Conditions that potentially affect the use of masks and chemical defense equipment extend beyond the military. Firefighters and law enforcement officers generally are required to maintain a clean-shaven face for proper fit of respirator masks; the standard is that no respirator fit test shall be conducted if hair—including stubble, beards, mustaches, or sideburns—grows between the skin and the facepiece sealing surface, and any apparel interfering with a proper seal must be altered or removed.¹² This creates challenges for uniformed professionals with PFB who must manage their condition while adhering to safety requirements. Some endure long-term pain and scarring in order to comply, while others seek waivers to treat and prevent symptoms while also facing the stigma of doing so.¹³ One of the most effective treatments for PFB is to discontinue shaving,¹⁴ which may not be feasible for those in uniformed professions with strict grooming standards. Research on mask seal effectiveness in individuals with neatly trimmed beards or PFB remains limited.⁵ Studies evaluating mask fit across facial hair types and lengths are needed, along with the development of protective equipment that accommodates career-limiting conditions such as PFB, cystic acne, and acne keloidalis nuchae. This also may encourage development of equipment that does not induce such conditions (eg, mechanical acne from friction). These efforts would promote safety, scientific innovation for dermatologic follicular-based disorders, and overall quality of life for service members as well as increase their ability to serve without stigma. These developments also would positively impact other fields that require intermittent or full-time use of masks, including health care and some food service industries.

Final Thoughts

The disproportionate impact of PFB in the military highlights the need for improved access to treatment, culturally informed care, and policies that avoid penalizing service members with tightly coiled hair and a desire to serve. We discussed PFB management strategies, clinical features, and implications across various skin tones in a previous publication.¹⁴ It is important to consider insights from individuals with PFB who are serving in the military as well as the medical personnel who care for them. Ensuring or creating effective treatment options drives innovation, and evidence-based accommodation plans can help individuals in uniformed professions avoid choosing between PFB management and their career. Promoting awareness about the impact of PFB beyond the razor is key to reducing disparities and supporting excellence among those who serve and desire to continue to do so.

The impact of pseudofolliculitis barbae (PFB) on military service members and other uniformed professionals has been a topic of recent interest due to the announcement of the US Army’s new shaving rule in July 2025.¹ The policy prohibits permanent shaving waivers, requires medical re-evaluation of shaving profiles within 90 days, and allows for administrative separation if a service member accumulates shaving exceptions totaling more than 12 months over a 24-month period.² A common skin condition triggered or worsened by shaving, PFB causes painful bumps, pustules, and hyperpigmentation most often in the beard and cheek areas and negatively impacts quality of life. It disproportionately affects 45% to 83% of men in the United States, particularly those of African, Hispanic, or Middle Eastern descent.^3,4 Genetic factors, particularly tightly coiled or coarse curly hair, can predispose individuals to PFB. The most successful treatment for PFB is to stop shaving, but this conflicts with military shaving standards and interferes with the use of protective equipment (eg, masks). Herein, we highlight the adverse impact of PFB on military career progression and provide context for clinicians who treat patients with PFB, especially as policies recently have shifted to allow nonmilitary clinicians to evaluate PFB in service members.⁵

Shaving Waivers and Advancement

Pseudofolliculitis barbae disproportionately prolongs the time to advancement of many service members, and those with PFB also are overburdened by policy changes related to shaving.⁶ In the US military, nearly 18% of the active-duty force is Black,⁷ a population that is more susceptible to PFB. Military personnel may request PFB-related accommodations, including medical shaving waivers that vary by branch. Through a formal documentation process, waivers allow service members to maintain facial hair up to one-quarter inch in length.⁵ Previously, waivers could be temporary (eg, up to 90 days) or permanent as subjectively determined based on clinician-documented disease severity. Almost 65% of US Air Force medical shaving waivers are held by Black men, and PFB is one of the most common reasons.⁶ Notably, the US Navy discontinued permanent shaving waivers in October 2019.⁸ A US Marine Corps policy issued in March 2025 now allows administrative separation of service members with PFB if symptoms do not improve after a 1-year medical shaving waiver due to “incompatibility with service.”⁹ This change reversed a 2022 policy that protected Marines from separation based on PFB.¹⁰ A Marine Corps spokesperson stated that this change aims to clarify how medical conditions can impact uniform compliance and standardize medical condition management while prioritizing compliance and duty readiness.¹

Even in the absence of policy changes, obtaining a medical shaving waiver for PFB can be challenging. Service members may have little to no access to military dermatologists who specialize in management of PFB and experience long wait times for civilian network deferment. Service members seen in civilian clinics may have restricted treatment options due to limited insurance coverage for laser hair reduction, even in the most difficult-to-manage areas (eg, neck, jawline). Expanding access to military dermatologists, civilian dermatologists who are experienced with PFB and understand the impact and necessity of military waivers, and teledermatology services could help improve and streamline care. Other challenges include the subjective nature of documenting PFB disease severity, the need for validated assessment tools, a lack of standardized policies across military branches, and stigma. A standardized approach to documentation may reduce variability in how shaving waivers are evaluated across service branches, but at a minimum, clinicians should document the diagnosis, clinical findings, severity of PFB, and the treatment used. Having a waiver would help these service members focus on mastering critical skillsets and performing duties without the time pressures, angst, and expense dedicated to caring for and managing PFB.

Clinical and Policy Barriers

Unfortunately, service members with PFB or shaving waivers often face stigma that can hinder career advancement.⁶ In a recent analysis of 9339 US Air Force personnel, those with shaving waivers experienced longer times to promotion compared to those without waivers: in the waiver group, 94.47% were enlisted and 5.53% were officers; in the nonwaiver group, 72.11% were enlisted and 27.89% were officers (P=.0003).⁶ While delays in promotion were consistent across racial groups, most of the waiver holders identified as Black (64.8%), despite this demographic group representing only a small portion of the overall cohort (12.9%).⁶ Promotion delays may be linked to perceptions of unprofessionalism and exclusion from high-profile assignments, which notably require “the highest standards of military appearance and professional conduct.”¹¹ The burden of career-limiting shaving policies falls disproportionately on military personnel with PFB who self-identify as Black. Perceptions about unprofessional appearance or job readiness often unintentionally introduce bias, unjustly restricting career advancement.⁶

Safety Equipment and Shaving Standards

Conditions that potentially affect the use of masks and chemical defense equipment extend beyond the military. Firefighters and law enforcement officers generally are required to maintain a clean-shaven face for proper fit of respirator masks; the standard is that no respirator fit test shall be conducted if hair—including stubble, beards, mustaches, or sideburns—grows between the skin and the facepiece sealing surface, and any apparel interfering with a proper seal must be altered or removed.¹² This creates challenges for uniformed professionals with PFB who must manage their condition while adhering to safety requirements. Some endure long-term pain and scarring in order to comply, while others seek waivers to treat and prevent symptoms while also facing the stigma of doing so.¹³ One of the most effective treatments for PFB is to discontinue shaving,¹⁴ which may not be feasible for those in uniformed professions with strict grooming standards. Research on mask seal effectiveness in individuals with neatly trimmed beards or PFB remains limited.⁵ Studies evaluating mask fit across facial hair types and lengths are needed, along with the development of protective equipment that accommodates career-limiting conditions such as PFB, cystic acne, and acne keloidalis nuchae. This also may encourage development of equipment that does not induce such conditions (eg, mechanical acne from friction). These efforts would promote safety, scientific innovation for dermatologic follicular-based disorders, and overall quality of life for service members as well as increase their ability to serve without stigma. These developments also would positively impact other fields that require intermittent or full-time use of masks, including health care and some food service industries.

Final Thoughts

The disproportionate impact of PFB in the military highlights the need for improved access to treatment, culturally informed care, and policies that avoid penalizing service members with tightly coiled hair and a desire to serve. We discussed PFB management strategies, clinical features, and implications across various skin tones in a previous publication.¹⁴ It is important to consider insights from individuals with PFB who are serving in the military as well as the medical personnel who care for them. Ensuring or creating effective treatment options drives innovation, and evidence-based accommodation plans can help individuals in uniformed professions avoid choosing between PFB management and their career. Promoting awareness about the impact of PFB beyond the razor is key to reducing disparities and supporting excellence among those who serve and desire to continue to do so.

The impact of pseudofolliculitis barbae (PFB) on military service members and other uniformed professionals has been a topic of recent interest due to the announcement of the US Army’s new shaving rule in July 2025.¹ The policy prohibits permanent shaving waivers, requires medical re-evaluation of shaving profiles within 90 days, and allows for administrative separation if a service member accumulates shaving exceptions totaling more than 12 months over a 24-month period.² A common skin condition triggered or worsened by shaving, PFB causes painful bumps, pustules, and hyperpigmentation most often in the beard and cheek areas and negatively impacts quality of life. It disproportionately affects 45% to 83% of men in the United States, particularly those of African, Hispanic, or Middle Eastern descent.^3,4 Genetic factors, particularly tightly coiled or coarse curly hair, can predispose individuals to PFB. The most successful treatment for PFB is to stop shaving, but this conflicts with military shaving standards and interferes with the use of protective equipment (eg, masks). Herein, we highlight the adverse impact of PFB on military career progression and provide context for clinicians who treat patients with PFB, especially as policies recently have shifted to allow nonmilitary clinicians to evaluate PFB in service members.⁵

Shaving Waivers and Advancement

Pseudofolliculitis barbae disproportionately prolongs the time to advancement of many service members, and those with PFB also are overburdened by policy changes related to shaving.⁶ In the US military, nearly 18% of the active-duty force is Black,⁷ a population that is more susceptible to PFB. Military personnel may request PFB-related accommodations, including medical shaving waivers that vary by branch. Through a formal documentation process, waivers allow service members to maintain facial hair up to one-quarter inch in length.⁵ Previously, waivers could be temporary (eg, up to 90 days) or permanent as subjectively determined based on clinician-documented disease severity. Almost 65% of US Air Force medical shaving waivers are held by Black men, and PFB is one of the most common reasons.⁶ Notably, the US Navy discontinued permanent shaving waivers in October 2019.⁸ A US Marine Corps policy issued in March 2025 now allows administrative separation of service members with PFB if symptoms do not improve after a 1-year medical shaving waiver due to “incompatibility with service.”⁹ This change reversed a 2022 policy that protected Marines from separation based on PFB.¹⁰ A Marine Corps spokesperson stated that this change aims to clarify how medical conditions can impact uniform compliance and standardize medical condition management while prioritizing compliance and duty readiness.¹

Even in the absence of policy changes, obtaining a medical shaving waiver for PFB can be challenging. Service members may have little to no access to military dermatologists who specialize in management of PFB and experience long wait times for civilian network deferment. Service members seen in civilian clinics may have restricted treatment options due to limited insurance coverage for laser hair reduction, even in the most difficult-to-manage areas (eg, neck, jawline). Expanding access to military dermatologists, civilian dermatologists who are experienced with PFB and understand the impact and necessity of military waivers, and teledermatology services could help improve and streamline care. Other challenges include the subjective nature of documenting PFB disease severity, the need for validated assessment tools, a lack of standardized policies across military branches, and stigma. A standardized approach to documentation may reduce variability in how shaving waivers are evaluated across service branches, but at a minimum, clinicians should document the diagnosis, clinical findings, severity of PFB, and the treatment used. Having a waiver would help these service members focus on mastering critical skillsets and performing duties without the time pressures, angst, and expense dedicated to caring for and managing PFB.

Clinical and Policy Barriers

Unfortunately, service members with PFB or shaving waivers often face stigma that can hinder career advancement.⁶ In a recent analysis of 9339 US Air Force personnel, those with shaving waivers experienced longer times to promotion compared to those without waivers: in the waiver group, 94.47% were enlisted and 5.53% were officers; in the nonwaiver group, 72.11% were enlisted and 27.89% were officers (P=.0003).⁶ While delays in promotion were consistent across racial groups, most of the waiver holders identified as Black (64.8%), despite this demographic group representing only a small portion of the overall cohort (12.9%).⁶ Promotion delays may be linked to perceptions of unprofessionalism and exclusion from high-profile assignments, which notably require “the highest standards of military appearance and professional conduct.”¹¹ The burden of career-limiting shaving policies falls disproportionately on military personnel with PFB who self-identify as Black. Perceptions about unprofessional appearance or job readiness often unintentionally introduce bias, unjustly restricting career advancement.⁶

Safety Equipment and Shaving Standards

Conditions that potentially affect the use of masks and chemical defense equipment extend beyond the military. Firefighters and law enforcement officers generally are required to maintain a clean-shaven face for proper fit of respirator masks; the standard is that no respirator fit test shall be conducted if hair—including stubble, beards, mustaches, or sideburns—grows between the skin and the facepiece sealing surface, and any apparel interfering with a proper seal must be altered or removed.¹² This creates challenges for uniformed professionals with PFB who must manage their condition while adhering to safety requirements. Some endure long-term pain and scarring in order to comply, while others seek waivers to treat and prevent symptoms while also facing the stigma of doing so.¹³ One of the most effective treatments for PFB is to discontinue shaving,¹⁴ which may not be feasible for those in uniformed professions with strict grooming standards. Research on mask seal effectiveness in individuals with neatly trimmed beards or PFB remains limited.⁵ Studies evaluating mask fit across facial hair types and lengths are needed, along with the development of protective equipment that accommodates career-limiting conditions such as PFB, cystic acne, and acne keloidalis nuchae. This also may encourage development of equipment that does not induce such conditions (eg, mechanical acne from friction). These efforts would promote safety, scientific innovation for dermatologic follicular-based disorders, and overall quality of life for service members as well as increase their ability to serve without stigma. These developments also would positively impact other fields that require intermittent or full-time use of masks, including health care and some food service industries.

Final Thoughts

The disproportionate impact of PFB in the military highlights the need for improved access to treatment, culturally informed care, and policies that avoid penalizing service members with tightly coiled hair and a desire to serve. We discussed PFB management strategies, clinical features, and implications across various skin tones in a previous publication.¹⁴ It is important to consider insights from individuals with PFB who are serving in the military as well as the medical personnel who care for them. Ensuring or creating effective treatment options drives innovation, and evidence-based accommodation plans can help individuals in uniformed professions avoid choosing between PFB management and their career. Promoting awareness about the impact of PFB beyond the razor is key to reducing disparities and supporting excellence among those who serve and desire to continue to do so.

THE DIAGNOSIS: Villar Nodule

The biopsy revealed features consistent with cutaneous endometriosis in the setting of a painful, tender, multilobulated nodule with a cyclical bleeding pattern (Figure 1). The bleeding pattern of the nodule during menses and lack of surgical history supported the diagnosis of primary cutaneous endometriosis in our patient. She was diagnosed with endometriosis by gynecology, and her primary care physician started her on an oral contraceptive based on this diagnosis. She also was referred to gynecology and plastic surgery for a joint surgical consultation to remove the nodule. She initially decided to do a trial of the oral contraceptive but subsequently underwent umbilical endometrioma excision with neo-umbilicus creation with no evidence of recurrence.

Primary cutaneous endometriosis should be considered in young females who present with tender umbilical nodules. Endometriosis refers to the presence of an endometriumlike epithelium outside the endometrium and myometrium.¹ The condition affects 10% to 15% of reproductive-aged (ie, 18-49 years) women in the United States and typically involves tissues within the pelvis, such as the ovaries, pouch of Douglas, or pelvic ligaments.² Cutaneous endometriosis is the growth of endometrial tissue in the skin and is rare, accounting for less than 5.5% of cases of extrapelvic endometriosis worldwide, affecting primarily the umbilicus, abdominal wall, and vulva.^3,4

The 2 main types of cutaneous endometriosis are primary (spontaneous) and secondary. Primary lesions develop in patients without prior surgical history, and secondary lesions occur within previous surgical incision sites, often scars from cesarean delivery.⁵ Less than 30% of cases of cutaneous endometriosis are primary disease.⁶ Primary cutaneous endometriosis of the umbilicus, known as Villar nodule, was first described in 1886.^3,7 Up to 40% of patients with extrapelvic endometriosis worldwide presented with Villar nodules in a systematic literature review.⁶ The prevalence of these nodules is unknown, but the incidence is less than 1% of cases of extragenital endometriosis.⁴

There are 2 leading theories of primary cutaneous endometriosis pathogenesis. The first is the transportation theory, in which endometrial cells are transported outside the uterus via the lymphatic system.⁸ The second is the metaplasia theory, which proposed that endometrial cells develop in the coelomic mesothelium in the presence of high estrogen levels.^8,9

Secondary cutaneous endometriosis, also known as scar endometriosis, is suspected to be caused by an iatrogenic implantation of endometrial cells at the scar of a prior surgical site.⁹ Although our patient had an existing umbilicus scar from a piercing, it was improbable for that to have been the nidus, as the keloid scar was superficial and did not have contact with the abdominal cavity for iatrogenic implantation. Clinical diagnosis for secondary cutaneous endometriosis often is made based on a triad of features: a nonmalignant abdominal mass, recurring pain and bleeding of the lesion with menses, and prior history of abdominal surgery.^9,10 On clinical examination, these features typically manifest as a palpable subcutaneous mass that is black, blue, brown, or red. Often, the lesions enlarge and bleed during the menstrual cycle, causing pain, tenderness, or pruritus.³ Dermoscopic features of secondary cutaneous endometriosis are erythematous umbilical nodules with a homogeneous vascular pattern that appears red with a brownish hue (Figure 2).^9,11 Dermoscopic features may vary with the hormone cycle; for example, the follicular phase (correlating with day 7 of menses) demonstrates polypoid projections, erythematous violaceous color, dark-brown spots, and active bleeding of the lesion.¹² Clinical and dermoscopic examination are useful tools in this diagnosis.

Imaging such as ultrasonography, computed tomography, or magnetic resonance imaging may be useful in identifying abdominal endometriomas.^8,13,14 Pelvic involvement of endometriosis was found in approximately 15% of patients in a case series,⁴ with concurrent primary umbilical endometriosis. Imaging studies may assist evaluation for fistula formation, presence of malignancies, and the extent of endometriosis within the abdominal cavity.

Histopathology is key to confirming cutaneous endometriosis and shows multiple bland-appearing glands of varying sizes with loose, concentric, edematous, or fibromyxoid stroma (Figure 1).³ Red blood cells sometimes are found with hemosiderin within the stroma. Immunohistochemical staining with estrogen receptors may aid in identifying the endometriumlike epithelial cells.¹³

Standard treatment involves surgical excision with 1-cm margins and umbilical preservation, which results in a recurrence rate of less than 10%.^4,10 Medical therapy, such as aromatase inhibitors, progestogens, antiprogestogens, combined oral contraceptives, or gonadotropin-releasing hormone agonists or antagonists may help manage pain or reduce the size of the nodule.^4,15 Simple observation also is a potential course for patients who decline treatment options.

Differential diagnoses include lobular capillary hemangioma, also known as pyogenic granuloma; Sister Mary Joseph nodule; umbilical hernia; and dermatofibrosarcoma protuberans. Lobular capillary hemangiomas commonly are acquired benign vascular proliferations of the skin that are friable and tend to ulcerate.¹⁶ These lesions typically grow rapidly and often are located on the face, lips, mucosae, and fingers. Histopathologic examination may show an exophytic lesion with lobules of proliferating capillaries within an edematous matrix, superficial ulceration, and an epithelial collarette.¹⁷ Treatment includes surgical excision, cauterization, laser treatments, sclerotherapy, injectable medications, and topical medications, but recurrence is possible with any of these interventions.¹⁸

Cutaneous metastasis of an internal solid organ cancer, commonly known as a Sister Mary Joseph nodule, typically manifests as an erythematous, irregularly shaped nodule that may protrude from the umbilicus.¹⁴ Gastrointestinal symptoms such as change in bowel habits or obstructive symptoms in the setting of a progressive malignancy are common.¹⁴ Clinical features include a firm fixed lesion, oozing, and ulceration.¹⁹ On dermoscopy, polymorphous vascular patterns, milky red structureless areas, and white lines typically are present.¹¹ Although dermoscopic features may differentiate this entity from cutaneous endometriosis, tissue sampling and histologic examination are crucial diagnostic tools to identify malignant vs benign lesions.

An umbilical hernia is a protrusion of omentum, bowel, or other intra-abdominal organs in an abdominal wall defect. Clinical presentation includes a soft protrusion that may be reduced on palpation if nonstrangulated.²⁰ Treatment includes watchful waiting or surgical repair. The reducibility and presence of an abdominal wall defect may point to this diagnosis. Imaging also may aid in the diagnosis if the history and physical examination are unclear.

Dermatofibrosarcoma protuberans is a slow-developing, low- to intermediate-grade, soft-tissue sarcoma that occurs in less than 0.1% of all cancers in the United States.²¹ Lesions often manifest as small, firm, slow-growing, painless, flesh-colored dermal plaques; subcutaneous thickening; or atrophic nonprotuberant lesions typically involving the trunk.²¹ Histopathologically, they are composed of uniform spindle-cell proliferation growing in a storiform pattern and subcutaneous fat trapping that has strong and diffuse CD34 immunoreactivity.^21,22 Pathologic examination typically distinguishes this diagnosis from cutaneous endometriosis. Treatment includes tumor resection that may or may not involve radiotherapy and targeted therapy, as recurrence and metastases are possible.

Primary cutaneous endometriosis is a rare but important diagnosis for dermatologists to consider when evaluating umbilical nodules. Clinical features may include bleeding masses during menses in females of reproductive age. Dermoscopic examination aids in workup, and histopathologic testing can confirm the diagnosis and rule out malignancies. Surgical excision is the treatment of choice with a low rate of recurrence.

THE DIAGNOSIS: Villar Nodule

The biopsy revealed features consistent with cutaneous endometriosis in the setting of a painful, tender, multilobulated nodule with a cyclical bleeding pattern (Figure 1). The bleeding pattern of the nodule during menses and lack of surgical history supported the diagnosis of primary cutaneous endometriosis in our patient. She was diagnosed with endometriosis by gynecology, and her primary care physician started her on an oral contraceptive based on this diagnosis. She also was referred to gynecology and plastic surgery for a joint surgical consultation to remove the nodule. She initially decided to do a trial of the oral contraceptive but subsequently underwent umbilical endometrioma excision with neo-umbilicus creation with no evidence of recurrence.

Primary cutaneous endometriosis should be considered in young females who present with tender umbilical nodules. Endometriosis refers to the presence of an endometriumlike epithelium outside the endometrium and myometrium.¹ The condition affects 10% to 15% of reproductive-aged (ie, 18-49 years) women in the United States and typically involves tissues within the pelvis, such as the ovaries, pouch of Douglas, or pelvic ligaments.² Cutaneous endometriosis is the growth of endometrial tissue in the skin and is rare, accounting for less than 5.5% of cases of extrapelvic endometriosis worldwide, affecting primarily the umbilicus, abdominal wall, and vulva.^3,4

The 2 main types of cutaneous endometriosis are primary (spontaneous) and secondary. Primary lesions develop in patients without prior surgical history, and secondary lesions occur within previous surgical incision sites, often scars from cesarean delivery.⁵ Less than 30% of cases of cutaneous endometriosis are primary disease.⁶ Primary cutaneous endometriosis of the umbilicus, known as Villar nodule, was first described in 1886.^3,7 Up to 40% of patients with extrapelvic endometriosis worldwide presented with Villar nodules in a systematic literature review.⁶ The prevalence of these nodules is unknown, but the incidence is less than 1% of cases of extragenital endometriosis.⁴

There are 2 leading theories of primary cutaneous endometriosis pathogenesis. The first is the transportation theory, in which endometrial cells are transported outside the uterus via the lymphatic system.⁸ The second is the metaplasia theory, which proposed that endometrial cells develop in the coelomic mesothelium in the presence of high estrogen levels.^8,9

Secondary cutaneous endometriosis, also known as scar endometriosis, is suspected to be caused by an iatrogenic implantation of endometrial cells at the scar of a prior surgical site.⁹ Although our patient had an existing umbilicus scar from a piercing, it was improbable for that to have been the nidus, as the keloid scar was superficial and did not have contact with the abdominal cavity for iatrogenic implantation. Clinical diagnosis for secondary cutaneous endometriosis often is made based on a triad of features: a nonmalignant abdominal mass, recurring pain and bleeding of the lesion with menses, and prior history of abdominal surgery.^9,10 On clinical examination, these features typically manifest as a palpable subcutaneous mass that is black, blue, brown, or red. Often, the lesions enlarge and bleed during the menstrual cycle, causing pain, tenderness, or pruritus.³ Dermoscopic features of secondary cutaneous endometriosis are erythematous umbilical nodules with a homogeneous vascular pattern that appears red with a brownish hue (Figure 2).^9,11 Dermoscopic features may vary with the hormone cycle; for example, the follicular phase (correlating with day 7 of menses) demonstrates polypoid projections, erythematous violaceous color, dark-brown spots, and active bleeding of the lesion.¹² Clinical and dermoscopic examination are useful tools in this diagnosis.

Imaging such as ultrasonography, computed tomography, or magnetic resonance imaging may be useful in identifying abdominal endometriomas.^8,13,14 Pelvic involvement of endometriosis was found in approximately 15% of patients in a case series,⁴ with concurrent primary umbilical endometriosis. Imaging studies may assist evaluation for fistula formation, presence of malignancies, and the extent of endometriosis within the abdominal cavity.

Histopathology is key to confirming cutaneous endometriosis and shows multiple bland-appearing glands of varying sizes with loose, concentric, edematous, or fibromyxoid stroma (Figure 1).³ Red blood cells sometimes are found with hemosiderin within the stroma. Immunohistochemical staining with estrogen receptors may aid in identifying the endometriumlike epithelial cells.¹³

Standard treatment involves surgical excision with 1-cm margins and umbilical preservation, which results in a recurrence rate of less than 10%.^4,10 Medical therapy, such as aromatase inhibitors, progestogens, antiprogestogens, combined oral contraceptives, or gonadotropin-releasing hormone agonists or antagonists may help manage pain or reduce the size of the nodule.^4,15 Simple observation also is a potential course for patients who decline treatment options.

Differential diagnoses include lobular capillary hemangioma, also known as pyogenic granuloma; Sister Mary Joseph nodule; umbilical hernia; and dermatofibrosarcoma protuberans. Lobular capillary hemangiomas commonly are acquired benign vascular proliferations of the skin that are friable and tend to ulcerate.¹⁶ These lesions typically grow rapidly and often are located on the face, lips, mucosae, and fingers. Histopathologic examination may show an exophytic lesion with lobules of proliferating capillaries within an edematous matrix, superficial ulceration, and an epithelial collarette.¹⁷ Treatment includes surgical excision, cauterization, laser treatments, sclerotherapy, injectable medications, and topical medications, but recurrence is possible with any of these interventions.¹⁸

Cutaneous metastasis of an internal solid organ cancer, commonly known as a Sister Mary Joseph nodule, typically manifests as an erythematous, irregularly shaped nodule that may protrude from the umbilicus.¹⁴ Gastrointestinal symptoms such as change in bowel habits or obstructive symptoms in the setting of a progressive malignancy are common.¹⁴ Clinical features include a firm fixed lesion, oozing, and ulceration.¹⁹ On dermoscopy, polymorphous vascular patterns, milky red structureless areas, and white lines typically are present.¹¹ Although dermoscopic features may differentiate this entity from cutaneous endometriosis, tissue sampling and histologic examination are crucial diagnostic tools to identify malignant vs benign lesions.

An umbilical hernia is a protrusion of omentum, bowel, or other intra-abdominal organs in an abdominal wall defect. Clinical presentation includes a soft protrusion that may be reduced on palpation if nonstrangulated.²⁰ Treatment includes watchful waiting or surgical repair. The reducibility and presence of an abdominal wall defect may point to this diagnosis. Imaging also may aid in the diagnosis if the history and physical examination are unclear.

Dermatofibrosarcoma protuberans is a slow-developing, low- to intermediate-grade, soft-tissue sarcoma that occurs in less than 0.1% of all cancers in the United States.²¹ Lesions often manifest as small, firm, slow-growing, painless, flesh-colored dermal plaques; subcutaneous thickening; or atrophic nonprotuberant lesions typically involving the trunk.²¹ Histopathologically, they are composed of uniform spindle-cell proliferation growing in a storiform pattern and subcutaneous fat trapping that has strong and diffuse CD34 immunoreactivity.^21,22 Pathologic examination typically distinguishes this diagnosis from cutaneous endometriosis. Treatment includes tumor resection that may or may not involve radiotherapy and targeted therapy, as recurrence and metastases are possible.

Primary cutaneous endometriosis is a rare but important diagnosis for dermatologists to consider when evaluating umbilical nodules. Clinical features may include bleeding masses during menses in females of reproductive age. Dermoscopic examination aids in workup, and histopathologic testing can confirm the diagnosis and rule out malignancies. Surgical excision is the treatment of choice with a low rate of recurrence.

THE DIAGNOSIS: Villar Nodule

The biopsy revealed features consistent with cutaneous endometriosis in the setting of a painful, tender, multilobulated nodule with a cyclical bleeding pattern (Figure 1). The bleeding pattern of the nodule during menses and lack of surgical history supported the diagnosis of primary cutaneous endometriosis in our patient. She was diagnosed with endometriosis by gynecology, and her primary care physician started her on an oral contraceptive based on this diagnosis. She also was referred to gynecology and plastic surgery for a joint surgical consultation to remove the nodule. She initially decided to do a trial of the oral contraceptive but subsequently underwent umbilical endometrioma excision with neo-umbilicus creation with no evidence of recurrence.

Primary cutaneous endometriosis should be considered in young females who present with tender umbilical nodules. Endometriosis refers to the presence of an endometriumlike epithelium outside the endometrium and myometrium.¹ The condition affects 10% to 15% of reproductive-aged (ie, 18-49 years) women in the United States and typically involves tissues within the pelvis, such as the ovaries, pouch of Douglas, or pelvic ligaments.² Cutaneous endometriosis is the growth of endometrial tissue in the skin and is rare, accounting for less than 5.5% of cases of extrapelvic endometriosis worldwide, affecting primarily the umbilicus, abdominal wall, and vulva.^3,4

The 2 main types of cutaneous endometriosis are primary (spontaneous) and secondary. Primary lesions develop in patients without prior surgical history, and secondary lesions occur within previous surgical incision sites, often scars from cesarean delivery.⁵ Less than 30% of cases of cutaneous endometriosis are primary disease.⁶ Primary cutaneous endometriosis of the umbilicus, known as Villar nodule, was first described in 1886.^3,7 Up to 40% of patients with extrapelvic endometriosis worldwide presented with Villar nodules in a systematic literature review.⁶ The prevalence of these nodules is unknown, but the incidence is less than 1% of cases of extragenital endometriosis.⁴

There are 2 leading theories of primary cutaneous endometriosis pathogenesis. The first is the transportation theory, in which endometrial cells are transported outside the uterus via the lymphatic system.⁸ The second is the metaplasia theory, which proposed that endometrial cells develop in the coelomic mesothelium in the presence of high estrogen levels.^8,9

Secondary cutaneous endometriosis, also known as scar endometriosis, is suspected to be caused by an iatrogenic implantation of endometrial cells at the scar of a prior surgical site.⁹ Although our patient had an existing umbilicus scar from a piercing, it was improbable for that to have been the nidus, as the keloid scar was superficial and did not have contact with the abdominal cavity for iatrogenic implantation. Clinical diagnosis for secondary cutaneous endometriosis often is made based on a triad of features: a nonmalignant abdominal mass, recurring pain and bleeding of the lesion with menses, and prior history of abdominal surgery.^9,10 On clinical examination, these features typically manifest as a palpable subcutaneous mass that is black, blue, brown, or red. Often, the lesions enlarge and bleed during the menstrual cycle, causing pain, tenderness, or pruritus.³ Dermoscopic features of secondary cutaneous endometriosis are erythematous umbilical nodules with a homogeneous vascular pattern that appears red with a brownish hue (Figure 2).^9,11 Dermoscopic features may vary with the hormone cycle; for example, the follicular phase (correlating with day 7 of menses) demonstrates polypoid projections, erythematous violaceous color, dark-brown spots, and active bleeding of the lesion.¹² Clinical and dermoscopic examination are useful tools in this diagnosis.

Imaging such as ultrasonography, computed tomography, or magnetic resonance imaging may be useful in identifying abdominal endometriomas.^8,13,14 Pelvic involvement of endometriosis was found in approximately 15% of patients in a case series,⁴ with concurrent primary umbilical endometriosis. Imaging studies may assist evaluation for fistula formation, presence of malignancies, and the extent of endometriosis within the abdominal cavity.

Histopathology is key to confirming cutaneous endometriosis and shows multiple bland-appearing glands of varying sizes with loose, concentric, edematous, or fibromyxoid stroma (Figure 1).³ Red blood cells sometimes are found with hemosiderin within the stroma. Immunohistochemical staining with estrogen receptors may aid in identifying the endometriumlike epithelial cells.¹³

Standard treatment involves surgical excision with 1-cm margins and umbilical preservation, which results in a recurrence rate of less than 10%.^4,10 Medical therapy, such as aromatase inhibitors, progestogens, antiprogestogens, combined oral contraceptives, or gonadotropin-releasing hormone agonists or antagonists may help manage pain or reduce the size of the nodule.^4,15 Simple observation also is a potential course for patients who decline treatment options.

Differential diagnoses include lobular capillary hemangioma, also known as pyogenic granuloma; Sister Mary Joseph nodule; umbilical hernia; and dermatofibrosarcoma protuberans. Lobular capillary hemangiomas commonly are acquired benign vascular proliferations of the skin that are friable and tend to ulcerate.¹⁶ These lesions typically grow rapidly and often are located on the face, lips, mucosae, and fingers. Histopathologic examination may show an exophytic lesion with lobules of proliferating capillaries within an edematous matrix, superficial ulceration, and an epithelial collarette.¹⁷ Treatment includes surgical excision, cauterization, laser treatments, sclerotherapy, injectable medications, and topical medications, but recurrence is possible with any of these interventions.¹⁸

Cutaneous metastasis of an internal solid organ cancer, commonly known as a Sister Mary Joseph nodule, typically manifests as an erythematous, irregularly shaped nodule that may protrude from the umbilicus.¹⁴ Gastrointestinal symptoms such as change in bowel habits or obstructive symptoms in the setting of a progressive malignancy are common.¹⁴ Clinical features include a firm fixed lesion, oozing, and ulceration.¹⁹ On dermoscopy, polymorphous vascular patterns, milky red structureless areas, and white lines typically are present.¹¹ Although dermoscopic features may differentiate this entity from cutaneous endometriosis, tissue sampling and histologic examination are crucial diagnostic tools to identify malignant vs benign lesions.

An umbilical hernia is a protrusion of omentum, bowel, or other intra-abdominal organs in an abdominal wall defect. Clinical presentation includes a soft protrusion that may be reduced on palpation if nonstrangulated.²⁰ Treatment includes watchful waiting or surgical repair. The reducibility and presence of an abdominal wall defect may point to this diagnosis. Imaging also may aid in the diagnosis if the history and physical examination are unclear.

Dermatofibrosarcoma protuberans is a slow-developing, low- to intermediate-grade, soft-tissue sarcoma that occurs in less than 0.1% of all cancers in the United States.²¹ Lesions often manifest as small, firm, slow-growing, painless, flesh-colored dermal plaques; subcutaneous thickening; or atrophic nonprotuberant lesions typically involving the trunk.²¹ Histopathologically, they are composed of uniform spindle-cell proliferation growing in a storiform pattern and subcutaneous fat trapping that has strong and diffuse CD34 immunoreactivity.^21,22 Pathologic examination typically distinguishes this diagnosis from cutaneous endometriosis. Treatment includes tumor resection that may or may not involve radiotherapy and targeted therapy, as recurrence and metastases are possible.

Primary cutaneous endometriosis is a rare but important diagnosis for dermatologists to consider when evaluating umbilical nodules. Clinical features may include bleeding masses during menses in females of reproductive age. Dermoscopic examination aids in workup, and histopathologic testing can confirm the diagnosis and rule out malignancies. Surgical excision is the treatment of choice with a low rate of recurrence.

THE DIAGNOSIS: Reactive Perforating Collagenosis

Histopathology revealed invagination of the epidermis with hyperkeratosis; prominent epidermal hyperplasia; and a central basophilic plug of keratin, collagen, and inflammatory debris. Transepidermal elimination of bright eosinophilic altered collagen fibers was seen (Figure). The findings were consistent with a diagnosis of reactive perforating collagenosis (RPC).

Reactive perforating collagenosis, a subtype of perforating dermatosis, is a rare skin condition in which altered collagen is eliminated through the epidermis.¹ There are 2 forms of RPC: the inherited form, which is very rare and manifests in childhood, and the acquired form, which manifests in adulthood and is associated with systemic diseases, most notably diabetes and/or chronic renal failure, both of which our patient had been diagnosed with.^1,2 The clinical presentation of RPC includes erythematous papules or nodules that evolve into umbilicated 4- to 10-mm craterlike ulcerations with a central keratotic plug. The lesions favor a linear distribution along the extensor surfaces of the arms and legs, trunk, and gluteal area. Involvement of the head, neck, and scalp has been reported less commonly, which makes our case particularly unique.³ Histopathologically, RPC is characterized by a cup-shaped depression of the epidermis with an overlying keratin plug containing inflammatory cells, keratinous debris, and collagen fibers. Vertically oriented collagen fibers are seen extruded through the epidermis.^4,5

While the pathogenesis of RPC remains unknown, it is believed that superficial trauma due to chronic scratching results in transepithelial elimination of collagen. Due to the association of acquired RPC (ARPC) with diabetes, it also has been proposed that scratching can cause microtrauma and necrosis of the dermal structures, potentially due to diabetic microangiopathy.³ Additionally, RPC is associated with overexpression of transforming growth factor beta 3 in lesional skin, suggesting that transforming growth factor beta 3 is involved with tissue repair and extracellular remodeling in this condition.⁶

Treatment of ARPC should include the management of underlying disease. While no definitive treatment has been reported to date, topical corticosteroids, retinoids, keratolytics, emollients, antihistamines, narrow-band UVB phototherapy, and psoralen plus UVA phototherapy have been used with varying degrees of improvement. Typically, the lesions self-resolve within 6 to 8 weeks; however, they often recur and usually leave scarring with or without hyperpigmentation.^2,7-10

Acquired RPC can be misdiagnosed initially, as it mimics several other conditions and commonly is associated with systemic diseases. While biopsy is necessary for diagnosis, if it cannot be performed or the results are indeterminate, dermoscopy can serve as a helpful diagnostic tool. The most common dermoscopic patterns seen in RPC include a yellow-brown structureless area in the center of the lesion with a peripheral surface crust and surrounding white rim—thought to represent epidermal invagination or keratinous debris. Additionally, inflammation with visible vessels both centrally and peripherally is represented by an outer pink circle on dermoscopy.^5,11

The differential diagnoses for RPC include perforating folliculitis (PF), elastosis perforans serpiginosa (EPS), prurigo nodularis, and keratoacanthomas. The primary perforating dermatoses (PF, EPS, and RPC) are similarly characterized by elimination of altered dermal material through the epidermis. As these conditions manifest with similar features on clinical examination, differentiation is made by the type of epidermal damage and the features of elimination material, making histopathologic examination paramount for definitive diagnosis.

Perforating folliculitis manifests as erythematous, follicular papules with a small central keratotic core or a central hair. Histopathologically, PF reveals a widely dilated follicle containing keratin, necrotic debris, and degenerated inflammatory cells. Elastosis perforans serpiginosa manifests clinically as hyperkeratotic papules in serpiginous patterns rather than the linear pattern commonly seen with ARPC. Histopathologically, EPS reveals thickened elastic fibers, rather than collagen fibers as seen in ARPC, extruded through the epidermis. Prurigo nodularis manifests clinically as dome-shaped papules with possible excoriation and crusting. Histopathologic examination reveals epidermal hyperplasia and hyperkeratosis; however, the characteristic features of transepithelial elimination of collagen and invaginations of epidermis differentiate ARPC from prurigo nodularis.^12,13 Keratoacanthomas manifest clinically as an eruption of small, round, pink papules that rapidly grow and evolve into 1- to 2-cm dome-shaped nodules with central keratinaceous plugs, mimicking a crateriform appearance. Histopathologic examination reveals a circumscribed proliferation of well-differentiated keratinocytes. Multilobular exophytic or endophytic cystlike invaginations of the epidermis also are noted. The expulsion of collagen from the epidermis is more consistent with ARPC.¹⁴

THE DIAGNOSIS: Reactive Perforating Collagenosis

Histopathology revealed invagination of the epidermis with hyperkeratosis; prominent epidermal hyperplasia; and a central basophilic plug of keratin, collagen, and inflammatory debris. Transepidermal elimination of bright eosinophilic altered collagen fibers was seen (Figure). The findings were consistent with a diagnosis of reactive perforating collagenosis (RPC).

Reactive perforating collagenosis, a subtype of perforating dermatosis, is a rare skin condition in which altered collagen is eliminated through the epidermis.¹ There are 2 forms of RPC: the inherited form, which is very rare and manifests in childhood, and the acquired form, which manifests in adulthood and is associated with systemic diseases, most notably diabetes and/or chronic renal failure, both of which our patient had been diagnosed with.^1,2 The clinical presentation of RPC includes erythematous papules or nodules that evolve into umbilicated 4- to 10-mm craterlike ulcerations with a central keratotic plug. The lesions favor a linear distribution along the extensor surfaces of the arms and legs, trunk, and gluteal area. Involvement of the head, neck, and scalp has been reported less commonly, which makes our case particularly unique.³ Histopathologically, RPC is characterized by a cup-shaped depression of the epidermis with an overlying keratin plug containing inflammatory cells, keratinous debris, and collagen fibers. Vertically oriented collagen fibers are seen extruded through the epidermis.^4,5

While the pathogenesis of RPC remains unknown, it is believed that superficial trauma due to chronic scratching results in transepithelial elimination of collagen. Due to the association of acquired RPC (ARPC) with diabetes, it also has been proposed that scratching can cause microtrauma and necrosis of the dermal structures, potentially due to diabetic microangiopathy.³ Additionally, RPC is associated with overexpression of transforming growth factor beta 3 in lesional skin, suggesting that transforming growth factor beta 3 is involved with tissue repair and extracellular remodeling in this condition.⁶

Treatment of ARPC should include the management of underlying disease. While no definitive treatment has been reported to date, topical corticosteroids, retinoids, keratolytics, emollients, antihistamines, narrow-band UVB phototherapy, and psoralen plus UVA phototherapy have been used with varying degrees of improvement. Typically, the lesions self-resolve within 6 to 8 weeks; however, they often recur and usually leave scarring with or without hyperpigmentation.^2,7-10

Acquired RPC can be misdiagnosed initially, as it mimics several other conditions and commonly is associated with systemic diseases. While biopsy is necessary for diagnosis, if it cannot be performed or the results are indeterminate, dermoscopy can serve as a helpful diagnostic tool. The most common dermoscopic patterns seen in RPC include a yellow-brown structureless area in the center of the lesion with a peripheral surface crust and surrounding white rim—thought to represent epidermal invagination or keratinous debris. Additionally, inflammation with visible vessels both centrally and peripherally is represented by an outer pink circle on dermoscopy.^5,11

The differential diagnoses for RPC include perforating folliculitis (PF), elastosis perforans serpiginosa (EPS), prurigo nodularis, and keratoacanthomas. The primary perforating dermatoses (PF, EPS, and RPC) are similarly characterized by elimination of altered dermal material through the epidermis. As these conditions manifest with similar features on clinical examination, differentiation is made by the type of epidermal damage and the features of elimination material, making histopathologic examination paramount for definitive diagnosis.

Perforating folliculitis manifests as erythematous, follicular papules with a small central keratotic core or a central hair. Histopathologically, PF reveals a widely dilated follicle containing keratin, necrotic debris, and degenerated inflammatory cells. Elastosis perforans serpiginosa manifests clinically as hyperkeratotic papules in serpiginous patterns rather than the linear pattern commonly seen with ARPC. Histopathologically, EPS reveals thickened elastic fibers, rather than collagen fibers as seen in ARPC, extruded through the epidermis. Prurigo nodularis manifests clinically as dome-shaped papules with possible excoriation and crusting. Histopathologic examination reveals epidermal hyperplasia and hyperkeratosis; however, the characteristic features of transepithelial elimination of collagen and invaginations of epidermis differentiate ARPC from prurigo nodularis.^12,13 Keratoacanthomas manifest clinically as an eruption of small, round, pink papules that rapidly grow and evolve into 1- to 2-cm dome-shaped nodules with central keratinaceous plugs, mimicking a crateriform appearance. Histopathologic examination reveals a circumscribed proliferation of well-differentiated keratinocytes. Multilobular exophytic or endophytic cystlike invaginations of the epidermis also are noted. The expulsion of collagen from the epidermis is more consistent with ARPC.¹⁴

THE DIAGNOSIS: Reactive Perforating Collagenosis

Histopathology revealed invagination of the epidermis with hyperkeratosis; prominent epidermal hyperplasia; and a central basophilic plug of keratin, collagen, and inflammatory debris. Transepidermal elimination of bright eosinophilic altered collagen fibers was seen (Figure). The findings were consistent with a diagnosis of reactive perforating collagenosis (RPC).

Reactive perforating collagenosis, a subtype of perforating dermatosis, is a rare skin condition in which altered collagen is eliminated through the epidermis.¹ There are 2 forms of RPC: the inherited form, which is very rare and manifests in childhood, and the acquired form, which manifests in adulthood and is associated with systemic diseases, most notably diabetes and/or chronic renal failure, both of which our patient had been diagnosed with.^1,2 The clinical presentation of RPC includes erythematous papules or nodules that evolve into umbilicated 4- to 10-mm craterlike ulcerations with a central keratotic plug. The lesions favor a linear distribution along the extensor surfaces of the arms and legs, trunk, and gluteal area. Involvement of the head, neck, and scalp has been reported less commonly, which makes our case particularly unique.³ Histopathologically, RPC is characterized by a cup-shaped depression of the epidermis with an overlying keratin plug containing inflammatory cells, keratinous debris, and collagen fibers. Vertically oriented collagen fibers are seen extruded through the epidermis.^4,5

While the pathogenesis of RPC remains unknown, it is believed that superficial trauma due to chronic scratching results in transepithelial elimination of collagen. Due to the association of acquired RPC (ARPC) with diabetes, it also has been proposed that scratching can cause microtrauma and necrosis of the dermal structures, potentially due to diabetic microangiopathy.³ Additionally, RPC is associated with overexpression of transforming growth factor beta 3 in lesional skin, suggesting that transforming growth factor beta 3 is involved with tissue repair and extracellular remodeling in this condition.⁶

Treatment of ARPC should include the management of underlying disease. While no definitive treatment has been reported to date, topical corticosteroids, retinoids, keratolytics, emollients, antihistamines, narrow-band UVB phototherapy, and psoralen plus UVA phototherapy have been used with varying degrees of improvement. Typically, the lesions self-resolve within 6 to 8 weeks; however, they often recur and usually leave scarring with or without hyperpigmentation.^2,7-10

Acquired RPC can be misdiagnosed initially, as it mimics several other conditions and commonly is associated with systemic diseases. While biopsy is necessary for diagnosis, if it cannot be performed or the results are indeterminate, dermoscopy can serve as a helpful diagnostic tool. The most common dermoscopic patterns seen in RPC include a yellow-brown structureless area in the center of the lesion with a peripheral surface crust and surrounding white rim—thought to represent epidermal invagination or keratinous debris. Additionally, inflammation with visible vessels both centrally and peripherally is represented by an outer pink circle on dermoscopy.^5,11

The differential diagnoses for RPC include perforating folliculitis (PF), elastosis perforans serpiginosa (EPS), prurigo nodularis, and keratoacanthomas. The primary perforating dermatoses (PF, EPS, and RPC) are similarly characterized by elimination of altered dermal material through the epidermis. As these conditions manifest with similar features on clinical examination, differentiation is made by the type of epidermal damage and the features of elimination material, making histopathologic examination paramount for definitive diagnosis.

Perforating folliculitis manifests as erythematous, follicular papules with a small central keratotic core or a central hair. Histopathologically, PF reveals a widely dilated follicle containing keratin, necrotic debris, and degenerated inflammatory cells. Elastosis perforans serpiginosa manifests clinically as hyperkeratotic papules in serpiginous patterns rather than the linear pattern commonly seen with ARPC. Histopathologically, EPS reveals thickened elastic fibers, rather than collagen fibers as seen in ARPC, extruded through the epidermis. Prurigo nodularis manifests clinically as dome-shaped papules with possible excoriation and crusting. Histopathologic examination reveals epidermal hyperplasia and hyperkeratosis; however, the characteristic features of transepithelial elimination of collagen and invaginations of epidermis differentiate ARPC from prurigo nodularis.^12,13 Keratoacanthomas manifest clinically as an eruption of small, round, pink papules that rapidly grow and evolve into 1- to 2-cm dome-shaped nodules with central keratinaceous plugs, mimicking a crateriform appearance. Histopathologic examination reveals a circumscribed proliferation of well-differentiated keratinocytes. Multilobular exophytic or endophytic cystlike invaginations of the epidermis also are noted. The expulsion of collagen from the epidermis is more consistent with ARPC.¹⁴

Dermatology is a rapidly growing, highly competitive specialty with patients that can be served via private practice, academic medicine, hybrid settings, and rural health clinics. Medical residents’ choice of a career path has been rapidly evolving alongside shifts in health care policy, increasing demand for dermatologic services, stagnant fees falling behind inflation for more than a decade, and payment methods that no longer reflect the traditional fee-for-service model. This places a lot of pressure on young dermatologists to evaluate which practice structure best fits their career goals. A nuanced understanding of the strengths and limitations of each practice model is essential for dermatologists to make informed career decisions that are aligned with their values.

While there are many health care practice models, the first decision dermatology residents must make is whether they would prefer working in the private sector or an academic practice. Of course, it is not uncommon for academic dermatologists to embark on a midcareer segue into private practice and, less commonly, for private dermatologists to culminate their careers with a move to academics. The private sector includes private practice, private equity (PE)–owned group practices that often are single-specialty focused, and hospital-owned group practices that usually are multispecialty. Traditionally, private practices are health care businesses owned by one physician (solo practice) or a group of physicians (group practice) operated independently from hospitals, health systems, or private investors. Financially, these practices rely heavily on volume-based services, especially clinic visits and cosmetic procedures, which provide higher reimbursement rates and usually cash payments at the time of service.¹ Roughly 35% of dermatologists in the United States work in private practice, and a dwindling 15% work in solo practice.^2,3

Medical practices that are not self-owned by physicians vary widely, and they include hospital- or medical center–owned, private equity, and university-based academic practices. Private equity practices typically are characterized as profit driven. Hospital-owned practices shoulder business decisions and administrative duties for the physician at the cost of provider autonomy. Academic medicine is the most different from the other practice types. In contrast to private practice dermatologists, university-based dermatologists practice at academic medical centers (AMCs) with the core goals of patient care, education, and research. Compensation generally is based on the relative value unit (RVU), which is supplemented by government support and research grants. 

As evidenced in this brief discussion, health care practice models are complex, and choosing the right model to align with professional goals can pose a major challenge for many physicians. The advantages and disadvantages of various practice models will be reviewed, highlighting trends and emerging models.

Solo or Small-Group Single-Specialty Private Practice 

Private practice offers dermatologists the advantage of higher income potential but with greater economic risk; it often requires physicians to be more involved in the business aspects of dermatologic practice. In the early 1990s, a survey of private practice dermatologists revealed that income was the first or second most important factor that contributed to their career choice of private vs academic practice.⁴ Earning potential in private practice largely is driven by the autonomy afforded in this setting. Physicians have the liberty of choosing their practice location, structure, schedule, and staff in addition to tailoring services toward profitability; this typically leads to a higher volume of cosmetic and procedural visits, which may be attractive to providers wishing to focus on aesthetics. Private practice dermatologists also are not subject to institutional requirements that may include the preparation of grant submissions, research productivity targets, and devotion of time to teaching. Many private dermatologists find satisfaction in tailoring their work environments to align with personal values and goals and in cultivating long-term relationships with patients in a more personal and less bureaucratic context.

There also are drawbacks to private practice. The profitability often can be attributed to the higher patient load and more hours devoted to practice.⁵ A 2006 study found that academics saw 32% to 41% fewer patients per week than private practice dermatologists.⁶ Along with the opportunity for financial gain is the risk of financial ruin. Cost is the largest hurdle for establishing a practice, and most practices do not turn a profit for the first few years.^1,5 The financial burden of running a practice includes pressure from the federal government to adopt expensive electronic health record systems to achieve maximum Medicare payment through the Merit-Based Incentive Payment System, liability insurance, health insurance, and staff salaries.⁷ These challenges require strong business acumen, including managing overhead costs, navigating insurance negotiations, marketing a practice, and maintaining compliance with evolving health care regulations. The purchase of a $100,000 laser could be a boon or bust, requiring the development of a business plan that ensures a positive return on investment. Additionally, private practice profitability has the potential to dwindle as governmental reimbursements fail to match inflation rates. Securing business advisors or even obtaining a Master of Business Administration degree can be helpful.

Insurance and government agencies also are infringing upon some of the autonomy of private practice dermatologists, as evidenced by a 2017 survey of dermatologists that found that more than half of respondents altered treatment plans based on insurance coverage more than 20% of the time.² Private equity firms also could infringe on private practice autonomy, as providers are beholden to the firm’s restrictions—from which company’s product will be stocked to which partner will be on call. Lastly, private practice is less conducive to consistent referral patterns and strong relationships with specialists when compared to academic practice. Additionally, reliance on high patient throughput or cosmetic services for financial sustainability can shift focus away from complex medical dermatology, which often is referred to AMCs.

Academic Medicine

Academic dermatology offers a stimulating and collaborative environment with opportunities to advance the field through research and education. Often, the opportunity to teach medical students, residents, and peers is the deciding factor for academic dermatologists, as supported by a 2016 survey that found teaching opportunities are a major influence on career decision.⁸ The mixture of patient care, education, and research roles can be satisfying when compared to the grind of seeing large numbers of patients every day. Because they typically are salaried with an RVU-based income, academic dermatologists often are less concerned with the costs associated with medical treatment, and they typically treat more medically complex patients and underserved populations.⁹ The salary structure of academic roles also provides the benefit of a stable and predictable income. Physicians in this setting often are considered experts in their field, positioning them to have a strong built-in referral system along with frequent participation in multidisciplinary care alongside colleagues in rheumatology, oncology, and infectious diseases. The benefits of downstream income from dermatopathology, Mohs surgery, and other ancillary testing can provide great financial advantages for an academic or large group practice.¹⁰ Academic medical centers also afford the benefit of resources, such as research offices, clinical trial units, and institutional support for scholarly publication.

Despite its benefits, academic dermatology is not without unique demands. The resources afforded by research work come with grant application deadlines and the pressure to maintain research productivity as measured by grant dollars. Academic providers also must navigate institutional political dynamics and deal with limits on autonomy. Additionally, the administrative burden associated with committee work, mentorship obligations, and publishing requirements further limit clinical time and contribute to burnout. According to Loo et al,⁵ 92% of 89 dermatology department chairmen responding to a poll believed that the lower compensation was the primary factor preventing more residents from pursuing academia. 

The adoption of RVU-based and incentive compensation models at many AMCs, along with dwindling government funds available for research, also have created pressure to increase patient volume, sometimes at the expense of teaching and research. Of those academic dermatologists spending more than half their time seeing patients, a majority reported that they lack the time to also conduct research, teach, and mentor students and resident physicians.⁶ A survey of academic dermatologists suggested that, for those already serving in academic positions, salary was less of a concern than the lack of protected academic time.⁴ While competing demands can erode the appeal of academic dermatology, academia continues to offer a meaningful and fulfilling career path for those motivated by scholarship, mentorship, teaching opportunities, and systemic impact.

Hybrid and Emerging Models 

To reconcile the trade-offs inherent in private and academic models, hybrid roles are becoming increasingly common. In these arrangements, dermatologists split their time between private practice and academic appointments settings, allowing for participation in resident education and research while also benefiting from the operational and financial structure of a private office. In some cases, private groups formally affiliate with academic institutions, creating academic-private practices that host trainees and produce scholarly work while operating financially outside of traditional hospital systems. Individual dermatologists also may choose to accept part-time academic roles that allow residents and medical students to rotate in their offices. Hybrid roles may be of most interest to individuals who feel that they are missing out on the mentorship and teaching opportunities afforded at AMCs.

Government-funded systems such as Veterans Affairs (VA) hospitals offer another alternative. Dermatologists at VA hospitals often hold faculty appointments, treat a wide range of conditions in a population with great need, and engage in teaching without the intensity of productivity requirements seen at AMCs. These roles can be attractive to physicians who value public service, work-life balance, and minimal malpractice risk, as well as dermatologists who wish to introduce variety in their practice through an additional clinical setting. Notably, these roles are limited, as roughly 80% of VA hospitals employ part-time dermatologists and 72% reported being understaffed.¹¹ Despite the challenges of limited resources and increased bureaucracy, the VA is the largest health care delivery system in the United States, offering the benefits of protection from most malpractice risk and participation in medical education at 80% of VA hospitals.¹² A VA-based practice may be most attractive to physicians with prior military service or those looking for a stable practice that serves the underserved and the mission of medical education. 

Similarly, rural health clinics are private practices with special subsidies from the federal government that bring Medicaid payments up to the level of Medicare.¹³ Rural dermatology also mirrors that of a VA-based practice by offering the opportunity to treat an array of conditions in a population of great need, as rural patients often are in care deserts and would otherwise need to travel for miles to receive dermatologic care. There is a shortage of dermatologists working in rural areas, and rural dermatologists are more likely than those in suburban or urban areas to practice alone.² Although potentially more physically isolating, rural dermatology offers providers the opportunity to establish a lucrative practice with minimal competition and development of meaningful patient relationships. 

The most rapidly increasing practice model emerging in dermatology over the past decade is the private equity (PE) group. Rajabi-Estarabadi et al¹⁴ estimated that at least 184 dermatology practices have been acquired by PE groups between 2010 and 2019. An estimated 15% of all PE acquisitions in health care have been within the field of dermatology.⁹ Private equity firms typically acquire 1 or more practices, then consolidate the operations with the short-term goals of reducing costs and maximizing profits and longer-term goals of selling the practice for further profit in 3 to 7 years.⁹ They often rely heavily on a dermatologist supervising a number of nurse practitioners.¹⁵ While PE acquisition may provide additional financial stability and income, providers have less autonomy and potentially risk a shift in their focus from patient care to profit. 

The blurred lines between practice settings reflect a broader shift in the profession. Dermatologists have increasingly crafted flexible, individualized careers that align with their goals and values while drawing from both academic and private models. Hybrid roles may prove critical in preserving the educational and research missions of dermatology while adapting to economic and institutional realities.

Gender Trends, Career Satisfaction, and Other Factors Influencing Career Choice 

The gender demographics of dermatology have changed greatly in recent decades. In the years 2010 to 2021, the percentage of women in the field rose from 41% to 52.2%, mirroring the rise in female medical students.¹⁶ Despite this, gender disparities persist through differences in pay, promotion rates, leadership opportunities, and research productivity.¹⁷ Women who are academic dermatologists are less likely to have protected research time and often shoulder a disproportionate share of mentorship and administrative responsibilities, which frequently are undervalued in promotion and compensation structures. Similarly, women physicians are less likely to own their own private practice.¹⁸ Notably, women physicians work part-time more often than their male counterparts, which likely impacts their income.¹⁹ Interestingly, no differences were noted in job satisfaction between men and women in academic or private practice settings, suggesting that dermatology is a fulfilling field for female physicians.¹⁶ Similar data were observed in the field of dermatopathology; in fact, there is no difference in job satisfaction when comparing providers in academics vs private practice.²⁰

Geographic factors also influence career decisions. Some dermatologists may choose private practice to remain close to family or serve a rural area, while some choose academic centers typically located in major metropolitan areas. Others are drawn to AMCs due to their reputation, resources, or opportunities for specialization. The number of practicing dermatologists in an area also may be considered, as areas with fewer providers likely have more individuals seeking a provider and thus more earning potential. 

In summary, career satisfaction is influenced by many factors, including practice setting, colleagues, institutional leadership, work environment, and professional goals. For individuals who are seeking intellectual stimulation and teaching opportunities, academic dermatology may be a great career option. Academic or large group practices may come with a large group of clinical dermatologists to provide a steady stream of specimens. Private practice appeals to those seeking autonomy, reduced bureaucracy, and higher earning potential. Tierney et al²¹ found that the greatest predictor of a future career in academics among Mohs surgeons was the number of publications a fellow had before and during fellowship training. These data suggest that personal interests greatly influence career decisions. 

The Role of Mentorship in Career Decision-Making

Just as personal preferences guide career decisions, so too do interpersonal interactions. Mentorship plays a large role in career success, and the involvement of faculty mentors in society meetings and editorial boards has been shown to positively correlate with the number of residents pursuing academia.¹⁴ Similarly, negative interactions have strong impacts, as the top cited reason for Mohs surgeons leaving academia was lack of support from their academic chair.²¹ While many academic dermatologists report fulfillment from the collegial environment, retention remains an issue. Tierney et al²¹ found that, among 455 academic Mohs surgeons, only 28% of those who began in academia remained in those roles over the long term, and this trend of low retention holds true across the field of academic dermatology. Lack of autonomy, insufficient institutional support, and more lucrative private practice opportunities were all cited as reasons for leaving. For dermatologists seeking separation from academics but continued research opportunities, data suggest that private practice allows for continued research and publications, indicating that scholarly engagement is not exclusive to academic settings. These trends point to the increasing viability of hybrid or academic-private models that combine academic productivity with greater flexibility and financial stability.

Final Thoughts

Academic and private practice dermatology each offer compelling advantages and distinct challenges (Table). The growing popularity of hybrid models reflects a desire among dermatologists to balance the intellectual fulfillment associated with academic medicine with professional sustainability and autonomy of private practice. Whether through part-time academic appointments, rural health clinics, VA employment, or affiliations between private groups and academic institutions, these emerging roles offer a flexible and adaptive approach to career development.

Ultimately, the ideal practice model is one that aligns with a physician’s personal values, long-term goals, and lifestyle preferences. No single path fits all, but thoughtful career planning supported by mentorship and institutional transparency can help dermatologists thrive in a rapidly evolving health care landscape.

Dermatology is a rapidly growing, highly competitive specialty with patients that can be served via private practice, academic medicine, hybrid settings, and rural health clinics. Medical residents’ choice of a career path has been rapidly evolving alongside shifts in health care policy, increasing demand for dermatologic services, stagnant fees falling behind inflation for more than a decade, and payment methods that no longer reflect the traditional fee-for-service model. This places a lot of pressure on young dermatologists to evaluate which practice structure best fits their career goals. A nuanced understanding of the strengths and limitations of each practice model is essential for dermatologists to make informed career decisions that are aligned with their values.

While there are many health care practice models, the first decision dermatology residents must make is whether they would prefer working in the private sector or an academic practice. Of course, it is not uncommon for academic dermatologists to embark on a midcareer segue into private practice and, less commonly, for private dermatologists to culminate their careers with a move to academics. The private sector includes private practice, private equity (PE)–owned group practices that often are single-specialty focused, and hospital-owned group practices that usually are multispecialty. Traditionally, private practices are health care businesses owned by one physician (solo practice) or a group of physicians (group practice) operated independently from hospitals, health systems, or private investors. Financially, these practices rely heavily on volume-based services, especially clinic visits and cosmetic procedures, which provide higher reimbursement rates and usually cash payments at the time of service.¹ Roughly 35% of dermatologists in the United States work in private practice, and a dwindling 15% work in solo practice.^2,3

Medical practices that are not self-owned by physicians vary widely, and they include hospital- or medical center–owned, private equity, and university-based academic practices. Private equity practices typically are characterized as profit driven. Hospital-owned practices shoulder business decisions and administrative duties for the physician at the cost of provider autonomy. Academic medicine is the most different from the other practice types. In contrast to private practice dermatologists, university-based dermatologists practice at academic medical centers (AMCs) with the core goals of patient care, education, and research. Compensation generally is based on the relative value unit (RVU), which is supplemented by government support and research grants. 

As evidenced in this brief discussion, health care practice models are complex, and choosing the right model to align with professional goals can pose a major challenge for many physicians. The advantages and disadvantages of various practice models will be reviewed, highlighting trends and emerging models.

Solo or Small-Group Single-Specialty Private Practice 

Private practice offers dermatologists the advantage of higher income potential but with greater economic risk; it often requires physicians to be more involved in the business aspects of dermatologic practice. In the early 1990s, a survey of private practice dermatologists revealed that income was the first or second most important factor that contributed to their career choice of private vs academic practice.⁴ Earning potential in private practice largely is driven by the autonomy afforded in this setting. Physicians have the liberty of choosing their practice location, structure, schedule, and staff in addition to tailoring services toward profitability; this typically leads to a higher volume of cosmetic and procedural visits, which may be attractive to providers wishing to focus on aesthetics. Private practice dermatologists also are not subject to institutional requirements that may include the preparation of grant submissions, research productivity targets, and devotion of time to teaching. Many private dermatologists find satisfaction in tailoring their work environments to align with personal values and goals and in cultivating long-term relationships with patients in a more personal and less bureaucratic context.

There also are drawbacks to private practice. The profitability often can be attributed to the higher patient load and more hours devoted to practice.⁵ A 2006 study found that academics saw 32% to 41% fewer patients per week than private practice dermatologists.⁶ Along with the opportunity for financial gain is the risk of financial ruin. Cost is the largest hurdle for establishing a practice, and most practices do not turn a profit for the first few years.^1,5 The financial burden of running a practice includes pressure from the federal government to adopt expensive electronic health record systems to achieve maximum Medicare payment through the Merit-Based Incentive Payment System, liability insurance, health insurance, and staff salaries.⁷ These challenges require strong business acumen, including managing overhead costs, navigating insurance negotiations, marketing a practice, and maintaining compliance with evolving health care regulations. The purchase of a $100,000 laser could be a boon or bust, requiring the development of a business plan that ensures a positive return on investment. Additionally, private practice profitability has the potential to dwindle as governmental reimbursements fail to match inflation rates. Securing business advisors or even obtaining a Master of Business Administration degree can be helpful.

Insurance and government agencies also are infringing upon some of the autonomy of private practice dermatologists, as evidenced by a 2017 survey of dermatologists that found that more than half of respondents altered treatment plans based on insurance coverage more than 20% of the time.² Private equity firms also could infringe on private practice autonomy, as providers are beholden to the firm’s restrictions—from which company’s product will be stocked to which partner will be on call. Lastly, private practice is less conducive to consistent referral patterns and strong relationships with specialists when compared to academic practice. Additionally, reliance on high patient throughput or cosmetic services for financial sustainability can shift focus away from complex medical dermatology, which often is referred to AMCs.

Academic Medicine

Academic dermatology offers a stimulating and collaborative environment with opportunities to advance the field through research and education. Often, the opportunity to teach medical students, residents, and peers is the deciding factor for academic dermatologists, as supported by a 2016 survey that found teaching opportunities are a major influence on career decision.⁸ The mixture of patient care, education, and research roles can be satisfying when compared to the grind of seeing large numbers of patients every day. Because they typically are salaried with an RVU-based income, academic dermatologists often are less concerned with the costs associated with medical treatment, and they typically treat more medically complex patients and underserved populations.⁹ The salary structure of academic roles also provides the benefit of a stable and predictable income. Physicians in this setting often are considered experts in their field, positioning them to have a strong built-in referral system along with frequent participation in multidisciplinary care alongside colleagues in rheumatology, oncology, and infectious diseases. The benefits of downstream income from dermatopathology, Mohs surgery, and other ancillary testing can provide great financial advantages for an academic or large group practice.¹⁰ Academic medical centers also afford the benefit of resources, such as research offices, clinical trial units, and institutional support for scholarly publication.

Despite its benefits, academic dermatology is not without unique demands. The resources afforded by research work come with grant application deadlines and the pressure to maintain research productivity as measured by grant dollars. Academic providers also must navigate institutional political dynamics and deal with limits on autonomy. Additionally, the administrative burden associated with committee work, mentorship obligations, and publishing requirements further limit clinical time and contribute to burnout. According to Loo et al,⁵ 92% of 89 dermatology department chairmen responding to a poll believed that the lower compensation was the primary factor preventing more residents from pursuing academia. 

The adoption of RVU-based and incentive compensation models at many AMCs, along with dwindling government funds available for research, also have created pressure to increase patient volume, sometimes at the expense of teaching and research. Of those academic dermatologists spending more than half their time seeing patients, a majority reported that they lack the time to also conduct research, teach, and mentor students and resident physicians.⁶ A survey of academic dermatologists suggested that, for those already serving in academic positions, salary was less of a concern than the lack of protected academic time.⁴ While competing demands can erode the appeal of academic dermatology, academia continues to offer a meaningful and fulfilling career path for those motivated by scholarship, mentorship, teaching opportunities, and systemic impact.

Hybrid and Emerging Models 

To reconcile the trade-offs inherent in private and academic models, hybrid roles are becoming increasingly common. In these arrangements, dermatologists split their time between private practice and academic appointments settings, allowing for participation in resident education and research while also benefiting from the operational and financial structure of a private office. In some cases, private groups formally affiliate with academic institutions, creating academic-private practices that host trainees and produce scholarly work while operating financially outside of traditional hospital systems. Individual dermatologists also may choose to accept part-time academic roles that allow residents and medical students to rotate in their offices. Hybrid roles may be of most interest to individuals who feel that they are missing out on the mentorship and teaching opportunities afforded at AMCs.

Government-funded systems such as Veterans Affairs (VA) hospitals offer another alternative. Dermatologists at VA hospitals often hold faculty appointments, treat a wide range of conditions in a population with great need, and engage in teaching without the intensity of productivity requirements seen at AMCs. These roles can be attractive to physicians who value public service, work-life balance, and minimal malpractice risk, as well as dermatologists who wish to introduce variety in their practice through an additional clinical setting. Notably, these roles are limited, as roughly 80% of VA hospitals employ part-time dermatologists and 72% reported being understaffed.¹¹ Despite the challenges of limited resources and increased bureaucracy, the VA is the largest health care delivery system in the United States, offering the benefits of protection from most malpractice risk and participation in medical education at 80% of VA hospitals.¹² A VA-based practice may be most attractive to physicians with prior military service or those looking for a stable practice that serves the underserved and the mission of medical education. 

Similarly, rural health clinics are private practices with special subsidies from the federal government that bring Medicaid payments up to the level of Medicare.¹³ Rural dermatology also mirrors that of a VA-based practice by offering the opportunity to treat an array of conditions in a population of great need, as rural patients often are in care deserts and would otherwise need to travel for miles to receive dermatologic care. There is a shortage of dermatologists working in rural areas, and rural dermatologists are more likely than those in suburban or urban areas to practice alone.² Although potentially more physically isolating, rural dermatology offers providers the opportunity to establish a lucrative practice with minimal competition and development of meaningful patient relationships. 

The most rapidly increasing practice model emerging in dermatology over the past decade is the private equity (PE) group. Rajabi-Estarabadi et al¹⁴ estimated that at least 184 dermatology practices have been acquired by PE groups between 2010 and 2019. An estimated 15% of all PE acquisitions in health care have been within the field of dermatology.⁹ Private equity firms typically acquire 1 or more practices, then consolidate the operations with the short-term goals of reducing costs and maximizing profits and longer-term goals of selling the practice for further profit in 3 to 7 years.⁹ They often rely heavily on a dermatologist supervising a number of nurse practitioners.¹⁵ While PE acquisition may provide additional financial stability and income, providers have less autonomy and potentially risk a shift in their focus from patient care to profit. 

The blurred lines between practice settings reflect a broader shift in the profession. Dermatologists have increasingly crafted flexible, individualized careers that align with their goals and values while drawing from both academic and private models. Hybrid roles may prove critical in preserving the educational and research missions of dermatology while adapting to economic and institutional realities.

Gender Trends, Career Satisfaction, and Other Factors Influencing Career Choice 

The gender demographics of dermatology have changed greatly in recent decades. In the years 2010 to 2021, the percentage of women in the field rose from 41% to 52.2%, mirroring the rise in female medical students.¹⁶ Despite this, gender disparities persist through differences in pay, promotion rates, leadership opportunities, and research productivity.¹⁷ Women who are academic dermatologists are less likely to have protected research time and often shoulder a disproportionate share of mentorship and administrative responsibilities, which frequently are undervalued in promotion and compensation structures. Similarly, women physicians are less likely to own their own private practice.¹⁸ Notably, women physicians work part-time more often than their male counterparts, which likely impacts their income.¹⁹ Interestingly, no differences were noted in job satisfaction between men and women in academic or private practice settings, suggesting that dermatology is a fulfilling field for female physicians.¹⁶ Similar data were observed in the field of dermatopathology; in fact, there is no difference in job satisfaction when comparing providers in academics vs private practice.²⁰

Geographic factors also influence career decisions. Some dermatologists may choose private practice to remain close to family or serve a rural area, while some choose academic centers typically located in major metropolitan areas. Others are drawn to AMCs due to their reputation, resources, or opportunities for specialization. The number of practicing dermatologists in an area also may be considered, as areas with fewer providers likely have more individuals seeking a provider and thus more earning potential. 

In summary, career satisfaction is influenced by many factors, including practice setting, colleagues, institutional leadership, work environment, and professional goals. For individuals who are seeking intellectual stimulation and teaching opportunities, academic dermatology may be a great career option. Academic or large group practices may come with a large group of clinical dermatologists to provide a steady stream of specimens. Private practice appeals to those seeking autonomy, reduced bureaucracy, and higher earning potential. Tierney et al²¹ found that the greatest predictor of a future career in academics among Mohs surgeons was the number of publications a fellow had before and during fellowship training. These data suggest that personal interests greatly influence career decisions. 

The Role of Mentorship in Career Decision-Making

Just as personal preferences guide career decisions, so too do interpersonal interactions. Mentorship plays a large role in career success, and the involvement of faculty mentors in society meetings and editorial boards has been shown to positively correlate with the number of residents pursuing academia.¹⁴ Similarly, negative interactions have strong impacts, as the top cited reason for Mohs surgeons leaving academia was lack of support from their academic chair.²¹ While many academic dermatologists report fulfillment from the collegial environment, retention remains an issue. Tierney et al²¹ found that, among 455 academic Mohs surgeons, only 28% of those who began in academia remained in those roles over the long term, and this trend of low retention holds true across the field of academic dermatology. Lack of autonomy, insufficient institutional support, and more lucrative private practice opportunities were all cited as reasons for leaving. For dermatologists seeking separation from academics but continued research opportunities, data suggest that private practice allows for continued research and publications, indicating that scholarly engagement is not exclusive to academic settings. These trends point to the increasing viability of hybrid or academic-private models that combine academic productivity with greater flexibility and financial stability.

Final Thoughts

Academic and private practice dermatology each offer compelling advantages and distinct challenges (Table). The growing popularity of hybrid models reflects a desire among dermatologists to balance the intellectual fulfillment associated with academic medicine with professional sustainability and autonomy of private practice. Whether through part-time academic appointments, rural health clinics, VA employment, or affiliations between private groups and academic institutions, these emerging roles offer a flexible and adaptive approach to career development.

Ultimately, the ideal practice model is one that aligns with a physician’s personal values, long-term goals, and lifestyle preferences. No single path fits all, but thoughtful career planning supported by mentorship and institutional transparency can help dermatologists thrive in a rapidly evolving health care landscape.

Dermatology is a rapidly growing, highly competitive specialty with patients that can be served via private practice, academic medicine, hybrid settings, and rural health clinics. Medical residents’ choice of a career path has been rapidly evolving alongside shifts in health care policy, increasing demand for dermatologic services, stagnant fees falling behind inflation for more than a decade, and payment methods that no longer reflect the traditional fee-for-service model. This places a lot of pressure on young dermatologists to evaluate which practice structure best fits their career goals. A nuanced understanding of the strengths and limitations of each practice model is essential for dermatologists to make informed career decisions that are aligned with their values.

While there are many health care practice models, the first decision dermatology residents must make is whether they would prefer working in the private sector or an academic practice. Of course, it is not uncommon for academic dermatologists to embark on a midcareer segue into private practice and, less commonly, for private dermatologists to culminate their careers with a move to academics. The private sector includes private practice, private equity (PE)–owned group practices that often are single-specialty focused, and hospital-owned group practices that usually are multispecialty. Traditionally, private practices are health care businesses owned by one physician (solo practice) or a group of physicians (group practice) operated independently from hospitals, health systems, or private investors. Financially, these practices rely heavily on volume-based services, especially clinic visits and cosmetic procedures, which provide higher reimbursement rates and usually cash payments at the time of service.¹ Roughly 35% of dermatologists in the United States work in private practice, and a dwindling 15% work in solo practice.^2,3

Medical practices that are not self-owned by physicians vary widely, and they include hospital- or medical center–owned, private equity, and university-based academic practices. Private equity practices typically are characterized as profit driven. Hospital-owned practices shoulder business decisions and administrative duties for the physician at the cost of provider autonomy. Academic medicine is the most different from the other practice types. In contrast to private practice dermatologists, university-based dermatologists practice at academic medical centers (AMCs) with the core goals of patient care, education, and research. Compensation generally is based on the relative value unit (RVU), which is supplemented by government support and research grants. 

As evidenced in this brief discussion, health care practice models are complex, and choosing the right model to align with professional goals can pose a major challenge for many physicians. The advantages and disadvantages of various practice models will be reviewed, highlighting trends and emerging models.

Solo or Small-Group Single-Specialty Private Practice 

Private practice offers dermatologists the advantage of higher income potential but with greater economic risk; it often requires physicians to be more involved in the business aspects of dermatologic practice. In the early 1990s, a survey of private practice dermatologists revealed that income was the first or second most important factor that contributed to their career choice of private vs academic practice.⁴ Earning potential in private practice largely is driven by the autonomy afforded in this setting. Physicians have the liberty of choosing their practice location, structure, schedule, and staff in addition to tailoring services toward profitability; this typically leads to a higher volume of cosmetic and procedural visits, which may be attractive to providers wishing to focus on aesthetics. Private practice dermatologists also are not subject to institutional requirements that may include the preparation of grant submissions, research productivity targets, and devotion of time to teaching. Many private dermatologists find satisfaction in tailoring their work environments to align with personal values and goals and in cultivating long-term relationships with patients in a more personal and less bureaucratic context.

There also are drawbacks to private practice. The profitability often can be attributed to the higher patient load and more hours devoted to practice.⁵ A 2006 study found that academics saw 32% to 41% fewer patients per week than private practice dermatologists.⁶ Along with the opportunity for financial gain is the risk of financial ruin. Cost is the largest hurdle for establishing a practice, and most practices do not turn a profit for the first few years.^1,5 The financial burden of running a practice includes pressure from the federal government to adopt expensive electronic health record systems to achieve maximum Medicare payment through the Merit-Based Incentive Payment System, liability insurance, health insurance, and staff salaries.⁷ These challenges require strong business acumen, including managing overhead costs, navigating insurance negotiations, marketing a practice, and maintaining compliance with evolving health care regulations. The purchase of a $100,000 laser could be a boon or bust, requiring the development of a business plan that ensures a positive return on investment. Additionally, private practice profitability has the potential to dwindle as governmental reimbursements fail to match inflation rates. Securing business advisors or even obtaining a Master of Business Administration degree can be helpful.

Insurance and government agencies also are infringing upon some of the autonomy of private practice dermatologists, as evidenced by a 2017 survey of dermatologists that found that more than half of respondents altered treatment plans based on insurance coverage more than 20% of the time.² Private equity firms also could infringe on private practice autonomy, as providers are beholden to the firm’s restrictions—from which company’s product will be stocked to which partner will be on call. Lastly, private practice is less conducive to consistent referral patterns and strong relationships with specialists when compared to academic practice. Additionally, reliance on high patient throughput or cosmetic services for financial sustainability can shift focus away from complex medical dermatology, which often is referred to AMCs.

Academic Medicine

Academic dermatology offers a stimulating and collaborative environment with opportunities to advance the field through research and education. Often, the opportunity to teach medical students, residents, and peers is the deciding factor for academic dermatologists, as supported by a 2016 survey that found teaching opportunities are a major influence on career decision.⁸ The mixture of patient care, education, and research roles can be satisfying when compared to the grind of seeing large numbers of patients every day. Because they typically are salaried with an RVU-based income, academic dermatologists often are less concerned with the costs associated with medical treatment, and they typically treat more medically complex patients and underserved populations.⁹ The salary structure of academic roles also provides the benefit of a stable and predictable income. Physicians in this setting often are considered experts in their field, positioning them to have a strong built-in referral system along with frequent participation in multidisciplinary care alongside colleagues in rheumatology, oncology, and infectious diseases. The benefits of downstream income from dermatopathology, Mohs surgery, and other ancillary testing can provide great financial advantages for an academic or large group practice.¹⁰ Academic medical centers also afford the benefit of resources, such as research offices, clinical trial units, and institutional support for scholarly publication.

Despite its benefits, academic dermatology is not without unique demands. The resources afforded by research work come with grant application deadlines and the pressure to maintain research productivity as measured by grant dollars. Academic providers also must navigate institutional political dynamics and deal with limits on autonomy. Additionally, the administrative burden associated with committee work, mentorship obligations, and publishing requirements further limit clinical time and contribute to burnout. According to Loo et al,⁵ 92% of 89 dermatology department chairmen responding to a poll believed that the lower compensation was the primary factor preventing more residents from pursuing academia. 

The adoption of RVU-based and incentive compensation models at many AMCs, along with dwindling government funds available for research, also have created pressure to increase patient volume, sometimes at the expense of teaching and research. Of those academic dermatologists spending more than half their time seeing patients, a majority reported that they lack the time to also conduct research, teach, and mentor students and resident physicians.⁶ A survey of academic dermatologists suggested that, for those already serving in academic positions, salary was less of a concern than the lack of protected academic time.⁴ While competing demands can erode the appeal of academic dermatology, academia continues to offer a meaningful and fulfilling career path for those motivated by scholarship, mentorship, teaching opportunities, and systemic impact.

Hybrid and Emerging Models 

To reconcile the trade-offs inherent in private and academic models, hybrid roles are becoming increasingly common. In these arrangements, dermatologists split their time between private practice and academic appointments settings, allowing for participation in resident education and research while also benefiting from the operational and financial structure of a private office. In some cases, private groups formally affiliate with academic institutions, creating academic-private practices that host trainees and produce scholarly work while operating financially outside of traditional hospital systems. Individual dermatologists also may choose to accept part-time academic roles that allow residents and medical students to rotate in their offices. Hybrid roles may be of most interest to individuals who feel that they are missing out on the mentorship and teaching opportunities afforded at AMCs.

Government-funded systems such as Veterans Affairs (VA) hospitals offer another alternative. Dermatologists at VA hospitals often hold faculty appointments, treat a wide range of conditions in a population with great need, and engage in teaching without the intensity of productivity requirements seen at AMCs. These roles can be attractive to physicians who value public service, work-life balance, and minimal malpractice risk, as well as dermatologists who wish to introduce variety in their practice through an additional clinical setting. Notably, these roles are limited, as roughly 80% of VA hospitals employ part-time dermatologists and 72% reported being understaffed.¹¹ Despite the challenges of limited resources and increased bureaucracy, the VA is the largest health care delivery system in the United States, offering the benefits of protection from most malpractice risk and participation in medical education at 80% of VA hospitals.¹² A VA-based practice may be most attractive to physicians with prior military service or those looking for a stable practice that serves the underserved and the mission of medical education. 

Similarly, rural health clinics are private practices with special subsidies from the federal government that bring Medicaid payments up to the level of Medicare.¹³ Rural dermatology also mirrors that of a VA-based practice by offering the opportunity to treat an array of conditions in a population of great need, as rural patients often are in care deserts and would otherwise need to travel for miles to receive dermatologic care. There is a shortage of dermatologists working in rural areas, and rural dermatologists are more likely than those in suburban or urban areas to practice alone.² Although potentially more physically isolating, rural dermatology offers providers the opportunity to establish a lucrative practice with minimal competition and development of meaningful patient relationships. 

The most rapidly increasing practice model emerging in dermatology over the past decade is the private equity (PE) group. Rajabi-Estarabadi et al¹⁴ estimated that at least 184 dermatology practices have been acquired by PE groups between 2010 and 2019. An estimated 15% of all PE acquisitions in health care have been within the field of dermatology.⁹ Private equity firms typically acquire 1 or more practices, then consolidate the operations with the short-term goals of reducing costs and maximizing profits and longer-term goals of selling the practice for further profit in 3 to 7 years.⁹ They often rely heavily on a dermatologist supervising a number of nurse practitioners.¹⁵ While PE acquisition may provide additional financial stability and income, providers have less autonomy and potentially risk a shift in their focus from patient care to profit. 

The blurred lines between practice settings reflect a broader shift in the profession. Dermatologists have increasingly crafted flexible, individualized careers that align with their goals and values while drawing from both academic and private models. Hybrid roles may prove critical in preserving the educational and research missions of dermatology while adapting to economic and institutional realities.

Gender Trends, Career Satisfaction, and Other Factors Influencing Career Choice 

The gender demographics of dermatology have changed greatly in recent decades. In the years 2010 to 2021, the percentage of women in the field rose from 41% to 52.2%, mirroring the rise in female medical students.¹⁶ Despite this, gender disparities persist through differences in pay, promotion rates, leadership opportunities, and research productivity.¹⁷ Women who are academic dermatologists are less likely to have protected research time and often shoulder a disproportionate share of mentorship and administrative responsibilities, which frequently are undervalued in promotion and compensation structures. Similarly, women physicians are less likely to own their own private practice.¹⁸ Notably, women physicians work part-time more often than their male counterparts, which likely impacts their income.¹⁹ Interestingly, no differences were noted in job satisfaction between men and women in academic or private practice settings, suggesting that dermatology is a fulfilling field for female physicians.¹⁶ Similar data were observed in the field of dermatopathology; in fact, there is no difference in job satisfaction when comparing providers in academics vs private practice.²⁰

Geographic factors also influence career decisions. Some dermatologists may choose private practice to remain close to family or serve a rural area, while some choose academic centers typically located in major metropolitan areas. Others are drawn to AMCs due to their reputation, resources, or opportunities for specialization. The number of practicing dermatologists in an area also may be considered, as areas with fewer providers likely have more individuals seeking a provider and thus more earning potential. 

In summary, career satisfaction is influenced by many factors, including practice setting, colleagues, institutional leadership, work environment, and professional goals. For individuals who are seeking intellectual stimulation and teaching opportunities, academic dermatology may be a great career option. Academic or large group practices may come with a large group of clinical dermatologists to provide a steady stream of specimens. Private practice appeals to those seeking autonomy, reduced bureaucracy, and higher earning potential. Tierney et al²¹ found that the greatest predictor of a future career in academics among Mohs surgeons was the number of publications a fellow had before and during fellowship training. These data suggest that personal interests greatly influence career decisions. 

The Role of Mentorship in Career Decision-Making

Just as personal preferences guide career decisions, so too do interpersonal interactions. Mentorship plays a large role in career success, and the involvement of faculty mentors in society meetings and editorial boards has been shown to positively correlate with the number of residents pursuing academia.¹⁴ Similarly, negative interactions have strong impacts, as the top cited reason for Mohs surgeons leaving academia was lack of support from their academic chair.²¹ While many academic dermatologists report fulfillment from the collegial environment, retention remains an issue. Tierney et al²¹ found that, among 455 academic Mohs surgeons, only 28% of those who began in academia remained in those roles over the long term, and this trend of low retention holds true across the field of academic dermatology. Lack of autonomy, insufficient institutional support, and more lucrative private practice opportunities were all cited as reasons for leaving. For dermatologists seeking separation from academics but continued research opportunities, data suggest that private practice allows for continued research and publications, indicating that scholarly engagement is not exclusive to academic settings. These trends point to the increasing viability of hybrid or academic-private models that combine academic productivity with greater flexibility and financial stability.

Final Thoughts

Academic and private practice dermatology each offer compelling advantages and distinct challenges (Table). The growing popularity of hybrid models reflects a desire among dermatologists to balance the intellectual fulfillment associated with academic medicine with professional sustainability and autonomy of private practice. Whether through part-time academic appointments, rural health clinics, VA employment, or affiliations between private groups and academic institutions, these emerging roles offer a flexible and adaptive approach to career development.

Ultimately, the ideal practice model is one that aligns with a physician’s personal values, long-term goals, and lifestyle preferences. No single path fits all, but thoughtful career planning supported by mentorship and institutional transparency can help dermatologists thrive in a rapidly evolving health care landscape.