2020 dermMentors™ Resident of Distinction Award™

The dermMentors™ Resident of Distinction Award™ recognizes top residents in dermatology. DermMentors.org and the dermMentors™ Resident of Distinction Award™ are sponsored by Beiersdorf Inc and administered by DermEd, Inc. The 2020 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the 19th Annual Caribbean Dermatology Symposium on January 25, 2020.

Overall Grand Prize
Topical Imiquimod in Combination With Brachytherapy for Unresectable Cutaneous Melanoma Metastases

Jennifer E. Yeh, MD, PhD, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts; Marilyn T. Wan, MBChB, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts; Allireza Alloo, MD, Department of Dermatology, Northwell Health, Lake Success, New York; Nageatte Ibrahim, MD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Phillip M. Devlin, MD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Patrick A. Ott, MD, PhD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Jennifer Y. Lin MD, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, and Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts 
Disclosures: None. 

Background

Despite numerous advances in the treatment of advanced melanoma, several management challenges remain. Large cutaneous metastases are often unresectable and previously described local therapies have not consistently led to disease control. Topical imiquimod, a synthetic immune modifier, has been found to be safe and effective in treating both cutaneous malignancies and cutaneous metastases of other tumor types. Moreover, radiotherapy can be used for palliation or as adjuvant therapy to reduce regional nodal recurrence. Brachytherapy is radiation delivered via sources within or close to the target, achieving more homogeneous doses and minimizing injury to adjacent structures. Here, we posit the utility of combining topical imiquimod with brachytherapy for locoregional control of cutaneous metastases. 

Case Presentation
Three patients with scalp melanoma initially treated with wide local excision and found to have negative sentinel lymph node biopsy presented with scalp lesions adjacent to the initial melanoma consistent with in-transit metastases. Given the presence of multiple metastatic lesions including 1 patient with numerous cutaneous metastases on reconstructed skin, each patient was treated with brachytherapy (5 fractions of 600 cGy over 2 to 3 weeks), followed by imiquimod cream 5% for 12 weeks. One patient’s excision showed residual melanoma as close as 1.4 mm to the nearest margin. All 3 patients achieved complete response and have been disease free for more than 2 years. Adverse effects were limited to pruritus and low-grade dermatitis. Of note, 2 patients later developed distant metastases that subsequently resolved with systemic immunotherapy. 

Conclusions
While surgical excision is the first-line treatment of single, discrete cutaneous metastases, it may not be practical in patients with multiple foci of disease distributed over large areas, as seen in the 3 patients presented here who achieved complete resolution of their cutaneous metastatic burden with concurrent topical imiquimod and brachytherapy. Brachytherapy may be especially beneficial for cutaneous metastases on complex surfaces such as the scalp, reducing excessive brain irradiation by using moldable applicators that allow precise targeting. Moreover, one of the cases presented here suggests that brachytherapy may have utility for close-margin excisions. Although further investigations using larger patient cohorts are needed to determine the reproducibility of our findings, concomitant use of topical imiquimod and brachytherapy may represent a promising strategy for control of cutaneous melanoma metastases.

Up next: Burden of Common Skin Diseases in the Caribbean

 

Burden of Common Skin Diseases in the Caribbean and Potential Correlation With Socioeconomics

Rachel Giesey, DO, Case Western Reserve University, Cleveland, Ohio, and University Hospitals Cleveland Medical Center, Cleveland, Ohio
Disclosures: None. 

Introduction
There is a significant burden of dermatoses on a global scale, including the Caribbean, exemplified by disproportionately high corresponding disability adjusted life years (DALYs). Promising steps are being taken in the Caribbean, such as the World Bank Group’s ongoing financial support for Caribbean Community (CARICOM) countries, which has reached nearly $2 billion with a focus on strengthening resilience and financial protection against disasters. Despite this, additional research is needed to help guide dermatologists interested in reducing global health disparities in this region to create more impactful and sustainable interventions. 

Objective
This observational study aims to measure the burden of common skin diseases in the Caribbean and the potential relationship with a country’s socioeconomic status.
 
Methods
For this study, we selected Global Burden of Disease Study (GBD) data sets analyzing the most recent DALYs of the most common dermatoses in 2017 among 18 Caribbean countries, along with the Caribbean as a region, and the United States for comparison. Three categories of dermatoses were analyzed by country: neoplastic, infectious, and inflammatory. Each country was assigned a ranking from 1 (highest DALYs) to 20 (lowest DALYs) for each disease. The principal country-level economic factor used to measure socioeconomic status was gross domestic product (GDP) per capita in 2017 from the International Monetary Fund and the World Bank. Statistical analysis of correlations between country wealth and disease was performed using a 2-tailed linear regression. Level of significance was set at P<.05.

Results
Countries were ordered by column from left (least wealthy) to right (most wealthy). To generate a heat table, the countries were ranked by DALYs (ranging from 1 [highest disease burden] to 20 [lowest burden]) for each skin disease. There was a statistically significant inverse relationship between country wealth and cutaneous neoplasms (melanoma, nonmelanoma skin cancers, and lip/oral cancers), as well as some inflammatory dermatoses (contact dermatitis, psoriasis, and pruritus). In contrast, there was a statistically significant positive correlation between country wealth and dermatology-related infectious diseases (scabies, viral skin infections, syphilis, human immunodeficiency virus/AIDS, and tuberculosis) and some other inflammatory dermatoses (urticaria, asthma, and atopic dermatitis). 

Conclusion
Dermatologists interested in a particular disease may elect to focus time and resources in a Caribbean country with the highest respective DALYs, or dermatologists interested in traveling to a particular country may find the most impactful and sustainable interventions by focusing on the dermatoses with highest DALYs in that country. The relationship between GDP and health expenditure on dermatologic disease is complex, and the influence of income levels on this causal relationship is unclear. Further work is necessary to more consistently assess the impact of income on common dermatoses in low- and middle-income countries across the globe.

Up next: Doxycycline for LPP and FFA

 

The Use of Doxycycline in Lichen Planopilaris and Frontal Fibrosing Alopecia: A Retrospective Study of 138 Patients at a Tertiary Referral Clinic

Janice Tiao, MD; Lynne J. Goldberg, MD, Department of Dermatology, Boston University Medical Center, Boston, Massachusetts 
Disclosures: None. 

Background
Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are lymphocyte-mediated primary cicatricial alopecias.¹ They are rare, and limited evidence exists on treatment options.^1,2 The best data supports hydroxychloroquine as the first-line systemic therapeutic agent,^1,3 though expert opinion cites doxycycline as an acceptable first-line alternative and small series support its potential efficacy.^4-6 The purpose of this study is to describe the use of doxycycline in patients with LPP and FFA at a single tertiary referral clinic. 

Methods
After obtaining institutional review board approval, the authors reviewed the medical records of 138 patients with LPP and FFA who presented to the outpatient specialty hair clinic at Boston University Medical Center from 2015-2017. 

Results
Of 138 subjects, 1 was excluded because there was no electronic medical record on file. Thirty-one subjects had a diagnosis of LPP, 103 had a diagnosis of FFA, and 3 were diagnosed with both LPP and FFA. Of the 31 LPP-only subjects, 16 had been prescribed doxycycline for their condition. Of these subjects, 9 (56.3%) reported or were observed to improve or stabilize, 2 (12.5%) did not improve, and 5 (31.3%) had unclear response or were lost to follow-up. Of the 106 subjects with FFA, 40 had been prescribed doxycycline for their condition. Of these 40 subjects, 17 (42.5%) were felt to improve or stabilize, 7 (17.5%) did not improve, and 15 (37.5%) had unclear response or were lost to follow-up. The average duration of use was 8 months. Of note, 14 of 56 (25%) subjects who took doxycycline discontinued the medication secondary to side effects, most commonly gastrointestinal.

Conclusion
Although a number of subjects did not tolerate the medication, the data confirm that doxycycline may be helpful in the treatment of LPP and FFA.

References

1. Bolduc C, Sperling LC, Shapiro J. Primary cicatricial alopecia. J Am Acad Dermatol. 2016;75:1081-1099.
2. Ochoa BE, King LE, Price VH. Lichen planopilaris: annual incidence in four hair referral centers in the United States. J Am Acad Dermatol. 2008;58:352-353.
3. Errichetti E, Figini M, Croatto M, et al. Therapeutic management of classic lichen planopilaris: a systematic review. Clin Cosmet Investig Dermatol. 2018;11:91-102.
4. Spencer LA, Hawryluk EB, English JC. Lichen planopilaris: Retrospective study and stepwise therapeutic approach. Arch Dermatol. 2009;45:333-334.
5. Lyakhovitsky A, Amichai B, Sizopoulou C, et al. A case series of 46 patients with lichen planopilaris: demographics, clinical evaluation, and treatment experience. J Dermatolog Treat. 2015;26:275-279.
6. Samrao A, Chew A-I, Price V. Frontal fibrosing alopecia: a clinical review of 36 patients. Br J Dermatol. 2010;163:1296-1300.

Up next: Counterfeits and Medical Spas

 

Counterfeits and Medical Spas in Dermatology: A Call for Patient Safety 

Jordan V. Wang, MD, MBE, MBA, Thomas Jefferson University, Philadelphia, Pennsylvania 
Disclosures: None. 

Counterfeits 
Counterfeit medical devices and injectables have recently garnered interest. These unregulated products are typically imported into the United States, marketed to practitioners, and then purchased at significantly reduced prices, either knowingly or unknowingly. The savings are generally passed on to patients as bargain prices. However, unlike their original counterparts, these counterfeits have neither been tested nor verified using certified quality control measures. Without clearance by the US Food and Drug Administration (FDA) for patient use, there can be no assurances of safety, efficacy, and reliability. Penalties by the FDA’s Office of Criminal Investigations can be steep. Shedding more light on the current state of counterfeit medical devices in dermatology can help to increase awareness and lead to improved patient safety. Our recent survey of aesthetic practitioners demonstrated that counterfeit medical devices and injectables are frequently encountered in dermatology, especially in the United States. For example, 37.4% and 41.1% of respondents have encountered counterfeit medical devices and injectables, respectively. About half of respondents were solicited to purchase them, and they were also witnessed for sale at conferences in both the United States and abroad. Some respondents admitted to purchasing them, both knowingly and unknowingly. The vast majority believed them to be endangering patient safety, have experienced related adverse events, and wanted stricter rules and regulations. 

Medical Spas 
Medical spas have experienced a recent rise in popularity by consumers. They can offer various aesthetic procedures, including neurotoxins, fillers, and lasers and light devices. Oftentimes their prices are marketed as lower than those directly from physician-based practices. Rules and regulations, especially concerning their oversight and credentialing processes, vary from state to state. Unfortunately, many patients have experienced various complications from medical spas. Shedding more light on the current state of medical spas and their complications in dermatology can help to increase awareness and lead to improved patient safety. Our recent survey of aesthetic practitioners demonstrated that patients who have experienced complications from medical spas are frequently encountered. For example, of all cosmetic complications encountered in the past 2 years, the majority reported that the percentage of complications seen in their practice attributable to medical spas ranged from 61% to 100%. The most commonly cited complications from medical spas were burns, discoloration, and misuse of product, while the most commonly cited treatments resulting in complications were fillers, intense pulsed light, and laser hair removal. For safety and outcomes, medical spas were rated as inferior to physician-based practices. Practitioners believed medical spas to be endangering patients, desired stricter rules and regulations, and requested more support from medical societies.

Up next: Online Reviews of Minimally and Noninvasive Cosmetic Procedures

 

Lessons From Unfavorable Online Reviews of Minimally and Noninvasive Cosmetic Procedures

Jacqueline D. Watchmaker, MD, Boston University School of Medicine, Boston, Massachusetts 
Disclosures: None. 

Introduction
The frequency of minimally and noninvasive cosmetic procedures performed in the United States is increasing; however, there have been few studies looking at patient-reported subjective outcomes of these procedures. Our study gathered data from RealSelf.com (Seattle, Washington), an online patient-driven review website, to determine the most common reasons patients are dissatisfied with cosmetic treatments. 

Methods
Between June 2019 and July 2019, the authors extracted patient-reported outcome data from RealSelf.com for the following treatments: Coolsculpting, Ultherapy, Kybella injections, miraDry, Thermage, Cellfina, Emsculpt, and thread-lifts. On the RealSelf website, patients are able to rate their aesthetic procedure as “worth it”, “not sure” or “not worth it”; only data from “not worth it” reviews were extracted for this study. In total, there were 1359 reviews. Reviews from outside the United States were excluded. If a patient listed 2 reasons for dissatisfaction (eg, complication and ineffective treatment) both reasons were recorded. Specific complications and postoperative time frame of review, when listed, were recorded. 
 
Results
In total, 1204 reviews were included in the analysis. The most frequent reason for patient dissatisfaction was ineffectiveness for Coolsculpting (n=427, 82.9%), Ultherapy (n=120, 67.8%), Kybella (n=55, 75.3%), miraDry (n=40, 85.1%), Thermage (n=81, 61.4%), Cellfina (n=18, 78.3%), and Emsculpt (n=5, 100%), with complications listed as the second most common reason for discontent. For thread-lifts, however, the most common reason for a “not worth it” rating was a complication (n=43, 70.5%) followed by perceived ineffectiveness (n=36, 59%). Severe pain during and/or after the procedure was the most common patient-reported complication for Coolsculpting (n=62, 37.3%) and thread-lifts (n=10, 23.3%). Perceived fat loss was the most common side effect for Ultherapy (n=32, 38.6%) and Thermage (n=26, 40%), with swelling, numbness, new-onset “lumps,” and flatter buttock muscles as the most common patient-reported complications for Kybella (n=9, 40.9%), miraDry (n=6, 27.3%), Cellfina (n=6, 46.2%), and Emsculpt (n=1, 100%). 

Discussion
Our study shows that perceived ineffectiveness and complications were the most common reasons for dissatisfaction of the minimally and noninvasive cosmetic procedures analyzed. Knowing the most common patient-reported complaints of a given procedure can help physicians counsel and educate patients prior to a procedure. Many of the patient-reported complications found in this study are known and unfortunate true potential complications; it is important to note, however, that many dissatisfied patients listed an expected side effect such as pain, bruising, or swelling, rather than a true complication as their reason for discontent. More thorough preprocedure education may help patients differentiate between a true complication and a transient and expected side effect that in turn may improve patient satisfaction. In the modern era of social media and online reviews, a positive patient perspective on an aesthetic treatment is increasingly important. Patient dissatisfaction due to true complications and ineffective treatment cannot be completely prevented; however, by learning from the negative patient-reported outcomes as detailed in this study, physicians can work toward improving the patient experience. 

The dermMentors™ Resident of Distinction Award™ recognizes top residents in dermatology. DermMentors.org and the dermMentors™ Resident of Distinction Award™ are sponsored by Beiersdorf Inc and administered by DermEd, Inc. The 2020 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the 19th Annual Caribbean Dermatology Symposium on January 25, 2020.

Overall Grand Prize
Topical Imiquimod in Combination With Brachytherapy for Unresectable Cutaneous Melanoma Metastases

Jennifer E. Yeh, MD, PhD, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts; Marilyn T. Wan, MBChB, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts; Allireza Alloo, MD, Department of Dermatology, Northwell Health, Lake Success, New York; Nageatte Ibrahim, MD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Phillip M. Devlin, MD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Patrick A. Ott, MD, PhD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Jennifer Y. Lin MD, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, and Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts 
Disclosures: None. 

Background

Despite numerous advances in the treatment of advanced melanoma, several management challenges remain. Large cutaneous metastases are often unresectable and previously described local therapies have not consistently led to disease control. Topical imiquimod, a synthetic immune modifier, has been found to be safe and effective in treating both cutaneous malignancies and cutaneous metastases of other tumor types. Moreover, radiotherapy can be used for palliation or as adjuvant therapy to reduce regional nodal recurrence. Brachytherapy is radiation delivered via sources within or close to the target, achieving more homogeneous doses and minimizing injury to adjacent structures. Here, we posit the utility of combining topical imiquimod with brachytherapy for locoregional control of cutaneous metastases. 

Case Presentation
Three patients with scalp melanoma initially treated with wide local excision and found to have negative sentinel lymph node biopsy presented with scalp lesions adjacent to the initial melanoma consistent with in-transit metastases. Given the presence of multiple metastatic lesions including 1 patient with numerous cutaneous metastases on reconstructed skin, each patient was treated with brachytherapy (5 fractions of 600 cGy over 2 to 3 weeks), followed by imiquimod cream 5% for 12 weeks. One patient’s excision showed residual melanoma as close as 1.4 mm to the nearest margin. All 3 patients achieved complete response and have been disease free for more than 2 years. Adverse effects were limited to pruritus and low-grade dermatitis. Of note, 2 patients later developed distant metastases that subsequently resolved with systemic immunotherapy. 

Conclusions
While surgical excision is the first-line treatment of single, discrete cutaneous metastases, it may not be practical in patients with multiple foci of disease distributed over large areas, as seen in the 3 patients presented here who achieved complete resolution of their cutaneous metastatic burden with concurrent topical imiquimod and brachytherapy. Brachytherapy may be especially beneficial for cutaneous metastases on complex surfaces such as the scalp, reducing excessive brain irradiation by using moldable applicators that allow precise targeting. Moreover, one of the cases presented here suggests that brachytherapy may have utility for close-margin excisions. Although further investigations using larger patient cohorts are needed to determine the reproducibility of our findings, concomitant use of topical imiquimod and brachytherapy may represent a promising strategy for control of cutaneous melanoma metastases.

Up next: Burden of Common Skin Diseases in the Caribbean

 

Burden of Common Skin Diseases in the Caribbean and Potential Correlation With Socioeconomics

Rachel Giesey, DO, Case Western Reserve University, Cleveland, Ohio, and University Hospitals Cleveland Medical Center, Cleveland, Ohio
Disclosures: None. 

Introduction
There is a significant burden of dermatoses on a global scale, including the Caribbean, exemplified by disproportionately high corresponding disability adjusted life years (DALYs). Promising steps are being taken in the Caribbean, such as the World Bank Group’s ongoing financial support for Caribbean Community (CARICOM) countries, which has reached nearly $2 billion with a focus on strengthening resilience and financial protection against disasters. Despite this, additional research is needed to help guide dermatologists interested in reducing global health disparities in this region to create more impactful and sustainable interventions. 

Objective
This observational study aims to measure the burden of common skin diseases in the Caribbean and the potential relationship with a country’s socioeconomic status.
 
Methods
For this study, we selected Global Burden of Disease Study (GBD) data sets analyzing the most recent DALYs of the most common dermatoses in 2017 among 18 Caribbean countries, along with the Caribbean as a region, and the United States for comparison. Three categories of dermatoses were analyzed by country: neoplastic, infectious, and inflammatory. Each country was assigned a ranking from 1 (highest DALYs) to 20 (lowest DALYs) for each disease. The principal country-level economic factor used to measure socioeconomic status was gross domestic product (GDP) per capita in 2017 from the International Monetary Fund and the World Bank. Statistical analysis of correlations between country wealth and disease was performed using a 2-tailed linear regression. Level of significance was set at P<.05.

Results
Countries were ordered by column from left (least wealthy) to right (most wealthy). To generate a heat table, the countries were ranked by DALYs (ranging from 1 [highest disease burden] to 20 [lowest burden]) for each skin disease. There was a statistically significant inverse relationship between country wealth and cutaneous neoplasms (melanoma, nonmelanoma skin cancers, and lip/oral cancers), as well as some inflammatory dermatoses (contact dermatitis, psoriasis, and pruritus). In contrast, there was a statistically significant positive correlation between country wealth and dermatology-related infectious diseases (scabies, viral skin infections, syphilis, human immunodeficiency virus/AIDS, and tuberculosis) and some other inflammatory dermatoses (urticaria, asthma, and atopic dermatitis). 

Conclusion
Dermatologists interested in a particular disease may elect to focus time and resources in a Caribbean country with the highest respective DALYs, or dermatologists interested in traveling to a particular country may find the most impactful and sustainable interventions by focusing on the dermatoses with highest DALYs in that country. The relationship between GDP and health expenditure on dermatologic disease is complex, and the influence of income levels on this causal relationship is unclear. Further work is necessary to more consistently assess the impact of income on common dermatoses in low- and middle-income countries across the globe.

Up next: Doxycycline for LPP and FFA

 

The Use of Doxycycline in Lichen Planopilaris and Frontal Fibrosing Alopecia: A Retrospective Study of 138 Patients at a Tertiary Referral Clinic

Janice Tiao, MD; Lynne J. Goldberg, MD, Department of Dermatology, Boston University Medical Center, Boston, Massachusetts 
Disclosures: None. 

Background
Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are lymphocyte-mediated primary cicatricial alopecias.¹ They are rare, and limited evidence exists on treatment options.^1,2 The best data supports hydroxychloroquine as the first-line systemic therapeutic agent,^1,3 though expert opinion cites doxycycline as an acceptable first-line alternative and small series support its potential efficacy.^4-6 The purpose of this study is to describe the use of doxycycline in patients with LPP and FFA at a single tertiary referral clinic. 

Methods
After obtaining institutional review board approval, the authors reviewed the medical records of 138 patients with LPP and FFA who presented to the outpatient specialty hair clinic at Boston University Medical Center from 2015-2017. 

Results
Of 138 subjects, 1 was excluded because there was no electronic medical record on file. Thirty-one subjects had a diagnosis of LPP, 103 had a diagnosis of FFA, and 3 were diagnosed with both LPP and FFA. Of the 31 LPP-only subjects, 16 had been prescribed doxycycline for their condition. Of these subjects, 9 (56.3%) reported or were observed to improve or stabilize, 2 (12.5%) did not improve, and 5 (31.3%) had unclear response or were lost to follow-up. Of the 106 subjects with FFA, 40 had been prescribed doxycycline for their condition. Of these 40 subjects, 17 (42.5%) were felt to improve or stabilize, 7 (17.5%) did not improve, and 15 (37.5%) had unclear response or were lost to follow-up. The average duration of use was 8 months. Of note, 14 of 56 (25%) subjects who took doxycycline discontinued the medication secondary to side effects, most commonly gastrointestinal.

Conclusion
Although a number of subjects did not tolerate the medication, the data confirm that doxycycline may be helpful in the treatment of LPP and FFA.

References

1. Bolduc C, Sperling LC, Shapiro J. Primary cicatricial alopecia. J Am Acad Dermatol. 2016;75:1081-1099.
2. Ochoa BE, King LE, Price VH. Lichen planopilaris: annual incidence in four hair referral centers in the United States. J Am Acad Dermatol. 2008;58:352-353.
3. Errichetti E, Figini M, Croatto M, et al. Therapeutic management of classic lichen planopilaris: a systematic review. Clin Cosmet Investig Dermatol. 2018;11:91-102.
4. Spencer LA, Hawryluk EB, English JC. Lichen planopilaris: Retrospective study and stepwise therapeutic approach. Arch Dermatol. 2009;45:333-334.
5. Lyakhovitsky A, Amichai B, Sizopoulou C, et al. A case series of 46 patients with lichen planopilaris: demographics, clinical evaluation, and treatment experience. J Dermatolog Treat. 2015;26:275-279.
6. Samrao A, Chew A-I, Price V. Frontal fibrosing alopecia: a clinical review of 36 patients. Br J Dermatol. 2010;163:1296-1300.

Up next: Counterfeits and Medical Spas

 

Counterfeits and Medical Spas in Dermatology: A Call for Patient Safety 

Jordan V. Wang, MD, MBE, MBA, Thomas Jefferson University, Philadelphia, Pennsylvania 
Disclosures: None. 

Counterfeits 
Counterfeit medical devices and injectables have recently garnered interest. These unregulated products are typically imported into the United States, marketed to practitioners, and then purchased at significantly reduced prices, either knowingly or unknowingly. The savings are generally passed on to patients as bargain prices. However, unlike their original counterparts, these counterfeits have neither been tested nor verified using certified quality control measures. Without clearance by the US Food and Drug Administration (FDA) for patient use, there can be no assurances of safety, efficacy, and reliability. Penalties by the FDA’s Office of Criminal Investigations can be steep. Shedding more light on the current state of counterfeit medical devices in dermatology can help to increase awareness and lead to improved patient safety. Our recent survey of aesthetic practitioners demonstrated that counterfeit medical devices and injectables are frequently encountered in dermatology, especially in the United States. For example, 37.4% and 41.1% of respondents have encountered counterfeit medical devices and injectables, respectively. About half of respondents were solicited to purchase them, and they were also witnessed for sale at conferences in both the United States and abroad. Some respondents admitted to purchasing them, both knowingly and unknowingly. The vast majority believed them to be endangering patient safety, have experienced related adverse events, and wanted stricter rules and regulations. 

Medical Spas 
Medical spas have experienced a recent rise in popularity by consumers. They can offer various aesthetic procedures, including neurotoxins, fillers, and lasers and light devices. Oftentimes their prices are marketed as lower than those directly from physician-based practices. Rules and regulations, especially concerning their oversight and credentialing processes, vary from state to state. Unfortunately, many patients have experienced various complications from medical spas. Shedding more light on the current state of medical spas and their complications in dermatology can help to increase awareness and lead to improved patient safety. Our recent survey of aesthetic practitioners demonstrated that patients who have experienced complications from medical spas are frequently encountered. For example, of all cosmetic complications encountered in the past 2 years, the majority reported that the percentage of complications seen in their practice attributable to medical spas ranged from 61% to 100%. The most commonly cited complications from medical spas were burns, discoloration, and misuse of product, while the most commonly cited treatments resulting in complications were fillers, intense pulsed light, and laser hair removal. For safety and outcomes, medical spas were rated as inferior to physician-based practices. Practitioners believed medical spas to be endangering patients, desired stricter rules and regulations, and requested more support from medical societies.

Up next: Online Reviews of Minimally and Noninvasive Cosmetic Procedures

 

Lessons From Unfavorable Online Reviews of Minimally and Noninvasive Cosmetic Procedures

Jacqueline D. Watchmaker, MD, Boston University School of Medicine, Boston, Massachusetts 
Disclosures: None. 

Introduction
The frequency of minimally and noninvasive cosmetic procedures performed in the United States is increasing; however, there have been few studies looking at patient-reported subjective outcomes of these procedures. Our study gathered data from RealSelf.com (Seattle, Washington), an online patient-driven review website, to determine the most common reasons patients are dissatisfied with cosmetic treatments. 

Methods
Between June 2019 and July 2019, the authors extracted patient-reported outcome data from RealSelf.com for the following treatments: Coolsculpting, Ultherapy, Kybella injections, miraDry, Thermage, Cellfina, Emsculpt, and thread-lifts. On the RealSelf website, patients are able to rate their aesthetic procedure as “worth it”, “not sure” or “not worth it”; only data from “not worth it” reviews were extracted for this study. In total, there were 1359 reviews. Reviews from outside the United States were excluded. If a patient listed 2 reasons for dissatisfaction (eg, complication and ineffective treatment) both reasons were recorded. Specific complications and postoperative time frame of review, when listed, were recorded. 
 
Results
In total, 1204 reviews were included in the analysis. The most frequent reason for patient dissatisfaction was ineffectiveness for Coolsculpting (n=427, 82.9%), Ultherapy (n=120, 67.8%), Kybella (n=55, 75.3%), miraDry (n=40, 85.1%), Thermage (n=81, 61.4%), Cellfina (n=18, 78.3%), and Emsculpt (n=5, 100%), with complications listed as the second most common reason for discontent. For thread-lifts, however, the most common reason for a “not worth it” rating was a complication (n=43, 70.5%) followed by perceived ineffectiveness (n=36, 59%). Severe pain during and/or after the procedure was the most common patient-reported complication for Coolsculpting (n=62, 37.3%) and thread-lifts (n=10, 23.3%). Perceived fat loss was the most common side effect for Ultherapy (n=32, 38.6%) and Thermage (n=26, 40%), with swelling, numbness, new-onset “lumps,” and flatter buttock muscles as the most common patient-reported complications for Kybella (n=9, 40.9%), miraDry (n=6, 27.3%), Cellfina (n=6, 46.2%), and Emsculpt (n=1, 100%). 

Discussion
Our study shows that perceived ineffectiveness and complications were the most common reasons for dissatisfaction of the minimally and noninvasive cosmetic procedures analyzed. Knowing the most common patient-reported complaints of a given procedure can help physicians counsel and educate patients prior to a procedure. Many of the patient-reported complications found in this study are known and unfortunate true potential complications; it is important to note, however, that many dissatisfied patients listed an expected side effect such as pain, bruising, or swelling, rather than a true complication as their reason for discontent. More thorough preprocedure education may help patients differentiate between a true complication and a transient and expected side effect that in turn may improve patient satisfaction. In the modern era of social media and online reviews, a positive patient perspective on an aesthetic treatment is increasingly important. Patient dissatisfaction due to true complications and ineffective treatment cannot be completely prevented; however, by learning from the negative patient-reported outcomes as detailed in this study, physicians can work toward improving the patient experience. 

The dermMentors™ Resident of Distinction Award™ recognizes top residents in dermatology. DermMentors.org and the dermMentors™ Resident of Distinction Award™ are sponsored by Beiersdorf Inc and administered by DermEd, Inc. The 2020 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the 19th Annual Caribbean Dermatology Symposium on January 25, 2020.

Overall Grand Prize
Topical Imiquimod in Combination With Brachytherapy for Unresectable Cutaneous Melanoma Metastases

Jennifer E. Yeh, MD, PhD, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts; Marilyn T. Wan, MBChB, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts; Allireza Alloo, MD, Department of Dermatology, Northwell Health, Lake Success, New York; Nageatte Ibrahim, MD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Phillip M. Devlin, MD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Patrick A. Ott, MD, PhD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Jennifer Y. Lin MD, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, and Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts 
Disclosures: None. 

Background

Despite numerous advances in the treatment of advanced melanoma, several management challenges remain. Large cutaneous metastases are often unresectable and previously described local therapies have not consistently led to disease control. Topical imiquimod, a synthetic immune modifier, has been found to be safe and effective in treating both cutaneous malignancies and cutaneous metastases of other tumor types. Moreover, radiotherapy can be used for palliation or as adjuvant therapy to reduce regional nodal recurrence. Brachytherapy is radiation delivered via sources within or close to the target, achieving more homogeneous doses and minimizing injury to adjacent structures. Here, we posit the utility of combining topical imiquimod with brachytherapy for locoregional control of cutaneous metastases. 

Case Presentation
Three patients with scalp melanoma initially treated with wide local excision and found to have negative sentinel lymph node biopsy presented with scalp lesions adjacent to the initial melanoma consistent with in-transit metastases. Given the presence of multiple metastatic lesions including 1 patient with numerous cutaneous metastases on reconstructed skin, each patient was treated with brachytherapy (5 fractions of 600 cGy over 2 to 3 weeks), followed by imiquimod cream 5% for 12 weeks. One patient’s excision showed residual melanoma as close as 1.4 mm to the nearest margin. All 3 patients achieved complete response and have been disease free for more than 2 years. Adverse effects were limited to pruritus and low-grade dermatitis. Of note, 2 patients later developed distant metastases that subsequently resolved with systemic immunotherapy. 

Conclusions
While surgical excision is the first-line treatment of single, discrete cutaneous metastases, it may not be practical in patients with multiple foci of disease distributed over large areas, as seen in the 3 patients presented here who achieved complete resolution of their cutaneous metastatic burden with concurrent topical imiquimod and brachytherapy. Brachytherapy may be especially beneficial for cutaneous metastases on complex surfaces such as the scalp, reducing excessive brain irradiation by using moldable applicators that allow precise targeting. Moreover, one of the cases presented here suggests that brachytherapy may have utility for close-margin excisions. Although further investigations using larger patient cohorts are needed to determine the reproducibility of our findings, concomitant use of topical imiquimod and brachytherapy may represent a promising strategy for control of cutaneous melanoma metastases.

Up next: Burden of Common Skin Diseases in the Caribbean

 

Burden of Common Skin Diseases in the Caribbean and Potential Correlation With Socioeconomics

Rachel Giesey, DO, Case Western Reserve University, Cleveland, Ohio, and University Hospitals Cleveland Medical Center, Cleveland, Ohio
Disclosures: None. 

Introduction
There is a significant burden of dermatoses on a global scale, including the Caribbean, exemplified by disproportionately high corresponding disability adjusted life years (DALYs). Promising steps are being taken in the Caribbean, such as the World Bank Group’s ongoing financial support for Caribbean Community (CARICOM) countries, which has reached nearly $2 billion with a focus on strengthening resilience and financial protection against disasters. Despite this, additional research is needed to help guide dermatologists interested in reducing global health disparities in this region to create more impactful and sustainable interventions. 

Objective
This observational study aims to measure the burden of common skin diseases in the Caribbean and the potential relationship with a country’s socioeconomic status.
 
Methods
For this study, we selected Global Burden of Disease Study (GBD) data sets analyzing the most recent DALYs of the most common dermatoses in 2017 among 18 Caribbean countries, along with the Caribbean as a region, and the United States for comparison. Three categories of dermatoses were analyzed by country: neoplastic, infectious, and inflammatory. Each country was assigned a ranking from 1 (highest DALYs) to 20 (lowest DALYs) for each disease. The principal country-level economic factor used to measure socioeconomic status was gross domestic product (GDP) per capita in 2017 from the International Monetary Fund and the World Bank. Statistical analysis of correlations between country wealth and disease was performed using a 2-tailed linear regression. Level of significance was set at P<.05.

Results
Countries were ordered by column from left (least wealthy) to right (most wealthy). To generate a heat table, the countries were ranked by DALYs (ranging from 1 [highest disease burden] to 20 [lowest burden]) for each skin disease. There was a statistically significant inverse relationship between country wealth and cutaneous neoplasms (melanoma, nonmelanoma skin cancers, and lip/oral cancers), as well as some inflammatory dermatoses (contact dermatitis, psoriasis, and pruritus). In contrast, there was a statistically significant positive correlation between country wealth and dermatology-related infectious diseases (scabies, viral skin infections, syphilis, human immunodeficiency virus/AIDS, and tuberculosis) and some other inflammatory dermatoses (urticaria, asthma, and atopic dermatitis). 

Conclusion
Dermatologists interested in a particular disease may elect to focus time and resources in a Caribbean country with the highest respective DALYs, or dermatologists interested in traveling to a particular country may find the most impactful and sustainable interventions by focusing on the dermatoses with highest DALYs in that country. The relationship between GDP and health expenditure on dermatologic disease is complex, and the influence of income levels on this causal relationship is unclear. Further work is necessary to more consistently assess the impact of income on common dermatoses in low- and middle-income countries across the globe.

Up next: Doxycycline for LPP and FFA

 

The Use of Doxycycline in Lichen Planopilaris and Frontal Fibrosing Alopecia: A Retrospective Study of 138 Patients at a Tertiary Referral Clinic

Janice Tiao, MD; Lynne J. Goldberg, MD, Department of Dermatology, Boston University Medical Center, Boston, Massachusetts 
Disclosures: None. 

Background
Lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) are lymphocyte-mediated primary cicatricial alopecias.¹ They are rare, and limited evidence exists on treatment options.^1,2 The best data supports hydroxychloroquine as the first-line systemic therapeutic agent,^1,3 though expert opinion cites doxycycline as an acceptable first-line alternative and small series support its potential efficacy.^4-6 The purpose of this study is to describe the use of doxycycline in patients with LPP and FFA at a single tertiary referral clinic. 

Methods
After obtaining institutional review board approval, the authors reviewed the medical records of 138 patients with LPP and FFA who presented to the outpatient specialty hair clinic at Boston University Medical Center from 2015-2017. 

Results
Of 138 subjects, 1 was excluded because there was no electronic medical record on file. Thirty-one subjects had a diagnosis of LPP, 103 had a diagnosis of FFA, and 3 were diagnosed with both LPP and FFA. Of the 31 LPP-only subjects, 16 had been prescribed doxycycline for their condition. Of these subjects, 9 (56.3%) reported or were observed to improve or stabilize, 2 (12.5%) did not improve, and 5 (31.3%) had unclear response or were lost to follow-up. Of the 106 subjects with FFA, 40 had been prescribed doxycycline for their condition. Of these 40 subjects, 17 (42.5%) were felt to improve or stabilize, 7 (17.5%) did not improve, and 15 (37.5%) had unclear response or were lost to follow-up. The average duration of use was 8 months. Of note, 14 of 56 (25%) subjects who took doxycycline discontinued the medication secondary to side effects, most commonly gastrointestinal.

Conclusion
Although a number of subjects did not tolerate the medication, the data confirm that doxycycline may be helpful in the treatment of LPP and FFA.

References

1. Bolduc C, Sperling LC, Shapiro J. Primary cicatricial alopecia. J Am Acad Dermatol. 2016;75:1081-1099.
2. Ochoa BE, King LE, Price VH. Lichen planopilaris: annual incidence in four hair referral centers in the United States. J Am Acad Dermatol. 2008;58:352-353.
3. Errichetti E, Figini M, Croatto M, et al. Therapeutic management of classic lichen planopilaris: a systematic review. Clin Cosmet Investig Dermatol. 2018;11:91-102.
4. Spencer LA, Hawryluk EB, English JC. Lichen planopilaris: Retrospective study and stepwise therapeutic approach. Arch Dermatol. 2009;45:333-334.
5. Lyakhovitsky A, Amichai B, Sizopoulou C, et al. A case series of 46 patients with lichen planopilaris: demographics, clinical evaluation, and treatment experience. J Dermatolog Treat. 2015;26:275-279.
6. Samrao A, Chew A-I, Price V. Frontal fibrosing alopecia: a clinical review of 36 patients. Br J Dermatol. 2010;163:1296-1300.

Up next: Counterfeits and Medical Spas

 

Counterfeits and Medical Spas in Dermatology: A Call for Patient Safety 

Jordan V. Wang, MD, MBE, MBA, Thomas Jefferson University, Philadelphia, Pennsylvania 
Disclosures: None. 

Counterfeits 
Counterfeit medical devices and injectables have recently garnered interest. These unregulated products are typically imported into the United States, marketed to practitioners, and then purchased at significantly reduced prices, either knowingly or unknowingly. The savings are generally passed on to patients as bargain prices. However, unlike their original counterparts, these counterfeits have neither been tested nor verified using certified quality control measures. Without clearance by the US Food and Drug Administration (FDA) for patient use, there can be no assurances of safety, efficacy, and reliability. Penalties by the FDA’s Office of Criminal Investigations can be steep. Shedding more light on the current state of counterfeit medical devices in dermatology can help to increase awareness and lead to improved patient safety. Our recent survey of aesthetic practitioners demonstrated that counterfeit medical devices and injectables are frequently encountered in dermatology, especially in the United States. For example, 37.4% and 41.1% of respondents have encountered counterfeit medical devices and injectables, respectively. About half of respondents were solicited to purchase them, and they were also witnessed for sale at conferences in both the United States and abroad. Some respondents admitted to purchasing them, both knowingly and unknowingly. The vast majority believed them to be endangering patient safety, have experienced related adverse events, and wanted stricter rules and regulations. 

Medical Spas 
Medical spas have experienced a recent rise in popularity by consumers. They can offer various aesthetic procedures, including neurotoxins, fillers, and lasers and light devices. Oftentimes their prices are marketed as lower than those directly from physician-based practices. Rules and regulations, especially concerning their oversight and credentialing processes, vary from state to state. Unfortunately, many patients have experienced various complications from medical spas. Shedding more light on the current state of medical spas and their complications in dermatology can help to increase awareness and lead to improved patient safety. Our recent survey of aesthetic practitioners demonstrated that patients who have experienced complications from medical spas are frequently encountered. For example, of all cosmetic complications encountered in the past 2 years, the majority reported that the percentage of complications seen in their practice attributable to medical spas ranged from 61% to 100%. The most commonly cited complications from medical spas were burns, discoloration, and misuse of product, while the most commonly cited treatments resulting in complications were fillers, intense pulsed light, and laser hair removal. For safety and outcomes, medical spas were rated as inferior to physician-based practices. Practitioners believed medical spas to be endangering patients, desired stricter rules and regulations, and requested more support from medical societies.

Up next: Online Reviews of Minimally and Noninvasive Cosmetic Procedures

 

Lessons From Unfavorable Online Reviews of Minimally and Noninvasive Cosmetic Procedures

Jacqueline D. Watchmaker, MD, Boston University School of Medicine, Boston, Massachusetts 
Disclosures: None. 

Introduction
The frequency of minimally and noninvasive cosmetic procedures performed in the United States is increasing; however, there have been few studies looking at patient-reported subjective outcomes of these procedures. Our study gathered data from RealSelf.com (Seattle, Washington), an online patient-driven review website, to determine the most common reasons patients are dissatisfied with cosmetic treatments. 

Methods
Between June 2019 and July 2019, the authors extracted patient-reported outcome data from RealSelf.com for the following treatments: Coolsculpting, Ultherapy, Kybella injections, miraDry, Thermage, Cellfina, Emsculpt, and thread-lifts. On the RealSelf website, patients are able to rate their aesthetic procedure as “worth it”, “not sure” or “not worth it”; only data from “not worth it” reviews were extracted for this study. In total, there were 1359 reviews. Reviews from outside the United States were excluded. If a patient listed 2 reasons for dissatisfaction (eg, complication and ineffective treatment) both reasons were recorded. Specific complications and postoperative time frame of review, when listed, were recorded. 
 
Results
In total, 1204 reviews were included in the analysis. The most frequent reason for patient dissatisfaction was ineffectiveness for Coolsculpting (n=427, 82.9%), Ultherapy (n=120, 67.8%), Kybella (n=55, 75.3%), miraDry (n=40, 85.1%), Thermage (n=81, 61.4%), Cellfina (n=18, 78.3%), and Emsculpt (n=5, 100%), with complications listed as the second most common reason for discontent. For thread-lifts, however, the most common reason for a “not worth it” rating was a complication (n=43, 70.5%) followed by perceived ineffectiveness (n=36, 59%). Severe pain during and/or after the procedure was the most common patient-reported complication for Coolsculpting (n=62, 37.3%) and thread-lifts (n=10, 23.3%). Perceived fat loss was the most common side effect for Ultherapy (n=32, 38.6%) and Thermage (n=26, 40%), with swelling, numbness, new-onset “lumps,” and flatter buttock muscles as the most common patient-reported complications for Kybella (n=9, 40.9%), miraDry (n=6, 27.3%), Cellfina (n=6, 46.2%), and Emsculpt (n=1, 100%). 

Discussion
Our study shows that perceived ineffectiveness and complications were the most common reasons for dissatisfaction of the minimally and noninvasive cosmetic procedures analyzed. Knowing the most common patient-reported complaints of a given procedure can help physicians counsel and educate patients prior to a procedure. Many of the patient-reported complications found in this study are known and unfortunate true potential complications; it is important to note, however, that many dissatisfied patients listed an expected side effect such as pain, bruising, or swelling, rather than a true complication as their reason for discontent. More thorough preprocedure education may help patients differentiate between a true complication and a transient and expected side effect that in turn may improve patient satisfaction. In the modern era of social media and online reviews, a positive patient perspective on an aesthetic treatment is increasingly important. Patient dissatisfaction due to true complications and ineffective treatment cannot be completely prevented; however, by learning from the negative patient-reported outcomes as detailed in this study, physicians can work toward improving the patient experience.