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Secretan Syndrome: A Fluctuating Case of Factitious Lymphedema
Secretan syndrome (SS) represents a recurrent or chronic form of factitious lymphedema, usually affecting the dorsal aspect of the hand.1-3 It is accepted as a subtype of Munchausen syndrome whereby the patient self-inflicts and simulates lymphedema.1,2 Historically, many of the cases reported with the term Charcot’s oedème bleu are now believed to represent clinical variants of SS.4-6
Case Report
A 38-year-old Turkish woman presented with progressive swelling of the right hand of 2 years’ duration that had caused difficulty in manual work and reduction in manual dexterity. She previously had sought medical treatment for this condition by visiting several hospitals. According to her medical record, the following laboratory or radiologic tests had revealed negative or normal findings, except for obvious soft-tissue edema: bacterial and fungal cultures, plain radiography, Doppler ultrasonography, lymphoscintigraphy, magnetic resonance imaging, fine needle aspiration, and punch biopsy. Reflex sympathetic dystrophy, compartment syndrome, filariasis, tuberculosis, and lymphatic and venous obstruction were all excluded by appropriate testing. Our patient was in good health prior to onset of this disorder, and her medical history was unremarkable. There was no family history of a similar condition.
Dermatologic examination revealed brawny, soft, pitting edema; erythema; and crusts affecting the dorsal aspect of the right hand and proximal parts of the fingers (Figure 1). The yellow discoloration of the skin and nails was attributed to potassium permanganate wet dressings. Under an elastic bandage at the wrist, which the patient unrolled herself, a sharp line of demarcation was evident, separating the lymphedematous and normal parts of the arm. There was no axillary lymphadenopathy.
The patient’s affect was discordant to the manifestation of the cutaneous findings. She wanted to show every physician in the department how swollen her hand was and seemed to be happy with this condition. Although she displayed no signs of disturbance when the affected extremity was touched or handled, she reported severe pain and tenderness as well as difficulty in housework. She noted that she normally resided in a city and that the swelling had started at the time she had relocated to a rural village to take care of her bedridden mother-in-law. She was under an intensive workload in the village, and the condition of the hand was impeding manual work.
Factitious lymphedema was considered, and hospitalization was recommended. The patient was then lost to follow-up; however, one of her relatives noted that the patient had returned to the city. When she presented again 1 year later, almost all physical signs had disappeared (Figure 2), and a psychiatric referral was recommended. A Minnesota Multiphasic Personality Inventory test yielded an invalid result due to the patient’s exaggeration of her preexisting physical symptoms. Further psychiatric workup was rejected by the patient.
Almost a year after the psychiatric referral, the patient’s follow-up photographs revealed that the lymphedema recurred when she went to visit her mother-in-law in the rural village and that it was completely ameliorated when she returned to the city. Thus, a positive “mother-in-law provocation test” was accepted as final proof of the self-inflicted nature of the condition.
Comment
In 1901, Henri Francois Secretan, a Swiss physician, reported workmen who had persistent hard swellings on the dorsal aspect of the hands after minor work-related trauma for which they had compensation claims.7 In his original report, Secretan did not suggest self-inflicted trauma in the etiology of this disorder.5,8,9 In 1890, Jean Martin Charcot, a French neurologist, described oedème bleu, a term that is now believed to denote a condition similar to SS.4-6 Currently, SS is attributed to self-inflicted injury and is considered a form of factitious lymphedema.9 As in dermatitis artefacta, most patients with SS are young women, and male patients with the condition tend to be older.3,8
The mechanism used to provoke this factitious lymphedema might be of traumatic or obstructive nature. Secretan syndrome either is induced by intermittent or constant application of a tourniquet, ligature, cord, elastic bandage, scarf, kerchief, rubber band, or compress around the affected extremity, or by repetitive blunt trauma, force, or skin irritation.1,4,5,8-10 There was an underlying psychopathology in all reported cases.1,8,11 Factitious lymphedema is unconsciously motivated and consciously produced.4,12 The affected patient often is experiencing a serious emotional conflict and is unlikely to be a malingerer, although exaggeration of symptoms may occur, as in our patient.12 Psychiatric evaluation in SS may uncover neurosis, hysteria, frank psychosis, schizophrenia, masochism, depression, or an abnormal personality disorder.1,12
Patients with SS present with recurrent or chronic lymphedema, usually affecting the dominant hand.1 Involvement usually is unilateral; bilateral cases are rare.3,6 Secretan syndrome is not solely limited to the hands; it also may involve the upper and lower extremities, including the feet.3,11 There may be a clear line of demarcation, a ring, sulcus, distinct circumferential linear bands of erythema, discoloration, or ecchymoses, separating the normal and lymphedematous parts of the extremity.1,4,6,8-10,12 Patients usually attempt to hide the constricted areas from sight.1 Over time, flexion contractures may develop due to peritendinous fibrosis.6 Histopathology displays a hematoma with adhesions to the extensor tendons; a hematoma surrounded by a thickened scar; or changes similar to ganglion tissue with cystic areas of mucin, fibrosis, and myxoid degeneration.4,6
Factitious lymphedema can only be definitively diagnosed when the patient confesses or is caught self-inflicting the injury. Nevertheless, a diagnosis by exclusion is possible.4 Lymphangiography, lymphoscintigraphy, vascular Doppler ultrasonography, and magnetic resonance imaging may be helpful in excluding congenital and acquired causes of lymphedema and venous obstruction.1,3,9,11 Magnetic resonance imaging may show soft tissue and tendon edema as well as diffuse peritendinous fibrosis extending to the fascia of the dorsal interosseous muscles.3,4
Factitious lymphedema should be suspected in all patients with recurrent or chronic unilateral lymphedema without an explicable or apparent predisposing factor.4,11,12 Patients with SS typically visit several hospitals or institutions; see many physicians; and willingly accept, request, and undergo unnecessary extensive, invasive, and costly diagnostic and therapeutic procedures and prolonged hospitalizations.1,2,5,12 The disorder promptly responds to immobilization and elevation of the limb.2,4 Plaster casts may prove useful in prevention of compression and thus amelioration of the lymphedema.1,4,6 Once the diagnosis is confirmed, direct confrontation should be avoided and ideally the patient should be referred for psychiatric evaluation.1,2,4,5,8,12 If the patient admits self-inflicting behavior, psychotherapy and/or behavior modification therapy along with psychotropic medications may be helpful to relieve emotional and behavioral symptoms.12 Unfortunately, if the patient denies a self-inflicting role in the occurrence of lymphedema and persists in self-injurious behavior, psychotherapy or psychotropic medications will be futile.9
1. Miyamoto Y, Hamanaka T, Yokoyama S, et al. Factitious lymphedema of the upper limb. Kawasaki Med J. 1979;5:39-45.
2. de Oliveira RK, Bayer LR, Lauxen D, et al. Factitious lesions of the hand. Rev Bras Ortop. 2013;48:381-386.
3. Hahm MH, Yi JH. A case report of Secretan’s disease in both hands. J Korean Soc Radiol. 2013;68:511-514.
4. Eldridge MP, Grunert BK, Matloub HS. Streamlined classification of psychopathological hand disorders: a literature review. Hand (NY). 2008;3:118-128.
5. Ostlere LS, Harris D, Denton C, et al. Boxing-glove hand: an unusual presentation of dermatitis artefacta. J Am Acad Dermatol. 1993;28:120-122.
6. Winkelmann RK, Barker SM. Factitial traumatic panniculitis. J Am Acad Dermatol. 1985;13:988-994.
7. Secretan H. Oederne dur et hyperplasie traumatique du metacarpe dorsal. RevMed Suisse Romande. 1901;21:409-416.
8. Barth JH, Pegum JS. The case of the speckled band: acquired lymphedema due to constriction bands. J Am Acad Dermatol. 1986;15:296-297.
9. Birman MV, Lee DH. Factitious disorders of the upper extremity. J Am Acad Orthop Surg. 2012;20:78-85.
10. Nwaejike N, Archbold H, Wilson DS. Factitious lymphoedema as a psychiatric condition mimicking reflex sympathetic dystrophy: a case report. J Med Case Rep. 2008;2:216.
11. De Fátima Guerreiro Godoy M, Pereira De Godoy JM. Factitious lymphedema of the arm: case report and review of publications. Eur J Phys Rehabil Med. 2015;51:337-339.
12. Abhari SAA, Alimalayeri N, Abhari SSA, et al. Factitious lymphedema of the hand. Iran J Psychiatry. 2006;1:166-168.
Secretan syndrome (SS) represents a recurrent or chronic form of factitious lymphedema, usually affecting the dorsal aspect of the hand.1-3 It is accepted as a subtype of Munchausen syndrome whereby the patient self-inflicts and simulates lymphedema.1,2 Historically, many of the cases reported with the term Charcot’s oedème bleu are now believed to represent clinical variants of SS.4-6
Case Report
A 38-year-old Turkish woman presented with progressive swelling of the right hand of 2 years’ duration that had caused difficulty in manual work and reduction in manual dexterity. She previously had sought medical treatment for this condition by visiting several hospitals. According to her medical record, the following laboratory or radiologic tests had revealed negative or normal findings, except for obvious soft-tissue edema: bacterial and fungal cultures, plain radiography, Doppler ultrasonography, lymphoscintigraphy, magnetic resonance imaging, fine needle aspiration, and punch biopsy. Reflex sympathetic dystrophy, compartment syndrome, filariasis, tuberculosis, and lymphatic and venous obstruction were all excluded by appropriate testing. Our patient was in good health prior to onset of this disorder, and her medical history was unremarkable. There was no family history of a similar condition.
Dermatologic examination revealed brawny, soft, pitting edema; erythema; and crusts affecting the dorsal aspect of the right hand and proximal parts of the fingers (Figure 1). The yellow discoloration of the skin and nails was attributed to potassium permanganate wet dressings. Under an elastic bandage at the wrist, which the patient unrolled herself, a sharp line of demarcation was evident, separating the lymphedematous and normal parts of the arm. There was no axillary lymphadenopathy.
The patient’s affect was discordant to the manifestation of the cutaneous findings. She wanted to show every physician in the department how swollen her hand was and seemed to be happy with this condition. Although she displayed no signs of disturbance when the affected extremity was touched or handled, she reported severe pain and tenderness as well as difficulty in housework. She noted that she normally resided in a city and that the swelling had started at the time she had relocated to a rural village to take care of her bedridden mother-in-law. She was under an intensive workload in the village, and the condition of the hand was impeding manual work.
Factitious lymphedema was considered, and hospitalization was recommended. The patient was then lost to follow-up; however, one of her relatives noted that the patient had returned to the city. When she presented again 1 year later, almost all physical signs had disappeared (Figure 2), and a psychiatric referral was recommended. A Minnesota Multiphasic Personality Inventory test yielded an invalid result due to the patient’s exaggeration of her preexisting physical symptoms. Further psychiatric workup was rejected by the patient.
Almost a year after the psychiatric referral, the patient’s follow-up photographs revealed that the lymphedema recurred when she went to visit her mother-in-law in the rural village and that it was completely ameliorated when she returned to the city. Thus, a positive “mother-in-law provocation test” was accepted as final proof of the self-inflicted nature of the condition.
Comment
In 1901, Henri Francois Secretan, a Swiss physician, reported workmen who had persistent hard swellings on the dorsal aspect of the hands after minor work-related trauma for which they had compensation claims.7 In his original report, Secretan did not suggest self-inflicted trauma in the etiology of this disorder.5,8,9 In 1890, Jean Martin Charcot, a French neurologist, described oedème bleu, a term that is now believed to denote a condition similar to SS.4-6 Currently, SS is attributed to self-inflicted injury and is considered a form of factitious lymphedema.9 As in dermatitis artefacta, most patients with SS are young women, and male patients with the condition tend to be older.3,8
The mechanism used to provoke this factitious lymphedema might be of traumatic or obstructive nature. Secretan syndrome either is induced by intermittent or constant application of a tourniquet, ligature, cord, elastic bandage, scarf, kerchief, rubber band, or compress around the affected extremity, or by repetitive blunt trauma, force, or skin irritation.1,4,5,8-10 There was an underlying psychopathology in all reported cases.1,8,11 Factitious lymphedema is unconsciously motivated and consciously produced.4,12 The affected patient often is experiencing a serious emotional conflict and is unlikely to be a malingerer, although exaggeration of symptoms may occur, as in our patient.12 Psychiatric evaluation in SS may uncover neurosis, hysteria, frank psychosis, schizophrenia, masochism, depression, or an abnormal personality disorder.1,12
Patients with SS present with recurrent or chronic lymphedema, usually affecting the dominant hand.1 Involvement usually is unilateral; bilateral cases are rare.3,6 Secretan syndrome is not solely limited to the hands; it also may involve the upper and lower extremities, including the feet.3,11 There may be a clear line of demarcation, a ring, sulcus, distinct circumferential linear bands of erythema, discoloration, or ecchymoses, separating the normal and lymphedematous parts of the extremity.1,4,6,8-10,12 Patients usually attempt to hide the constricted areas from sight.1 Over time, flexion contractures may develop due to peritendinous fibrosis.6 Histopathology displays a hematoma with adhesions to the extensor tendons; a hematoma surrounded by a thickened scar; or changes similar to ganglion tissue with cystic areas of mucin, fibrosis, and myxoid degeneration.4,6
Factitious lymphedema can only be definitively diagnosed when the patient confesses or is caught self-inflicting the injury. Nevertheless, a diagnosis by exclusion is possible.4 Lymphangiography, lymphoscintigraphy, vascular Doppler ultrasonography, and magnetic resonance imaging may be helpful in excluding congenital and acquired causes of lymphedema and venous obstruction.1,3,9,11 Magnetic resonance imaging may show soft tissue and tendon edema as well as diffuse peritendinous fibrosis extending to the fascia of the dorsal interosseous muscles.3,4
Factitious lymphedema should be suspected in all patients with recurrent or chronic unilateral lymphedema without an explicable or apparent predisposing factor.4,11,12 Patients with SS typically visit several hospitals or institutions; see many physicians; and willingly accept, request, and undergo unnecessary extensive, invasive, and costly diagnostic and therapeutic procedures and prolonged hospitalizations.1,2,5,12 The disorder promptly responds to immobilization and elevation of the limb.2,4 Plaster casts may prove useful in prevention of compression and thus amelioration of the lymphedema.1,4,6 Once the diagnosis is confirmed, direct confrontation should be avoided and ideally the patient should be referred for psychiatric evaluation.1,2,4,5,8,12 If the patient admits self-inflicting behavior, psychotherapy and/or behavior modification therapy along with psychotropic medications may be helpful to relieve emotional and behavioral symptoms.12 Unfortunately, if the patient denies a self-inflicting role in the occurrence of lymphedema and persists in self-injurious behavior, psychotherapy or psychotropic medications will be futile.9
Secretan syndrome (SS) represents a recurrent or chronic form of factitious lymphedema, usually affecting the dorsal aspect of the hand.1-3 It is accepted as a subtype of Munchausen syndrome whereby the patient self-inflicts and simulates lymphedema.1,2 Historically, many of the cases reported with the term Charcot’s oedème bleu are now believed to represent clinical variants of SS.4-6
Case Report
A 38-year-old Turkish woman presented with progressive swelling of the right hand of 2 years’ duration that had caused difficulty in manual work and reduction in manual dexterity. She previously had sought medical treatment for this condition by visiting several hospitals. According to her medical record, the following laboratory or radiologic tests had revealed negative or normal findings, except for obvious soft-tissue edema: bacterial and fungal cultures, plain radiography, Doppler ultrasonography, lymphoscintigraphy, magnetic resonance imaging, fine needle aspiration, and punch biopsy. Reflex sympathetic dystrophy, compartment syndrome, filariasis, tuberculosis, and lymphatic and venous obstruction were all excluded by appropriate testing. Our patient was in good health prior to onset of this disorder, and her medical history was unremarkable. There was no family history of a similar condition.
Dermatologic examination revealed brawny, soft, pitting edema; erythema; and crusts affecting the dorsal aspect of the right hand and proximal parts of the fingers (Figure 1). The yellow discoloration of the skin and nails was attributed to potassium permanganate wet dressings. Under an elastic bandage at the wrist, which the patient unrolled herself, a sharp line of demarcation was evident, separating the lymphedematous and normal parts of the arm. There was no axillary lymphadenopathy.
The patient’s affect was discordant to the manifestation of the cutaneous findings. She wanted to show every physician in the department how swollen her hand was and seemed to be happy with this condition. Although she displayed no signs of disturbance when the affected extremity was touched or handled, she reported severe pain and tenderness as well as difficulty in housework. She noted that she normally resided in a city and that the swelling had started at the time she had relocated to a rural village to take care of her bedridden mother-in-law. She was under an intensive workload in the village, and the condition of the hand was impeding manual work.
Factitious lymphedema was considered, and hospitalization was recommended. The patient was then lost to follow-up; however, one of her relatives noted that the patient had returned to the city. When she presented again 1 year later, almost all physical signs had disappeared (Figure 2), and a psychiatric referral was recommended. A Minnesota Multiphasic Personality Inventory test yielded an invalid result due to the patient’s exaggeration of her preexisting physical symptoms. Further psychiatric workup was rejected by the patient.
Almost a year after the psychiatric referral, the patient’s follow-up photographs revealed that the lymphedema recurred when she went to visit her mother-in-law in the rural village and that it was completely ameliorated when she returned to the city. Thus, a positive “mother-in-law provocation test” was accepted as final proof of the self-inflicted nature of the condition.
Comment
In 1901, Henri Francois Secretan, a Swiss physician, reported workmen who had persistent hard swellings on the dorsal aspect of the hands after minor work-related trauma for which they had compensation claims.7 In his original report, Secretan did not suggest self-inflicted trauma in the etiology of this disorder.5,8,9 In 1890, Jean Martin Charcot, a French neurologist, described oedème bleu, a term that is now believed to denote a condition similar to SS.4-6 Currently, SS is attributed to self-inflicted injury and is considered a form of factitious lymphedema.9 As in dermatitis artefacta, most patients with SS are young women, and male patients with the condition tend to be older.3,8
The mechanism used to provoke this factitious lymphedema might be of traumatic or obstructive nature. Secretan syndrome either is induced by intermittent or constant application of a tourniquet, ligature, cord, elastic bandage, scarf, kerchief, rubber band, or compress around the affected extremity, or by repetitive blunt trauma, force, or skin irritation.1,4,5,8-10 There was an underlying psychopathology in all reported cases.1,8,11 Factitious lymphedema is unconsciously motivated and consciously produced.4,12 The affected patient often is experiencing a serious emotional conflict and is unlikely to be a malingerer, although exaggeration of symptoms may occur, as in our patient.12 Psychiatric evaluation in SS may uncover neurosis, hysteria, frank psychosis, schizophrenia, masochism, depression, or an abnormal personality disorder.1,12
Patients with SS present with recurrent or chronic lymphedema, usually affecting the dominant hand.1 Involvement usually is unilateral; bilateral cases are rare.3,6 Secretan syndrome is not solely limited to the hands; it also may involve the upper and lower extremities, including the feet.3,11 There may be a clear line of demarcation, a ring, sulcus, distinct circumferential linear bands of erythema, discoloration, or ecchymoses, separating the normal and lymphedematous parts of the extremity.1,4,6,8-10,12 Patients usually attempt to hide the constricted areas from sight.1 Over time, flexion contractures may develop due to peritendinous fibrosis.6 Histopathology displays a hematoma with adhesions to the extensor tendons; a hematoma surrounded by a thickened scar; or changes similar to ganglion tissue with cystic areas of mucin, fibrosis, and myxoid degeneration.4,6
Factitious lymphedema can only be definitively diagnosed when the patient confesses or is caught self-inflicting the injury. Nevertheless, a diagnosis by exclusion is possible.4 Lymphangiography, lymphoscintigraphy, vascular Doppler ultrasonography, and magnetic resonance imaging may be helpful in excluding congenital and acquired causes of lymphedema and venous obstruction.1,3,9,11 Magnetic resonance imaging may show soft tissue and tendon edema as well as diffuse peritendinous fibrosis extending to the fascia of the dorsal interosseous muscles.3,4
Factitious lymphedema should be suspected in all patients with recurrent or chronic unilateral lymphedema without an explicable or apparent predisposing factor.4,11,12 Patients with SS typically visit several hospitals or institutions; see many physicians; and willingly accept, request, and undergo unnecessary extensive, invasive, and costly diagnostic and therapeutic procedures and prolonged hospitalizations.1,2,5,12 The disorder promptly responds to immobilization and elevation of the limb.2,4 Plaster casts may prove useful in prevention of compression and thus amelioration of the lymphedema.1,4,6 Once the diagnosis is confirmed, direct confrontation should be avoided and ideally the patient should be referred for psychiatric evaluation.1,2,4,5,8,12 If the patient admits self-inflicting behavior, psychotherapy and/or behavior modification therapy along with psychotropic medications may be helpful to relieve emotional and behavioral symptoms.12 Unfortunately, if the patient denies a self-inflicting role in the occurrence of lymphedema and persists in self-injurious behavior, psychotherapy or psychotropic medications will be futile.9
1. Miyamoto Y, Hamanaka T, Yokoyama S, et al. Factitious lymphedema of the upper limb. Kawasaki Med J. 1979;5:39-45.
2. de Oliveira RK, Bayer LR, Lauxen D, et al. Factitious lesions of the hand. Rev Bras Ortop. 2013;48:381-386.
3. Hahm MH, Yi JH. A case report of Secretan’s disease in both hands. J Korean Soc Radiol. 2013;68:511-514.
4. Eldridge MP, Grunert BK, Matloub HS. Streamlined classification of psychopathological hand disorders: a literature review. Hand (NY). 2008;3:118-128.
5. Ostlere LS, Harris D, Denton C, et al. Boxing-glove hand: an unusual presentation of dermatitis artefacta. J Am Acad Dermatol. 1993;28:120-122.
6. Winkelmann RK, Barker SM. Factitial traumatic panniculitis. J Am Acad Dermatol. 1985;13:988-994.
7. Secretan H. Oederne dur et hyperplasie traumatique du metacarpe dorsal. RevMed Suisse Romande. 1901;21:409-416.
8. Barth JH, Pegum JS. The case of the speckled band: acquired lymphedema due to constriction bands. J Am Acad Dermatol. 1986;15:296-297.
9. Birman MV, Lee DH. Factitious disorders of the upper extremity. J Am Acad Orthop Surg. 2012;20:78-85.
10. Nwaejike N, Archbold H, Wilson DS. Factitious lymphoedema as a psychiatric condition mimicking reflex sympathetic dystrophy: a case report. J Med Case Rep. 2008;2:216.
11. De Fátima Guerreiro Godoy M, Pereira De Godoy JM. Factitious lymphedema of the arm: case report and review of publications. Eur J Phys Rehabil Med. 2015;51:337-339.
12. Abhari SAA, Alimalayeri N, Abhari SSA, et al. Factitious lymphedema of the hand. Iran J Psychiatry. 2006;1:166-168.
1. Miyamoto Y, Hamanaka T, Yokoyama S, et al. Factitious lymphedema of the upper limb. Kawasaki Med J. 1979;5:39-45.
2. de Oliveira RK, Bayer LR, Lauxen D, et al. Factitious lesions of the hand. Rev Bras Ortop. 2013;48:381-386.
3. Hahm MH, Yi JH. A case report of Secretan’s disease in both hands. J Korean Soc Radiol. 2013;68:511-514.
4. Eldridge MP, Grunert BK, Matloub HS. Streamlined classification of psychopathological hand disorders: a literature review. Hand (NY). 2008;3:118-128.
5. Ostlere LS, Harris D, Denton C, et al. Boxing-glove hand: an unusual presentation of dermatitis artefacta. J Am Acad Dermatol. 1993;28:120-122.
6. Winkelmann RK, Barker SM. Factitial traumatic panniculitis. J Am Acad Dermatol. 1985;13:988-994.
7. Secretan H. Oederne dur et hyperplasie traumatique du metacarpe dorsal. RevMed Suisse Romande. 1901;21:409-416.
8. Barth JH, Pegum JS. The case of the speckled band: acquired lymphedema due to constriction bands. J Am Acad Dermatol. 1986;15:296-297.
9. Birman MV, Lee DH. Factitious disorders of the upper extremity. J Am Acad Orthop Surg. 2012;20:78-85.
10. Nwaejike N, Archbold H, Wilson DS. Factitious lymphoedema as a psychiatric condition mimicking reflex sympathetic dystrophy: a case report. J Med Case Rep. 2008;2:216.
11. De Fátima Guerreiro Godoy M, Pereira De Godoy JM. Factitious lymphedema of the arm: case report and review of publications. Eur J Phys Rehabil Med. 2015;51:337-339.
12. Abhari SAA, Alimalayeri N, Abhari SSA, et al. Factitious lymphedema of the hand. Iran J Psychiatry. 2006;1:166-168.
Practice Points
- Secretan syndrome is a recurrent or chronic form of factitious lymphedema that usually affects the dorsal aspect of the hand; it is accepted as a subtype of Munchausen syndrome.
- Secretan syndrome usually is induced by compression of the extremity by tourniquets, ligatures, cords, or similar equipment.
- This unconsciously motivated and consciously produced lymphedema is an expression of underlying psychiatric disease.
Skin imaging working group releases first guidelines for AI algorithms used in dermatology
The
The guidelines, published in JAMA Dermatology on Dec. 1, 2021, contain a broad range of recommendations stakeholders should consider when developing and assessing image-based AI algorithms in dermatology. The recommendations are divided into categories of data, technique, technical assessment, and application. ISIC is “an academia and industry partnership designed to facilitate the application of digital skin imaging to help reduce melanoma mortality,” and is organized into different working groups, including the AI working group, according to its website.
“Our goal with these guidelines was to create higher-quality reporting of dataset and algorithm characteristics for dermatology AI,” first author Roxana Daneshjou, MD, PhD, clinical scholar in dermatology, in the department of dermatology at Stanford (Calif.) University, said in an interview. “We hope these guidelines also aid regulatory bodies around the world when they are assessing algorithms to be used in dermatology.”
Recommendations for data
The authors recommended that datasets used by AI algorithms have image descriptions and details on image artifacts. “For photography, these include the type of camera used; whether images were taken under standardized or varying conditions; whether they were taken by professional photographers, laymen, or health care professionals; and image quality,” they wrote. They also recommended that developers include in an image description the type of lighting used and whether the photo contains pen markings, hair, tattoos, injuries, surgical effects, or other “physical perturbations.”
Exchangeable image file format data obtained from the camera, and preprocessing procedures like color normalization and “postprocessing” of images, such as filtering, should also be disclosed. In addition, developers should disclose and justify inclusion of images that have been created by an algorithm within a dataset. Any public images used in the datasets should have references, and privately used images should be made public where possible, the authors said.
The ISIC working group guidelines also provided recommendations for patient-level metadata. Each image should include a patient’s geographical location and medical center they visited as well as their age, sex and gender, ethnicity and/or race, and skin tone. Dr. Daneshjou said this was one area where she and her colleagues found a lack of transparency in AI datasets in algorithms in a recent review. “We found that many AI papers provided sparse details about the images used to train and test their algorithms,” Dr. Daneshjou explained. “For example, only 7 out of 70 papers had any information about the skin tones in the images used for developing and/or testing AI algorithms. Understanding the diversity of images used to train and test algorithms is important because algorithms that are developed on images of predominantly white skin likely won’t work as well on Black and brown skin.”
The guideline authors also asked algorithm developers to describe the limitations of not including patient-level metadata information when it is incomplete or unavailable. In addition, “we ask that algorithm developers comment on potential biases of their algorithms,” Dr. Daneshjou said. “For example, an algorithm based only on telemedicine images may not capture the full range of diseases seen within an in-person clinic.”
When describing their AI algorithm, developers should detail their reasoning for the dataset size and partitions, inclusion and exclusion criteria for images, and use of any external samples for test sets. “Authors should consider any differences between the image characteristics used for algorithm development and those that might be encountered in the real world,” the guidelines stated.
Recommendations for technique
How the images in a dataset are labeled is a unique challenge in developing AI algorithms for dermatology, the authors noted. Developers should use histopathological diagnosis in their labeling, but this can sometimes result in label noise.
“Many of the AI algorithms in dermatology use supervised learning, which requires labeled examples to help the algorithm ‘learn’ features for discriminating between lesions. We found that some papers use consensus labeling – dermatologists providing a label – to label skin cancers; however, the standard for diagnosing skin cancer is using histopathology from a biopsy,” she said. “Dermatologists can biopsy seven to eight suspected melanomas before discovering a true melanoma, so dermatologist labeling of skin cancers is prone to label noise.”
ISIC’s guidelines stated a gold standard of labeling for dermatologic images is one area that still needs future research, but currently, “diagnoses, labels and diagnostic groups used in data repositories as well as public ontologies” such as ICD-11, AnatomyMapper, and SNOMED-CT should be included in dermatologic image datasets.
AI developers should also provide a detailed description of their algorithm, which includes methods, work flows, mathematical formulas as well as the generalizability of the algorithm across more than one dataset.
Recommendations for technical assessment
“Another important recommendation is that algorithm developers should provide a way for algorithms to be publicly evaluable by researchers,” Dr. Daneshjou said. “Many dermatology AI algorithms do not share either their data or their algorithm. Algorithm sharing is important for assessing reproducibility and robustness.”
Google’s recently announced AI-powered dermatology assistant tool, for example, “has made claims about its accuracy and ability to diagnose skin disease at a dermatologist level, but there is no way for researchers to independently test these claims,” she said. Other options like Model Dermatology, developed by Seung Seog Han, MD, PhD, of the Dermatology Clinic in Seoul, South Korea, and colleagues, offer an application programming interface “that allows researchers to test the algorithm,” Dr. Daneshjou said. “This kind of openness is key for assessing algorithm robustness.”
Developers should also note in their algorithm explanations how performance markers and benchmarks would translate to proposed clinical application. “In this context,” the use case – the context in which the AI application is being used – “should be clearly described – who are the intended users and under what clinical scenario are they using the algorithm,” the authors wrote.
Recommendations for application
The guidelines note that use case for the model should also be described by the AI developers. “Our checklist includes delineating use cases for algorithms and describing what use cases may be within the scope of the algorithm versus which use cases are out of scope,” Dr. Daneshjou said. “For example, an algorithm developed to provide decision support to dermatologists, with a human in the loop, may not be accurate enough to release directly to consumers.”
As the goal of AI algorithms in dermatology is eventual implementation for clinicians and patients, the authors asked developers to consider shortcomings and potential harms of the algorithm during implementation. “Ethical considerations and impact on vulnerable populations should also be considered and discussed,” they wrote. An algorithm “suggesting aesthetic medical treatments may have negative effects given the biased nature of beauty standards,” and “an algorithm that diagnoses basal cell carcinomas but lacks any pigmented basal cell carcinomas, which are more often seen in skin of color, will not perform equitably across populations.”
Prior to implementing an AI algorithm, the ISIC working group recommended developers perform prospective clinical trials for validation. Checklists and guidelines like SPIRIT-AI and CONSORT-AI “provide guidance on how to design clinical trials to test AI algorithms,” Dr. Daneshjou said.
After implementation, “I believe we need additional research in how we monitor algorithms after they are deployed clinically, Dr. Daneshjou said. “Currently there are no [Food and Drug Administration]–approved AI algorithms in dermatology; however, there are several applications that have CE mark in Europe, and there are no mechanisms for postmarket surveillance there.
'Timely' recommendations
Commenting on the ISIC working group guidelines, Justin M. Ko, MD, MBA, director and chief of medical dermatology for Stanford Health Care, who was not involved with the work, said that the recommendations are timely and provide “a framework for a ‘common language’ around AI datasets specifically tailored to dermatology.” Dr. Ko, chair of the American Academy of Dermatology’s Ad Hoc Task Force on Augmented Intelligence, noted the work by Dr. Daneshjou and colleagues “is consistent with and builds further details” on the position statement released by the AAD AI task force in 2019.
“As machine-learning capabilities and commercial efforts continue to mature, it becomes increasingly important that we are able to ‘look under the hood,’ and evaluate all the critical factors that influence development of these capabilities,” he said in an interview. “A standard set of reporting guidelines not only allows for transparency in evaluating data and performance of models and algorithms, but also forces the consideration of issues of equity, fairness, mitigation of bias, and clinically meaningful outcomes.”
One concern is the impact of AI algorithms on societal or health systems, he noted, which is brought up in the guidelines. “The last thing we would want is the development of robust AI systems that exacerbate access challenges, or generate patient anxiety/worry, or drive low-value utilization, or adds to care team burden, or create a technological barrier to care, or increases inequity in dermatologic care,” he said.
In developing AI algorithms for dermatology, a “major practical issue” is how performance on paper will translate to real-world use, Dr. Ko explained, and the ISIC guidelines “provide a critical step in empowering clinicians, practices, and our field to shape the advent of the AI and augmented intelligence tools and systems to promote and enhance meaningful clinical outcomes, and augment the core patient-clinician relationship and ensure they are grounded in principles of fairness, equity and transparency.”
This research was funded by awards and grants to individual authors from the Charina Fund, a Google Research Award, Melanoma Research Alliance, National Health and Medical Research Council, National Institutes of Health/National Cancer Institute, National Science Foundation, and the Department of Veterans Affairs. The authors disclosed relationships with governmental entities, pharmaceutical companies, technology startups, medical publishers, charitable trusts, consulting firms, dermatology training companies, providers of medical devices, manufacturers of dermatologic products, and other organizations related to the paper in the form of supplied equipment, having founded a company; receiving grants, patents, or personal fees; holding shares; and medical reporting. Dr. Ko reported that he serves as a clinical advisor for Skin Analytics, and has an ongoing research collaboration with Google.
The
The guidelines, published in JAMA Dermatology on Dec. 1, 2021, contain a broad range of recommendations stakeholders should consider when developing and assessing image-based AI algorithms in dermatology. The recommendations are divided into categories of data, technique, technical assessment, and application. ISIC is “an academia and industry partnership designed to facilitate the application of digital skin imaging to help reduce melanoma mortality,” and is organized into different working groups, including the AI working group, according to its website.
“Our goal with these guidelines was to create higher-quality reporting of dataset and algorithm characteristics for dermatology AI,” first author Roxana Daneshjou, MD, PhD, clinical scholar in dermatology, in the department of dermatology at Stanford (Calif.) University, said in an interview. “We hope these guidelines also aid regulatory bodies around the world when they are assessing algorithms to be used in dermatology.”
Recommendations for data
The authors recommended that datasets used by AI algorithms have image descriptions and details on image artifacts. “For photography, these include the type of camera used; whether images were taken under standardized or varying conditions; whether they were taken by professional photographers, laymen, or health care professionals; and image quality,” they wrote. They also recommended that developers include in an image description the type of lighting used and whether the photo contains pen markings, hair, tattoos, injuries, surgical effects, or other “physical perturbations.”
Exchangeable image file format data obtained from the camera, and preprocessing procedures like color normalization and “postprocessing” of images, such as filtering, should also be disclosed. In addition, developers should disclose and justify inclusion of images that have been created by an algorithm within a dataset. Any public images used in the datasets should have references, and privately used images should be made public where possible, the authors said.
The ISIC working group guidelines also provided recommendations for patient-level metadata. Each image should include a patient’s geographical location and medical center they visited as well as their age, sex and gender, ethnicity and/or race, and skin tone. Dr. Daneshjou said this was one area where she and her colleagues found a lack of transparency in AI datasets in algorithms in a recent review. “We found that many AI papers provided sparse details about the images used to train and test their algorithms,” Dr. Daneshjou explained. “For example, only 7 out of 70 papers had any information about the skin tones in the images used for developing and/or testing AI algorithms. Understanding the diversity of images used to train and test algorithms is important because algorithms that are developed on images of predominantly white skin likely won’t work as well on Black and brown skin.”
The guideline authors also asked algorithm developers to describe the limitations of not including patient-level metadata information when it is incomplete or unavailable. In addition, “we ask that algorithm developers comment on potential biases of their algorithms,” Dr. Daneshjou said. “For example, an algorithm based only on telemedicine images may not capture the full range of diseases seen within an in-person clinic.”
When describing their AI algorithm, developers should detail their reasoning for the dataset size and partitions, inclusion and exclusion criteria for images, and use of any external samples for test sets. “Authors should consider any differences between the image characteristics used for algorithm development and those that might be encountered in the real world,” the guidelines stated.
Recommendations for technique
How the images in a dataset are labeled is a unique challenge in developing AI algorithms for dermatology, the authors noted. Developers should use histopathological diagnosis in their labeling, but this can sometimes result in label noise.
“Many of the AI algorithms in dermatology use supervised learning, which requires labeled examples to help the algorithm ‘learn’ features for discriminating between lesions. We found that some papers use consensus labeling – dermatologists providing a label – to label skin cancers; however, the standard for diagnosing skin cancer is using histopathology from a biopsy,” she said. “Dermatologists can biopsy seven to eight suspected melanomas before discovering a true melanoma, so dermatologist labeling of skin cancers is prone to label noise.”
ISIC’s guidelines stated a gold standard of labeling for dermatologic images is one area that still needs future research, but currently, “diagnoses, labels and diagnostic groups used in data repositories as well as public ontologies” such as ICD-11, AnatomyMapper, and SNOMED-CT should be included in dermatologic image datasets.
AI developers should also provide a detailed description of their algorithm, which includes methods, work flows, mathematical formulas as well as the generalizability of the algorithm across more than one dataset.
Recommendations for technical assessment
“Another important recommendation is that algorithm developers should provide a way for algorithms to be publicly evaluable by researchers,” Dr. Daneshjou said. “Many dermatology AI algorithms do not share either their data or their algorithm. Algorithm sharing is important for assessing reproducibility and robustness.”
Google’s recently announced AI-powered dermatology assistant tool, for example, “has made claims about its accuracy and ability to diagnose skin disease at a dermatologist level, but there is no way for researchers to independently test these claims,” she said. Other options like Model Dermatology, developed by Seung Seog Han, MD, PhD, of the Dermatology Clinic in Seoul, South Korea, and colleagues, offer an application programming interface “that allows researchers to test the algorithm,” Dr. Daneshjou said. “This kind of openness is key for assessing algorithm robustness.”
Developers should also note in their algorithm explanations how performance markers and benchmarks would translate to proposed clinical application. “In this context,” the use case – the context in which the AI application is being used – “should be clearly described – who are the intended users and under what clinical scenario are they using the algorithm,” the authors wrote.
Recommendations for application
The guidelines note that use case for the model should also be described by the AI developers. “Our checklist includes delineating use cases for algorithms and describing what use cases may be within the scope of the algorithm versus which use cases are out of scope,” Dr. Daneshjou said. “For example, an algorithm developed to provide decision support to dermatologists, with a human in the loop, may not be accurate enough to release directly to consumers.”
As the goal of AI algorithms in dermatology is eventual implementation for clinicians and patients, the authors asked developers to consider shortcomings and potential harms of the algorithm during implementation. “Ethical considerations and impact on vulnerable populations should also be considered and discussed,” they wrote. An algorithm “suggesting aesthetic medical treatments may have negative effects given the biased nature of beauty standards,” and “an algorithm that diagnoses basal cell carcinomas but lacks any pigmented basal cell carcinomas, which are more often seen in skin of color, will not perform equitably across populations.”
Prior to implementing an AI algorithm, the ISIC working group recommended developers perform prospective clinical trials for validation. Checklists and guidelines like SPIRIT-AI and CONSORT-AI “provide guidance on how to design clinical trials to test AI algorithms,” Dr. Daneshjou said.
After implementation, “I believe we need additional research in how we monitor algorithms after they are deployed clinically, Dr. Daneshjou said. “Currently there are no [Food and Drug Administration]–approved AI algorithms in dermatology; however, there are several applications that have CE mark in Europe, and there are no mechanisms for postmarket surveillance there.
'Timely' recommendations
Commenting on the ISIC working group guidelines, Justin M. Ko, MD, MBA, director and chief of medical dermatology for Stanford Health Care, who was not involved with the work, said that the recommendations are timely and provide “a framework for a ‘common language’ around AI datasets specifically tailored to dermatology.” Dr. Ko, chair of the American Academy of Dermatology’s Ad Hoc Task Force on Augmented Intelligence, noted the work by Dr. Daneshjou and colleagues “is consistent with and builds further details” on the position statement released by the AAD AI task force in 2019.
“As machine-learning capabilities and commercial efforts continue to mature, it becomes increasingly important that we are able to ‘look under the hood,’ and evaluate all the critical factors that influence development of these capabilities,” he said in an interview. “A standard set of reporting guidelines not only allows for transparency in evaluating data and performance of models and algorithms, but also forces the consideration of issues of equity, fairness, mitigation of bias, and clinically meaningful outcomes.”
One concern is the impact of AI algorithms on societal or health systems, he noted, which is brought up in the guidelines. “The last thing we would want is the development of robust AI systems that exacerbate access challenges, or generate patient anxiety/worry, or drive low-value utilization, or adds to care team burden, or create a technological barrier to care, or increases inequity in dermatologic care,” he said.
In developing AI algorithms for dermatology, a “major practical issue” is how performance on paper will translate to real-world use, Dr. Ko explained, and the ISIC guidelines “provide a critical step in empowering clinicians, practices, and our field to shape the advent of the AI and augmented intelligence tools and systems to promote and enhance meaningful clinical outcomes, and augment the core patient-clinician relationship and ensure they are grounded in principles of fairness, equity and transparency.”
This research was funded by awards and grants to individual authors from the Charina Fund, a Google Research Award, Melanoma Research Alliance, National Health and Medical Research Council, National Institutes of Health/National Cancer Institute, National Science Foundation, and the Department of Veterans Affairs. The authors disclosed relationships with governmental entities, pharmaceutical companies, technology startups, medical publishers, charitable trusts, consulting firms, dermatology training companies, providers of medical devices, manufacturers of dermatologic products, and other organizations related to the paper in the form of supplied equipment, having founded a company; receiving grants, patents, or personal fees; holding shares; and medical reporting. Dr. Ko reported that he serves as a clinical advisor for Skin Analytics, and has an ongoing research collaboration with Google.
The
The guidelines, published in JAMA Dermatology on Dec. 1, 2021, contain a broad range of recommendations stakeholders should consider when developing and assessing image-based AI algorithms in dermatology. The recommendations are divided into categories of data, technique, technical assessment, and application. ISIC is “an academia and industry partnership designed to facilitate the application of digital skin imaging to help reduce melanoma mortality,” and is organized into different working groups, including the AI working group, according to its website.
“Our goal with these guidelines was to create higher-quality reporting of dataset and algorithm characteristics for dermatology AI,” first author Roxana Daneshjou, MD, PhD, clinical scholar in dermatology, in the department of dermatology at Stanford (Calif.) University, said in an interview. “We hope these guidelines also aid regulatory bodies around the world when they are assessing algorithms to be used in dermatology.”
Recommendations for data
The authors recommended that datasets used by AI algorithms have image descriptions and details on image artifacts. “For photography, these include the type of camera used; whether images were taken under standardized or varying conditions; whether they were taken by professional photographers, laymen, or health care professionals; and image quality,” they wrote. They also recommended that developers include in an image description the type of lighting used and whether the photo contains pen markings, hair, tattoos, injuries, surgical effects, or other “physical perturbations.”
Exchangeable image file format data obtained from the camera, and preprocessing procedures like color normalization and “postprocessing” of images, such as filtering, should also be disclosed. In addition, developers should disclose and justify inclusion of images that have been created by an algorithm within a dataset. Any public images used in the datasets should have references, and privately used images should be made public where possible, the authors said.
The ISIC working group guidelines also provided recommendations for patient-level metadata. Each image should include a patient’s geographical location and medical center they visited as well as their age, sex and gender, ethnicity and/or race, and skin tone. Dr. Daneshjou said this was one area where she and her colleagues found a lack of transparency in AI datasets in algorithms in a recent review. “We found that many AI papers provided sparse details about the images used to train and test their algorithms,” Dr. Daneshjou explained. “For example, only 7 out of 70 papers had any information about the skin tones in the images used for developing and/or testing AI algorithms. Understanding the diversity of images used to train and test algorithms is important because algorithms that are developed on images of predominantly white skin likely won’t work as well on Black and brown skin.”
The guideline authors also asked algorithm developers to describe the limitations of not including patient-level metadata information when it is incomplete or unavailable. In addition, “we ask that algorithm developers comment on potential biases of their algorithms,” Dr. Daneshjou said. “For example, an algorithm based only on telemedicine images may not capture the full range of diseases seen within an in-person clinic.”
When describing their AI algorithm, developers should detail their reasoning for the dataset size and partitions, inclusion and exclusion criteria for images, and use of any external samples for test sets. “Authors should consider any differences between the image characteristics used for algorithm development and those that might be encountered in the real world,” the guidelines stated.
Recommendations for technique
How the images in a dataset are labeled is a unique challenge in developing AI algorithms for dermatology, the authors noted. Developers should use histopathological diagnosis in their labeling, but this can sometimes result in label noise.
“Many of the AI algorithms in dermatology use supervised learning, which requires labeled examples to help the algorithm ‘learn’ features for discriminating between lesions. We found that some papers use consensus labeling – dermatologists providing a label – to label skin cancers; however, the standard for diagnosing skin cancer is using histopathology from a biopsy,” she said. “Dermatologists can biopsy seven to eight suspected melanomas before discovering a true melanoma, so dermatologist labeling of skin cancers is prone to label noise.”
ISIC’s guidelines stated a gold standard of labeling for dermatologic images is one area that still needs future research, but currently, “diagnoses, labels and diagnostic groups used in data repositories as well as public ontologies” such as ICD-11, AnatomyMapper, and SNOMED-CT should be included in dermatologic image datasets.
AI developers should also provide a detailed description of their algorithm, which includes methods, work flows, mathematical formulas as well as the generalizability of the algorithm across more than one dataset.
Recommendations for technical assessment
“Another important recommendation is that algorithm developers should provide a way for algorithms to be publicly evaluable by researchers,” Dr. Daneshjou said. “Many dermatology AI algorithms do not share either their data or their algorithm. Algorithm sharing is important for assessing reproducibility and robustness.”
Google’s recently announced AI-powered dermatology assistant tool, for example, “has made claims about its accuracy and ability to diagnose skin disease at a dermatologist level, but there is no way for researchers to independently test these claims,” she said. Other options like Model Dermatology, developed by Seung Seog Han, MD, PhD, of the Dermatology Clinic in Seoul, South Korea, and colleagues, offer an application programming interface “that allows researchers to test the algorithm,” Dr. Daneshjou said. “This kind of openness is key for assessing algorithm robustness.”
Developers should also note in their algorithm explanations how performance markers and benchmarks would translate to proposed clinical application. “In this context,” the use case – the context in which the AI application is being used – “should be clearly described – who are the intended users and under what clinical scenario are they using the algorithm,” the authors wrote.
Recommendations for application
The guidelines note that use case for the model should also be described by the AI developers. “Our checklist includes delineating use cases for algorithms and describing what use cases may be within the scope of the algorithm versus which use cases are out of scope,” Dr. Daneshjou said. “For example, an algorithm developed to provide decision support to dermatologists, with a human in the loop, may not be accurate enough to release directly to consumers.”
As the goal of AI algorithms in dermatology is eventual implementation for clinicians and patients, the authors asked developers to consider shortcomings and potential harms of the algorithm during implementation. “Ethical considerations and impact on vulnerable populations should also be considered and discussed,” they wrote. An algorithm “suggesting aesthetic medical treatments may have negative effects given the biased nature of beauty standards,” and “an algorithm that diagnoses basal cell carcinomas but lacks any pigmented basal cell carcinomas, which are more often seen in skin of color, will not perform equitably across populations.”
Prior to implementing an AI algorithm, the ISIC working group recommended developers perform prospective clinical trials for validation. Checklists and guidelines like SPIRIT-AI and CONSORT-AI “provide guidance on how to design clinical trials to test AI algorithms,” Dr. Daneshjou said.
After implementation, “I believe we need additional research in how we monitor algorithms after they are deployed clinically, Dr. Daneshjou said. “Currently there are no [Food and Drug Administration]–approved AI algorithms in dermatology; however, there are several applications that have CE mark in Europe, and there are no mechanisms for postmarket surveillance there.
'Timely' recommendations
Commenting on the ISIC working group guidelines, Justin M. Ko, MD, MBA, director and chief of medical dermatology for Stanford Health Care, who was not involved with the work, said that the recommendations are timely and provide “a framework for a ‘common language’ around AI datasets specifically tailored to dermatology.” Dr. Ko, chair of the American Academy of Dermatology’s Ad Hoc Task Force on Augmented Intelligence, noted the work by Dr. Daneshjou and colleagues “is consistent with and builds further details” on the position statement released by the AAD AI task force in 2019.
“As machine-learning capabilities and commercial efforts continue to mature, it becomes increasingly important that we are able to ‘look under the hood,’ and evaluate all the critical factors that influence development of these capabilities,” he said in an interview. “A standard set of reporting guidelines not only allows for transparency in evaluating data and performance of models and algorithms, but also forces the consideration of issues of equity, fairness, mitigation of bias, and clinically meaningful outcomes.”
One concern is the impact of AI algorithms on societal or health systems, he noted, which is brought up in the guidelines. “The last thing we would want is the development of robust AI systems that exacerbate access challenges, or generate patient anxiety/worry, or drive low-value utilization, or adds to care team burden, or create a technological barrier to care, or increases inequity in dermatologic care,” he said.
In developing AI algorithms for dermatology, a “major practical issue” is how performance on paper will translate to real-world use, Dr. Ko explained, and the ISIC guidelines “provide a critical step in empowering clinicians, practices, and our field to shape the advent of the AI and augmented intelligence tools and systems to promote and enhance meaningful clinical outcomes, and augment the core patient-clinician relationship and ensure they are grounded in principles of fairness, equity and transparency.”
This research was funded by awards and grants to individual authors from the Charina Fund, a Google Research Award, Melanoma Research Alliance, National Health and Medical Research Council, National Institutes of Health/National Cancer Institute, National Science Foundation, and the Department of Veterans Affairs. The authors disclosed relationships with governmental entities, pharmaceutical companies, technology startups, medical publishers, charitable trusts, consulting firms, dermatology training companies, providers of medical devices, manufacturers of dermatologic products, and other organizations related to the paper in the form of supplied equipment, having founded a company; receiving grants, patents, or personal fees; holding shares; and medical reporting. Dr. Ko reported that he serves as a clinical advisor for Skin Analytics, and has an ongoing research collaboration with Google.
FROM JAMA DERMATOLOGY
Ophthalmologist who developed medical botox dies at 89
his family confirmed to National Public Radio.
Four decades ago, Alan Brown Scott, MD, a native of Berkeley, Calif., turned the drug, once a deadly poison, into a revolutionary treatment for obscure eye diseases. It later became a well-known blockbuster treatment for reducing the appearance of wrinkles and treating hyperhidrosis (excessive sweating). Other approved medical uses include treatment of overactive bladder and urinary incontinence.
According to the American Society of Plastic Surgeons, its popularity for cosmetic use was boosted further during the pandemic and it was the No. 1 minimally invasive cosmetic procedure performed in 2020. Among the 13.3 million procedures, 4.4 million involved Botox.
According to Bloomberg Businessweek, Ed Schantz, who was working in the military’s biological weapons program, was the one to first send the toxin to Dr. Scott, who wanted to explore its properties for medical use.
The same Bloomberg article also noted that the original botulinum toxin itself “is so powerful that a tiny amount can suffocate a person by paralyzing the muscles used for breathing.”
Dr. Scott was looking for a way to help his patients avoid extensive surgeries.
“Specifically, he was aiming to treat people with strabismus, or cross-eyes, and blepharospasm, which is an uncontrollable closure of eyes. Today, it’s also used as a treatment to help with migraines, hair loss, and drooling,” NPR reported.
The New York Times once described Botox as “medicine’s answer to duct tape.”
Dr. Scott was the executive director of the Smith-Kettlewell Eye Research Institute in San Francisco when he did his pioneering research with botulinum toxin in the 1970s and 1980s, according to a 2002 article in SFGate.
In 1991, Dr. Scott sold the drug to Allergan, when it was called Oculinum. The next year, the name was officially changed to Botox.
In 2002, Dr. Scott told SFGate, when asked about the more popular use for the drug, “I think that’s a charming, slightly frivolous use,” adding, “but it’s not along the lines of what I was into, applications for serious disorders.”
According to Scientific American in 2016, Dr. Scott, then age 83, kept working on the noncosmetic benefits of botulism-toxin injections for eye-related disorders at the Strabismus Research Foundation,
He told Scientific American he was proud that his efforts “are directly helpful to people.”
“There are interesting and difficult problems still to be solved, and I’m a practicing physician and I see them every day,” he said.
Dr. Scott’s daughter, Ann Scott, told NPR: “He definitely loved his work and he was also a really great father.” She said her dad involved his children in his research and work.
She added, “He was a really calm, more of a quiet reserved person,” and said he was committed to teaching his students, many of them international students.
“That was what he really loved,” she said.
Dr. Scott, who died Dec. 16, was in intensive care for the last 10 days from an unspecified illness, his daughter told NPR.
A version of this article first appeared on Medscape.com.
his family confirmed to National Public Radio.
Four decades ago, Alan Brown Scott, MD, a native of Berkeley, Calif., turned the drug, once a deadly poison, into a revolutionary treatment for obscure eye diseases. It later became a well-known blockbuster treatment for reducing the appearance of wrinkles and treating hyperhidrosis (excessive sweating). Other approved medical uses include treatment of overactive bladder and urinary incontinence.
According to the American Society of Plastic Surgeons, its popularity for cosmetic use was boosted further during the pandemic and it was the No. 1 minimally invasive cosmetic procedure performed in 2020. Among the 13.3 million procedures, 4.4 million involved Botox.
According to Bloomberg Businessweek, Ed Schantz, who was working in the military’s biological weapons program, was the one to first send the toxin to Dr. Scott, who wanted to explore its properties for medical use.
The same Bloomberg article also noted that the original botulinum toxin itself “is so powerful that a tiny amount can suffocate a person by paralyzing the muscles used for breathing.”
Dr. Scott was looking for a way to help his patients avoid extensive surgeries.
“Specifically, he was aiming to treat people with strabismus, or cross-eyes, and blepharospasm, which is an uncontrollable closure of eyes. Today, it’s also used as a treatment to help with migraines, hair loss, and drooling,” NPR reported.
The New York Times once described Botox as “medicine’s answer to duct tape.”
Dr. Scott was the executive director of the Smith-Kettlewell Eye Research Institute in San Francisco when he did his pioneering research with botulinum toxin in the 1970s and 1980s, according to a 2002 article in SFGate.
In 1991, Dr. Scott sold the drug to Allergan, when it was called Oculinum. The next year, the name was officially changed to Botox.
In 2002, Dr. Scott told SFGate, when asked about the more popular use for the drug, “I think that’s a charming, slightly frivolous use,” adding, “but it’s not along the lines of what I was into, applications for serious disorders.”
According to Scientific American in 2016, Dr. Scott, then age 83, kept working on the noncosmetic benefits of botulism-toxin injections for eye-related disorders at the Strabismus Research Foundation,
He told Scientific American he was proud that his efforts “are directly helpful to people.”
“There are interesting and difficult problems still to be solved, and I’m a practicing physician and I see them every day,” he said.
Dr. Scott’s daughter, Ann Scott, told NPR: “He definitely loved his work and he was also a really great father.” She said her dad involved his children in his research and work.
She added, “He was a really calm, more of a quiet reserved person,” and said he was committed to teaching his students, many of them international students.
“That was what he really loved,” she said.
Dr. Scott, who died Dec. 16, was in intensive care for the last 10 days from an unspecified illness, his daughter told NPR.
A version of this article first appeared on Medscape.com.
his family confirmed to National Public Radio.
Four decades ago, Alan Brown Scott, MD, a native of Berkeley, Calif., turned the drug, once a deadly poison, into a revolutionary treatment for obscure eye diseases. It later became a well-known blockbuster treatment for reducing the appearance of wrinkles and treating hyperhidrosis (excessive sweating). Other approved medical uses include treatment of overactive bladder and urinary incontinence.
According to the American Society of Plastic Surgeons, its popularity for cosmetic use was boosted further during the pandemic and it was the No. 1 minimally invasive cosmetic procedure performed in 2020. Among the 13.3 million procedures, 4.4 million involved Botox.
According to Bloomberg Businessweek, Ed Schantz, who was working in the military’s biological weapons program, was the one to first send the toxin to Dr. Scott, who wanted to explore its properties for medical use.
The same Bloomberg article also noted that the original botulinum toxin itself “is so powerful that a tiny amount can suffocate a person by paralyzing the muscles used for breathing.”
Dr. Scott was looking for a way to help his patients avoid extensive surgeries.
“Specifically, he was aiming to treat people with strabismus, or cross-eyes, and blepharospasm, which is an uncontrollable closure of eyes. Today, it’s also used as a treatment to help with migraines, hair loss, and drooling,” NPR reported.
The New York Times once described Botox as “medicine’s answer to duct tape.”
Dr. Scott was the executive director of the Smith-Kettlewell Eye Research Institute in San Francisco when he did his pioneering research with botulinum toxin in the 1970s and 1980s, according to a 2002 article in SFGate.
In 1991, Dr. Scott sold the drug to Allergan, when it was called Oculinum. The next year, the name was officially changed to Botox.
In 2002, Dr. Scott told SFGate, when asked about the more popular use for the drug, “I think that’s a charming, slightly frivolous use,” adding, “but it’s not along the lines of what I was into, applications for serious disorders.”
According to Scientific American in 2016, Dr. Scott, then age 83, kept working on the noncosmetic benefits of botulism-toxin injections for eye-related disorders at the Strabismus Research Foundation,
He told Scientific American he was proud that his efforts “are directly helpful to people.”
“There are interesting and difficult problems still to be solved, and I’m a practicing physician and I see them every day,” he said.
Dr. Scott’s daughter, Ann Scott, told NPR: “He definitely loved his work and he was also a really great father.” She said her dad involved his children in his research and work.
She added, “He was a really calm, more of a quiet reserved person,” and said he was committed to teaching his students, many of them international students.
“That was what he really loved,” she said.
Dr. Scott, who died Dec. 16, was in intensive care for the last 10 days from an unspecified illness, his daughter told NPR.
A version of this article first appeared on Medscape.com.
What is your diagnosis?
Answer: Infectious gastroparesis secondary to acute hepatitis A infection.
A computed tomography scan of the abdomen/pelvis demonstrated marked gastric distention without obvious obstructing mass and normal caliber small bowel and colon. Additional laboratory workup revealed a positive hepatitis A IgM antibody. Hepatitis B surface antigen and core IgM antibody were negative, as was the hepatitis C virus antibody. Human immunodeficiency virus antigen and antibody were negative. An esophagogastroduodenoscopy was performed that showed a large amount of food in a dilated and atonic stomach.
With conservative treatment, the patient’s liver enzymes trended down over the next 2 days to alanine aminotransferase 993 U/L, aspartate aminotransferase 244 U/L, and direct bilirubin 3.8 mg/dL. At the time of discharge, she was tolerating soft foods without any difficulty. She was educated on taking appropriate precautions to avoid transmitting the hepatitis A infection to others. Her risk factor for hepatitis A was recent incarceration.
Here we highlight a rare case of infectious gastroparesis secondary to hepatitis A infection. Hepatitis A virus is a small, nonenveloped, RNA-containing virus.1 It typically presents with a self-limited illness with liver failure occurring in rare cases. Common presenting symptoms including nausea, vomiting, jaundice, fever, diarrhea, and abdominal pain.Laboratory abnormalities include elevations in the serum aminotransferases, alkaline phosphatase, and total bilirubin.2 The diagnosis is confirmed with a positive hepatitis A IgM antibody. The most common route of transmission is the fecal-oral route such as through consumption of contaminated water and food or from person-to-person contact.1 Individuals can develop immunity to the virus either from prior infection or vaccination.
Gastroparesis refers to delayed emptying of gastric contents when mechanical obstruction has been ruled out. Common causes of gastroparesis include diabetes mellitus, medications, postoperative complications, and infections. Infectious gastroparesis may present acutely after a viral prodrome and symptoms may be severe and slow to resolve.3
References
1. Lemon SM. N Engl J Med. 1985 Oct 24;313(17):1059-67.
2. Tong MJ et al. J Infect Dis. 1995 Mar;171 Suppl 1:S15-8.
3. Bityutskiy LP. Am J Gastroenterol. 1997 Sep;92(9):1501-4.
Answer: Infectious gastroparesis secondary to acute hepatitis A infection.
A computed tomography scan of the abdomen/pelvis demonstrated marked gastric distention without obvious obstructing mass and normal caliber small bowel and colon. Additional laboratory workup revealed a positive hepatitis A IgM antibody. Hepatitis B surface antigen and core IgM antibody were negative, as was the hepatitis C virus antibody. Human immunodeficiency virus antigen and antibody were negative. An esophagogastroduodenoscopy was performed that showed a large amount of food in a dilated and atonic stomach.
With conservative treatment, the patient’s liver enzymes trended down over the next 2 days to alanine aminotransferase 993 U/L, aspartate aminotransferase 244 U/L, and direct bilirubin 3.8 mg/dL. At the time of discharge, she was tolerating soft foods without any difficulty. She was educated on taking appropriate precautions to avoid transmitting the hepatitis A infection to others. Her risk factor for hepatitis A was recent incarceration.
Here we highlight a rare case of infectious gastroparesis secondary to hepatitis A infection. Hepatitis A virus is a small, nonenveloped, RNA-containing virus.1 It typically presents with a self-limited illness with liver failure occurring in rare cases. Common presenting symptoms including nausea, vomiting, jaundice, fever, diarrhea, and abdominal pain.Laboratory abnormalities include elevations in the serum aminotransferases, alkaline phosphatase, and total bilirubin.2 The diagnosis is confirmed with a positive hepatitis A IgM antibody. The most common route of transmission is the fecal-oral route such as through consumption of contaminated water and food or from person-to-person contact.1 Individuals can develop immunity to the virus either from prior infection or vaccination.
Gastroparesis refers to delayed emptying of gastric contents when mechanical obstruction has been ruled out. Common causes of gastroparesis include diabetes mellitus, medications, postoperative complications, and infections. Infectious gastroparesis may present acutely after a viral prodrome and symptoms may be severe and slow to resolve.3
References
1. Lemon SM. N Engl J Med. 1985 Oct 24;313(17):1059-67.
2. Tong MJ et al. J Infect Dis. 1995 Mar;171 Suppl 1:S15-8.
3. Bityutskiy LP. Am J Gastroenterol. 1997 Sep;92(9):1501-4.
Answer: Infectious gastroparesis secondary to acute hepatitis A infection.
A computed tomography scan of the abdomen/pelvis demonstrated marked gastric distention without obvious obstructing mass and normal caliber small bowel and colon. Additional laboratory workup revealed a positive hepatitis A IgM antibody. Hepatitis B surface antigen and core IgM antibody were negative, as was the hepatitis C virus antibody. Human immunodeficiency virus antigen and antibody were negative. An esophagogastroduodenoscopy was performed that showed a large amount of food in a dilated and atonic stomach.
With conservative treatment, the patient’s liver enzymes trended down over the next 2 days to alanine aminotransferase 993 U/L, aspartate aminotransferase 244 U/L, and direct bilirubin 3.8 mg/dL. At the time of discharge, she was tolerating soft foods without any difficulty. She was educated on taking appropriate precautions to avoid transmitting the hepatitis A infection to others. Her risk factor for hepatitis A was recent incarceration.
Here we highlight a rare case of infectious gastroparesis secondary to hepatitis A infection. Hepatitis A virus is a small, nonenveloped, RNA-containing virus.1 It typically presents with a self-limited illness with liver failure occurring in rare cases. Common presenting symptoms including nausea, vomiting, jaundice, fever, diarrhea, and abdominal pain.Laboratory abnormalities include elevations in the serum aminotransferases, alkaline phosphatase, and total bilirubin.2 The diagnosis is confirmed with a positive hepatitis A IgM antibody. The most common route of transmission is the fecal-oral route such as through consumption of contaminated water and food or from person-to-person contact.1 Individuals can develop immunity to the virus either from prior infection or vaccination.
Gastroparesis refers to delayed emptying of gastric contents when mechanical obstruction has been ruled out. Common causes of gastroparesis include diabetes mellitus, medications, postoperative complications, and infections. Infectious gastroparesis may present acutely after a viral prodrome and symptoms may be severe and slow to resolve.3
References
1. Lemon SM. N Engl J Med. 1985 Oct 24;313(17):1059-67.
2. Tong MJ et al. J Infect Dis. 1995 Mar;171 Suppl 1:S15-8.
3. Bityutskiy LP. Am J Gastroenterol. 1997 Sep;92(9):1501-4.
A 33-year-old woman presented with a 10-day history of painless jaundice. During this time, she also noted decreased appetite, malaise, and pruritus. On occasion, she would have heartburn and belching that would improve with an antacid. She denied any right upper quadrant pain and weight loss. She was not currently taking any medications, including acetaminophen. She had a past medical history of methamphetamine use in recent remission. She had recently been incarcerated for about 1 month. 
What is the most likely etiology of the patient's condition?
Dermatologists driving use of vascular lasers in the Medicare population
In addition, as a proportion of Medicare charges submitted that were reimbursed, the highest reimbursements were for dermatologists and those in the Western geographic region.
Those are among the key findings from an analysis that aimed to characterize trends in use and reimbursement patterns of vascular lasers in the Medicare-insured population.
“There are several modalities for vascular laser treatment, including the pulse dye laser, the frequency doubled KTP laser, and others,” presenting author Partik Singh, MD, MBA, said during a virtual abstract session at the annual meeting of the American Society for Dermatologic Surgery. “Laser treatment of vascular lesions may sometimes be covered by insurance, depending on the indication, but little is known about how and which clinicians are taking advantage of this covered treatment.”
Dr. Singh, a 2nd-year dermatology resident at the University of Rochester Medical Center, and coauthor Mara Weinstein Velez, MD, extracted data from the 2012-2018 Medicare Public Use File, which includes 100% fee-for-service, non–Medicare Advantage claims based on CPT codes, yet no information on patient data, clinical context, or indications. Outcomes of interest were total vascular laser claims per year, annual vascular laser claims per clinician, annual clinicians using vascular lasers, accepted reimbursements defined by the allowed charge or the submitted charge to Medicare, and clinical specialties and geographic location.
The researchers found that more than half of clinicians who used vascular lasers during the study period were dermatologists (55%), followed by general surgeons (6%), family practice/internal medicine physicians (5% each) and various others. Use of vascular lasers among all clinicians increased 10.5% annually during the study period, from 3,786 to 6,883, and was most pronounced among dermatologists, whose use increased 18.4% annually, from 1,878 to 5,182. “Nondermatologists did not have a big change in their overall utilization rate, but they did have a steady utilization of vascular lasers, roughly at almost 2,000 claims per year,” Dr. Singh said.
The researchers also observed that the use of vascular lasers on a per-clinician basis increased 7.4% annually among all clinicians during the study period, from 77.3 to 118.7. This was mostly driven by dermatologists, whose per-clinician use increased 10.4% annually, from 81.7 to 148.7. Use by nondermatologists remained about stable, with just a 0.1% increase annually, from 73.4 to 74. In addition, the number of clinicians who billed for vascular laser procedures increased 2.9% annually between 2012 and 2018, from 49 to 58. This growth was driven mostly by dermatologists, who increased their billing for vascular laser procedures by 7.2% annually, from 23 to 35 clinicians.
In other findings, dermatologists were reimbursed at 68.3% of submitted charges, compared with 59.3% of charges submitted by other clinicians (P = .0001), and reimbursement rates were greatest in the Western geographic region of the United States vs. the Northeast, Midwest, and Southern regions (73.1% vs. 50.2%, 65.4%, and 55.3%, respectively; P < .0001).
“Use of vascular lasers is increasing primarily among dermatologists, though there is steady use of these procedures by nondermatologists,” Dr. Singh concluded. “Medicare charges were more often fully reimbursed when billed by dermatologists and those in the Western U.S., perhaps suggesting a better familiarity with appropriate indications and better administrative resources for coverage of vascular laser procedures.”
After the meeting, Dr. Singh acknowledged certain limitations of the analysis, including the fact that it “was limited only to Medicare Part B fee-for-service claims, not including Medicare Advantage,” he told this news organization. “Our conclusions do not necessarily hold true for Medicaid or commercial insurers, for instance. Moreover, this dataset doesn’t provide patient-specific information, such as the indication for the procedure. Further studies are needed to characterize utilization of various lasers in not only Medicare beneficiaries, but also those with Medicaid, private insurance, and patients paying out-of-pocket. Additionally, study is also needed to explain why these differences in reimbursement hold true.”
The researchers reported having no relevant financial disclosures.
In addition, as a proportion of Medicare charges submitted that were reimbursed, the highest reimbursements were for dermatologists and those in the Western geographic region.
Those are among the key findings from an analysis that aimed to characterize trends in use and reimbursement patterns of vascular lasers in the Medicare-insured population.
“There are several modalities for vascular laser treatment, including the pulse dye laser, the frequency doubled KTP laser, and others,” presenting author Partik Singh, MD, MBA, said during a virtual abstract session at the annual meeting of the American Society for Dermatologic Surgery. “Laser treatment of vascular lesions may sometimes be covered by insurance, depending on the indication, but little is known about how and which clinicians are taking advantage of this covered treatment.”
Dr. Singh, a 2nd-year dermatology resident at the University of Rochester Medical Center, and coauthor Mara Weinstein Velez, MD, extracted data from the 2012-2018 Medicare Public Use File, which includes 100% fee-for-service, non–Medicare Advantage claims based on CPT codes, yet no information on patient data, clinical context, or indications. Outcomes of interest were total vascular laser claims per year, annual vascular laser claims per clinician, annual clinicians using vascular lasers, accepted reimbursements defined by the allowed charge or the submitted charge to Medicare, and clinical specialties and geographic location.
The researchers found that more than half of clinicians who used vascular lasers during the study period were dermatologists (55%), followed by general surgeons (6%), family practice/internal medicine physicians (5% each) and various others. Use of vascular lasers among all clinicians increased 10.5% annually during the study period, from 3,786 to 6,883, and was most pronounced among dermatologists, whose use increased 18.4% annually, from 1,878 to 5,182. “Nondermatologists did not have a big change in their overall utilization rate, but they did have a steady utilization of vascular lasers, roughly at almost 2,000 claims per year,” Dr. Singh said.
The researchers also observed that the use of vascular lasers on a per-clinician basis increased 7.4% annually among all clinicians during the study period, from 77.3 to 118.7. This was mostly driven by dermatologists, whose per-clinician use increased 10.4% annually, from 81.7 to 148.7. Use by nondermatologists remained about stable, with just a 0.1% increase annually, from 73.4 to 74. In addition, the number of clinicians who billed for vascular laser procedures increased 2.9% annually between 2012 and 2018, from 49 to 58. This growth was driven mostly by dermatologists, who increased their billing for vascular laser procedures by 7.2% annually, from 23 to 35 clinicians.
In other findings, dermatologists were reimbursed at 68.3% of submitted charges, compared with 59.3% of charges submitted by other clinicians (P = .0001), and reimbursement rates were greatest in the Western geographic region of the United States vs. the Northeast, Midwest, and Southern regions (73.1% vs. 50.2%, 65.4%, and 55.3%, respectively; P < .0001).
“Use of vascular lasers is increasing primarily among dermatologists, though there is steady use of these procedures by nondermatologists,” Dr. Singh concluded. “Medicare charges were more often fully reimbursed when billed by dermatologists and those in the Western U.S., perhaps suggesting a better familiarity with appropriate indications and better administrative resources for coverage of vascular laser procedures.”
After the meeting, Dr. Singh acknowledged certain limitations of the analysis, including the fact that it “was limited only to Medicare Part B fee-for-service claims, not including Medicare Advantage,” he told this news organization. “Our conclusions do not necessarily hold true for Medicaid or commercial insurers, for instance. Moreover, this dataset doesn’t provide patient-specific information, such as the indication for the procedure. Further studies are needed to characterize utilization of various lasers in not only Medicare beneficiaries, but also those with Medicaid, private insurance, and patients paying out-of-pocket. Additionally, study is also needed to explain why these differences in reimbursement hold true.”
The researchers reported having no relevant financial disclosures.
In addition, as a proportion of Medicare charges submitted that were reimbursed, the highest reimbursements were for dermatologists and those in the Western geographic region.
Those are among the key findings from an analysis that aimed to characterize trends in use and reimbursement patterns of vascular lasers in the Medicare-insured population.
“There are several modalities for vascular laser treatment, including the pulse dye laser, the frequency doubled KTP laser, and others,” presenting author Partik Singh, MD, MBA, said during a virtual abstract session at the annual meeting of the American Society for Dermatologic Surgery. “Laser treatment of vascular lesions may sometimes be covered by insurance, depending on the indication, but little is known about how and which clinicians are taking advantage of this covered treatment.”
Dr. Singh, a 2nd-year dermatology resident at the University of Rochester Medical Center, and coauthor Mara Weinstein Velez, MD, extracted data from the 2012-2018 Medicare Public Use File, which includes 100% fee-for-service, non–Medicare Advantage claims based on CPT codes, yet no information on patient data, clinical context, or indications. Outcomes of interest were total vascular laser claims per year, annual vascular laser claims per clinician, annual clinicians using vascular lasers, accepted reimbursements defined by the allowed charge or the submitted charge to Medicare, and clinical specialties and geographic location.
The researchers found that more than half of clinicians who used vascular lasers during the study period were dermatologists (55%), followed by general surgeons (6%), family practice/internal medicine physicians (5% each) and various others. Use of vascular lasers among all clinicians increased 10.5% annually during the study period, from 3,786 to 6,883, and was most pronounced among dermatologists, whose use increased 18.4% annually, from 1,878 to 5,182. “Nondermatologists did not have a big change in their overall utilization rate, but they did have a steady utilization of vascular lasers, roughly at almost 2,000 claims per year,” Dr. Singh said.
The researchers also observed that the use of vascular lasers on a per-clinician basis increased 7.4% annually among all clinicians during the study period, from 77.3 to 118.7. This was mostly driven by dermatologists, whose per-clinician use increased 10.4% annually, from 81.7 to 148.7. Use by nondermatologists remained about stable, with just a 0.1% increase annually, from 73.4 to 74. In addition, the number of clinicians who billed for vascular laser procedures increased 2.9% annually between 2012 and 2018, from 49 to 58. This growth was driven mostly by dermatologists, who increased their billing for vascular laser procedures by 7.2% annually, from 23 to 35 clinicians.
In other findings, dermatologists were reimbursed at 68.3% of submitted charges, compared with 59.3% of charges submitted by other clinicians (P = .0001), and reimbursement rates were greatest in the Western geographic region of the United States vs. the Northeast, Midwest, and Southern regions (73.1% vs. 50.2%, 65.4%, and 55.3%, respectively; P < .0001).
“Use of vascular lasers is increasing primarily among dermatologists, though there is steady use of these procedures by nondermatologists,” Dr. Singh concluded. “Medicare charges were more often fully reimbursed when billed by dermatologists and those in the Western U.S., perhaps suggesting a better familiarity with appropriate indications and better administrative resources for coverage of vascular laser procedures.”
After the meeting, Dr. Singh acknowledged certain limitations of the analysis, including the fact that it “was limited only to Medicare Part B fee-for-service claims, not including Medicare Advantage,” he told this news organization. “Our conclusions do not necessarily hold true for Medicaid or commercial insurers, for instance. Moreover, this dataset doesn’t provide patient-specific information, such as the indication for the procedure. Further studies are needed to characterize utilization of various lasers in not only Medicare beneficiaries, but also those with Medicaid, private insurance, and patients paying out-of-pocket. Additionally, study is also needed to explain why these differences in reimbursement hold true.”
The researchers reported having no relevant financial disclosures.
FROM ASDS 2021
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Overlap in a Pregnant Patient
To the Editor:
A 34-year-old pregnant woman at 5 weeks’ gestation was transferred to dermatology from an outside hospital with a full-body rash. Three days after noting a fever and generalized body aches, she developed a painful rash on the legs that had gradually spread to the arms, trunk, and face. Symptoms of eyelid pruritus and edema initially were improved with intravenous (IV) steroids at an emergency department visit, but they started to flare soon thereafter with worsening mucosal involvement and dysphagia. After a second visit to the emergency department and repeat treatment with IV steroids, she was transferred to our institution for a higher level of care.
The patient denied taking any new medications in the 2 months prior to the onset of the rash. Her medication history only consisted of over-the-counter prenatal vitamins, a single use of over-the-counter migraine medication (containing acetaminophen, aspirin, and caffeine as active ingredients), and a possible use of ibuprofen or acetaminophen separately. She reported ocular discomfort and blurriness, dysphagia, dysuria, and vaginal discomfort. Physical examination revealed dusky red to violaceous macules and patches that involved approximately 65% of the body surface area (BSA), with bullae involving approximately 10% BSA. The face was diffusely red and edematous with crusted erosions and scattered bullae on the cheeks. Mucosal involvement was notable for injected conjunctivae and erosions present on the upper hard palate of the mouth and lips (Figure, A). Erythematous macules with dusky centers coalescing into patches with overlying vesicles and bullae were scattered on the arms (Figure, B), hands, trunk (Figure, C), and legs. The Nikolsky sign was positive. The vulva was swollen and covered with erythematous macules with dusky centers.
A biopsy from the upper back revealed a vacuolar interface with subepidermal bullae and confluent keratinocyte necrosis with many CD8+ cells and scattered granzyme B. Given these results in conjunction with the clinical findings, a diagnosis of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) overlap was made. In addition to providing supportive care, the patient was started on a 4-day course of IV immunoglobulin (IVIG)(3g/kg total) and prednisone 60 mg daily, tapered over several weeks with a good clinical response. At outpatient follow-up she was found to have postinflammatory hypopigmentation on the face, trunk, and extremities, as well as tear duct scarring, but she had no vulvovaginal scarring or stenosis. She was progressing well in her pregnancy with no serious complications for 4 months after admission, at which point she was lost to follow-up.
Stevens-Johnson syndrome and TEN represent a spectrum of severe mucocutaneous reactions with high morbidity and mortality. Medications are the leading trigger, followed by infection. The most common inciting medications include antibacterial sulfonamides, antiepileptics such as carbamazepine and lamotrigine, nonsteroidal anti-inflammatory drugs, nevirapine, and allopurinol. The onset of symptoms from 1 to 4 weeks combined with characteristic morphologic features helps distinguish SJS/TEN from other drug eruptions. The initial presentation classically consists of a flulike prodrome followed by mucocutaneous eruption. Skin lesions often present as a diffuse erythema or ill-defined, coalescing, erythematous macules with purpuric centers that may evolve into vesicles and bullae with sloughing of the skin. Histopathology reveals full-thickness epidermal necrosis with detachment.1
Erythema multiforme and Mycoplasma-induced rash and mucositis (MIRM) are high on the differential diagnosis. Distinguishing features of erythema multiforme include the morphology of targetoid lesions and a common distribution on the extremities, in addition to the limited bullae and epidermal detachment in comparison with SJS/TEN. In MIRM, mucositis often is more severe and extensive, with multiple mucosal surfaces affected. It typically has less cutaneous involvement than SJS/TEN, though clinical variants can include diffuse rash and affect fewer than 2 mucosal sites.2 Depending on the timing of rash onset, Mycoplasma IgM/IgG titers may be drawn to further support the diagnosis. A diagnosis of MIRM was not favored in our patient due to lack of respiratory symptoms, normal chest radiography, and negative Mycoplasma IgM and IgG titers.
Stevens-Johnson syndrome/toxic epidermal necrolysis overlap has been reported in pregnant patients, typically in association with HIV infection or new medication exposure.3 A combination of genetic susceptibility and an altered immune system during pregnancy may contribute to the pathogenesis, involving a cytotoxic T-cell mediated reaction with release of inflammatory cytokines.1 Interestingly, these factors that may predispose a patient to developing SJS/TEN may not pass on to the neonate, evidenced by a few cases that showed no reaction in the newborn when given the same offending drug.4
Stevens-Johnson syndrome/toxic epidermal necrolysis more frequently presents in the second or third trimester, with no increase in maternal mortality and an equally high survival rate of the fetus.1,5 Unique sequelae in pregnant patients may include vaginal stenosis, vulvar swelling, and postpartum sepsis. Fetal complications can include low birth weight, preterm delivery, and respiratory distress. The fetus rarely exhibits cutaneous manifestations of the disease.6
A multidisciplinary approach to the diagnosis and management of SJS/TEN overlap in special patient populations such as pregnant women is vital. Supportive measures consisting of wound care, fluid and electrolyte management, infection monitoring, and nutritional support have sufficed in treating SJS/TEN in pregnant patients.3 Although adjunctive therapy with systemic corticosteroids, IVIG, cyclosporine, and tumor necrosis factor inhibitors commonly are used in clinical practice, the safety of these treatments in pregnant patients affected by SJS/TEN has not been established. However, use of these medications for other indications, primarily rheumatologic diseases, has been reported to be safe in the pregnant population.7 If necessary, glucocorticoids should be used in the lowest effective dose to avoid complications such as premature rupture of membranes; intrauterine growth restriction; and increased risk for pregnancy-induced hypertension, gestational diabetes, osteoporosis, and infection. Little is known about IVIG use in pregnancy. While it has not been associated with increased risk of fetal malformations, it may cross the placenta in a notable amount when administered after 30 weeks’ gestation.7
Unlike most cases of SJS/TEN in pregnancy that largely were associated with HIV infection or drug exposure, primarily antiretrovirals such as nevirapine or antiepileptics, our case is a rare incidence of SJS/TEN in a pregnant patient with no clear medication or infectious trigger. Although the causative drug was unclear, we suspected it was secondary to nonsteroidal anti-inflammatory drug use. The patient had a SCORTEN (SCORe of Toxic Epidermal Necrosis) of 0, which portends a relatively good prognosis with an estimated mortality rate of approximately 3% (Table).8 However, the large BSA involvement of the morbilliform rash warranted aggressive management to prevent the involved skin from fully detaching.
1. Struck MF, Illert T, Liss Y, et al. Toxic epidermal necrolysis in pregnancy: case report and review of the literature. J Burn Care Res. 2010;31:816-821. doi:10.1097/BCR.0b013e3181eed441
2. Canavan TN, Mathes EF, Frieden I, et al. Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. J Am Acad Dermatol. 2015;72:239-245.e4. doi:10.1016/j.jaad.2014.06.026
3. Knight L, Todd G, Muloiwa R, et al. Stevens Johnson syndrome and toxic epidermal necrolysis: maternal and foetal outcomes in twenty-two consecutive pregnant HIV infected women. PLoS One. 2015;10:1-11. doi:10.1371/journal.pone.0135501
4. Velter C, Hotz C, Ingen-Housz-Oro S. Stevens-Johnson syndrome during pregnancy: case report of a newborn treated with the culprit drug. JAMA Dermatol. 2018;154:224-225. doi:10.1001/jamadermatol.2017.4607
5. El Daief SG, Das S, Ekekwe G, et al. A successful pregnancy outcome after Stevens-Johnson syndrome. J Obstet Gynaecol (Lahore). 2014;34:445-446. doi:10.3109/01443615.2014.914897
6. Rodriguez G, Trent JT, Mirzabeigi M. Toxic epidermal necrolysis in a mother and fetus. J Am Acad Dermatol. 2006;55(5 suppl):96-98. doi:10.1016/j.jaad.2005.09.023
7. Bermas BL. Safety of rheumatic disease medication use during pregnancy and lactation. UptoDate website. Updated March 24, 2021. Accessed December 16, 2021. https://www.uptodate.com/contents/safety-of-rheumatic-disease-medication-use-during-pregnancy-and-lactation#H11
8. Bastuji-Garin S, Fouchard N, Bertocchi M, et al. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol. 2000;115:149-153. doi:10.1046/j.1523-1747.2000.00061.x
To the Editor:
A 34-year-old pregnant woman at 5 weeks’ gestation was transferred to dermatology from an outside hospital with a full-body rash. Three days after noting a fever and generalized body aches, she developed a painful rash on the legs that had gradually spread to the arms, trunk, and face. Symptoms of eyelid pruritus and edema initially were improved with intravenous (IV) steroids at an emergency department visit, but they started to flare soon thereafter with worsening mucosal involvement and dysphagia. After a second visit to the emergency department and repeat treatment with IV steroids, she was transferred to our institution for a higher level of care.
The patient denied taking any new medications in the 2 months prior to the onset of the rash. Her medication history only consisted of over-the-counter prenatal vitamins, a single use of over-the-counter migraine medication (containing acetaminophen, aspirin, and caffeine as active ingredients), and a possible use of ibuprofen or acetaminophen separately. She reported ocular discomfort and blurriness, dysphagia, dysuria, and vaginal discomfort. Physical examination revealed dusky red to violaceous macules and patches that involved approximately 65% of the body surface area (BSA), with bullae involving approximately 10% BSA. The face was diffusely red and edematous with crusted erosions and scattered bullae on the cheeks. Mucosal involvement was notable for injected conjunctivae and erosions present on the upper hard palate of the mouth and lips (Figure, A). Erythematous macules with dusky centers coalescing into patches with overlying vesicles and bullae were scattered on the arms (Figure, B), hands, trunk (Figure, C), and legs. The Nikolsky sign was positive. The vulva was swollen and covered with erythematous macules with dusky centers.
A biopsy from the upper back revealed a vacuolar interface with subepidermal bullae and confluent keratinocyte necrosis with many CD8+ cells and scattered granzyme B. Given these results in conjunction with the clinical findings, a diagnosis of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) overlap was made. In addition to providing supportive care, the patient was started on a 4-day course of IV immunoglobulin (IVIG)(3g/kg total) and prednisone 60 mg daily, tapered over several weeks with a good clinical response. At outpatient follow-up she was found to have postinflammatory hypopigmentation on the face, trunk, and extremities, as well as tear duct scarring, but she had no vulvovaginal scarring or stenosis. She was progressing well in her pregnancy with no serious complications for 4 months after admission, at which point she was lost to follow-up.
Stevens-Johnson syndrome and TEN represent a spectrum of severe mucocutaneous reactions with high morbidity and mortality. Medications are the leading trigger, followed by infection. The most common inciting medications include antibacterial sulfonamides, antiepileptics such as carbamazepine and lamotrigine, nonsteroidal anti-inflammatory drugs, nevirapine, and allopurinol. The onset of symptoms from 1 to 4 weeks combined with characteristic morphologic features helps distinguish SJS/TEN from other drug eruptions. The initial presentation classically consists of a flulike prodrome followed by mucocutaneous eruption. Skin lesions often present as a diffuse erythema or ill-defined, coalescing, erythematous macules with purpuric centers that may evolve into vesicles and bullae with sloughing of the skin. Histopathology reveals full-thickness epidermal necrosis with detachment.1
Erythema multiforme and Mycoplasma-induced rash and mucositis (MIRM) are high on the differential diagnosis. Distinguishing features of erythema multiforme include the morphology of targetoid lesions and a common distribution on the extremities, in addition to the limited bullae and epidermal detachment in comparison with SJS/TEN. In MIRM, mucositis often is more severe and extensive, with multiple mucosal surfaces affected. It typically has less cutaneous involvement than SJS/TEN, though clinical variants can include diffuse rash and affect fewer than 2 mucosal sites.2 Depending on the timing of rash onset, Mycoplasma IgM/IgG titers may be drawn to further support the diagnosis. A diagnosis of MIRM was not favored in our patient due to lack of respiratory symptoms, normal chest radiography, and negative Mycoplasma IgM and IgG titers.
Stevens-Johnson syndrome/toxic epidermal necrolysis overlap has been reported in pregnant patients, typically in association with HIV infection or new medication exposure.3 A combination of genetic susceptibility and an altered immune system during pregnancy may contribute to the pathogenesis, involving a cytotoxic T-cell mediated reaction with release of inflammatory cytokines.1 Interestingly, these factors that may predispose a patient to developing SJS/TEN may not pass on to the neonate, evidenced by a few cases that showed no reaction in the newborn when given the same offending drug.4
Stevens-Johnson syndrome/toxic epidermal necrolysis more frequently presents in the second or third trimester, with no increase in maternal mortality and an equally high survival rate of the fetus.1,5 Unique sequelae in pregnant patients may include vaginal stenosis, vulvar swelling, and postpartum sepsis. Fetal complications can include low birth weight, preterm delivery, and respiratory distress. The fetus rarely exhibits cutaneous manifestations of the disease.6
A multidisciplinary approach to the diagnosis and management of SJS/TEN overlap in special patient populations such as pregnant women is vital. Supportive measures consisting of wound care, fluid and electrolyte management, infection monitoring, and nutritional support have sufficed in treating SJS/TEN in pregnant patients.3 Although adjunctive therapy with systemic corticosteroids, IVIG, cyclosporine, and tumor necrosis factor inhibitors commonly are used in clinical practice, the safety of these treatments in pregnant patients affected by SJS/TEN has not been established. However, use of these medications for other indications, primarily rheumatologic diseases, has been reported to be safe in the pregnant population.7 If necessary, glucocorticoids should be used in the lowest effective dose to avoid complications such as premature rupture of membranes; intrauterine growth restriction; and increased risk for pregnancy-induced hypertension, gestational diabetes, osteoporosis, and infection. Little is known about IVIG use in pregnancy. While it has not been associated with increased risk of fetal malformations, it may cross the placenta in a notable amount when administered after 30 weeks’ gestation.7
Unlike most cases of SJS/TEN in pregnancy that largely were associated with HIV infection or drug exposure, primarily antiretrovirals such as nevirapine or antiepileptics, our case is a rare incidence of SJS/TEN in a pregnant patient with no clear medication or infectious trigger. Although the causative drug was unclear, we suspected it was secondary to nonsteroidal anti-inflammatory drug use. The patient had a SCORTEN (SCORe of Toxic Epidermal Necrosis) of 0, which portends a relatively good prognosis with an estimated mortality rate of approximately 3% (Table).8 However, the large BSA involvement of the morbilliform rash warranted aggressive management to prevent the involved skin from fully detaching.
To the Editor:
A 34-year-old pregnant woman at 5 weeks’ gestation was transferred to dermatology from an outside hospital with a full-body rash. Three days after noting a fever and generalized body aches, she developed a painful rash on the legs that had gradually spread to the arms, trunk, and face. Symptoms of eyelid pruritus and edema initially were improved with intravenous (IV) steroids at an emergency department visit, but they started to flare soon thereafter with worsening mucosal involvement and dysphagia. After a second visit to the emergency department and repeat treatment with IV steroids, she was transferred to our institution for a higher level of care.
The patient denied taking any new medications in the 2 months prior to the onset of the rash. Her medication history only consisted of over-the-counter prenatal vitamins, a single use of over-the-counter migraine medication (containing acetaminophen, aspirin, and caffeine as active ingredients), and a possible use of ibuprofen or acetaminophen separately. She reported ocular discomfort and blurriness, dysphagia, dysuria, and vaginal discomfort. Physical examination revealed dusky red to violaceous macules and patches that involved approximately 65% of the body surface area (BSA), with bullae involving approximately 10% BSA. The face was diffusely red and edematous with crusted erosions and scattered bullae on the cheeks. Mucosal involvement was notable for injected conjunctivae and erosions present on the upper hard palate of the mouth and lips (Figure, A). Erythematous macules with dusky centers coalescing into patches with overlying vesicles and bullae were scattered on the arms (Figure, B), hands, trunk (Figure, C), and legs. The Nikolsky sign was positive. The vulva was swollen and covered with erythematous macules with dusky centers.
A biopsy from the upper back revealed a vacuolar interface with subepidermal bullae and confluent keratinocyte necrosis with many CD8+ cells and scattered granzyme B. Given these results in conjunction with the clinical findings, a diagnosis of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) overlap was made. In addition to providing supportive care, the patient was started on a 4-day course of IV immunoglobulin (IVIG)(3g/kg total) and prednisone 60 mg daily, tapered over several weeks with a good clinical response. At outpatient follow-up she was found to have postinflammatory hypopigmentation on the face, trunk, and extremities, as well as tear duct scarring, but she had no vulvovaginal scarring or stenosis. She was progressing well in her pregnancy with no serious complications for 4 months after admission, at which point she was lost to follow-up.
Stevens-Johnson syndrome and TEN represent a spectrum of severe mucocutaneous reactions with high morbidity and mortality. Medications are the leading trigger, followed by infection. The most common inciting medications include antibacterial sulfonamides, antiepileptics such as carbamazepine and lamotrigine, nonsteroidal anti-inflammatory drugs, nevirapine, and allopurinol. The onset of symptoms from 1 to 4 weeks combined with characteristic morphologic features helps distinguish SJS/TEN from other drug eruptions. The initial presentation classically consists of a flulike prodrome followed by mucocutaneous eruption. Skin lesions often present as a diffuse erythema or ill-defined, coalescing, erythematous macules with purpuric centers that may evolve into vesicles and bullae with sloughing of the skin. Histopathology reveals full-thickness epidermal necrosis with detachment.1
Erythema multiforme and Mycoplasma-induced rash and mucositis (MIRM) are high on the differential diagnosis. Distinguishing features of erythema multiforme include the morphology of targetoid lesions and a common distribution on the extremities, in addition to the limited bullae and epidermal detachment in comparison with SJS/TEN. In MIRM, mucositis often is more severe and extensive, with multiple mucosal surfaces affected. It typically has less cutaneous involvement than SJS/TEN, though clinical variants can include diffuse rash and affect fewer than 2 mucosal sites.2 Depending on the timing of rash onset, Mycoplasma IgM/IgG titers may be drawn to further support the diagnosis. A diagnosis of MIRM was not favored in our patient due to lack of respiratory symptoms, normal chest radiography, and negative Mycoplasma IgM and IgG titers.
Stevens-Johnson syndrome/toxic epidermal necrolysis overlap has been reported in pregnant patients, typically in association with HIV infection or new medication exposure.3 A combination of genetic susceptibility and an altered immune system during pregnancy may contribute to the pathogenesis, involving a cytotoxic T-cell mediated reaction with release of inflammatory cytokines.1 Interestingly, these factors that may predispose a patient to developing SJS/TEN may not pass on to the neonate, evidenced by a few cases that showed no reaction in the newborn when given the same offending drug.4
Stevens-Johnson syndrome/toxic epidermal necrolysis more frequently presents in the second or third trimester, with no increase in maternal mortality and an equally high survival rate of the fetus.1,5 Unique sequelae in pregnant patients may include vaginal stenosis, vulvar swelling, and postpartum sepsis. Fetal complications can include low birth weight, preterm delivery, and respiratory distress. The fetus rarely exhibits cutaneous manifestations of the disease.6
A multidisciplinary approach to the diagnosis and management of SJS/TEN overlap in special patient populations such as pregnant women is vital. Supportive measures consisting of wound care, fluid and electrolyte management, infection monitoring, and nutritional support have sufficed in treating SJS/TEN in pregnant patients.3 Although adjunctive therapy with systemic corticosteroids, IVIG, cyclosporine, and tumor necrosis factor inhibitors commonly are used in clinical practice, the safety of these treatments in pregnant patients affected by SJS/TEN has not been established. However, use of these medications for other indications, primarily rheumatologic diseases, has been reported to be safe in the pregnant population.7 If necessary, glucocorticoids should be used in the lowest effective dose to avoid complications such as premature rupture of membranes; intrauterine growth restriction; and increased risk for pregnancy-induced hypertension, gestational diabetes, osteoporosis, and infection. Little is known about IVIG use in pregnancy. While it has not been associated with increased risk of fetal malformations, it may cross the placenta in a notable amount when administered after 30 weeks’ gestation.7
Unlike most cases of SJS/TEN in pregnancy that largely were associated with HIV infection or drug exposure, primarily antiretrovirals such as nevirapine or antiepileptics, our case is a rare incidence of SJS/TEN in a pregnant patient with no clear medication or infectious trigger. Although the causative drug was unclear, we suspected it was secondary to nonsteroidal anti-inflammatory drug use. The patient had a SCORTEN (SCORe of Toxic Epidermal Necrosis) of 0, which portends a relatively good prognosis with an estimated mortality rate of approximately 3% (Table).8 However, the large BSA involvement of the morbilliform rash warranted aggressive management to prevent the involved skin from fully detaching.
1. Struck MF, Illert T, Liss Y, et al. Toxic epidermal necrolysis in pregnancy: case report and review of the literature. J Burn Care Res. 2010;31:816-821. doi:10.1097/BCR.0b013e3181eed441
2. Canavan TN, Mathes EF, Frieden I, et al. Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. J Am Acad Dermatol. 2015;72:239-245.e4. doi:10.1016/j.jaad.2014.06.026
3. Knight L, Todd G, Muloiwa R, et al. Stevens Johnson syndrome and toxic epidermal necrolysis: maternal and foetal outcomes in twenty-two consecutive pregnant HIV infected women. PLoS One. 2015;10:1-11. doi:10.1371/journal.pone.0135501
4. Velter C, Hotz C, Ingen-Housz-Oro S. Stevens-Johnson syndrome during pregnancy: case report of a newborn treated with the culprit drug. JAMA Dermatol. 2018;154:224-225. doi:10.1001/jamadermatol.2017.4607
5. El Daief SG, Das S, Ekekwe G, et al. A successful pregnancy outcome after Stevens-Johnson syndrome. J Obstet Gynaecol (Lahore). 2014;34:445-446. doi:10.3109/01443615.2014.914897
6. Rodriguez G, Trent JT, Mirzabeigi M. Toxic epidermal necrolysis in a mother and fetus. J Am Acad Dermatol. 2006;55(5 suppl):96-98. doi:10.1016/j.jaad.2005.09.023
7. Bermas BL. Safety of rheumatic disease medication use during pregnancy and lactation. UptoDate website. Updated March 24, 2021. Accessed December 16, 2021. https://www.uptodate.com/contents/safety-of-rheumatic-disease-medication-use-during-pregnancy-and-lactation#H11
8. Bastuji-Garin S, Fouchard N, Bertocchi M, et al. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol. 2000;115:149-153. doi:10.1046/j.1523-1747.2000.00061.x
1. Struck MF, Illert T, Liss Y, et al. Toxic epidermal necrolysis in pregnancy: case report and review of the literature. J Burn Care Res. 2010;31:816-821. doi:10.1097/BCR.0b013e3181eed441
2. Canavan TN, Mathes EF, Frieden I, et al. Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. J Am Acad Dermatol. 2015;72:239-245.e4. doi:10.1016/j.jaad.2014.06.026
3. Knight L, Todd G, Muloiwa R, et al. Stevens Johnson syndrome and toxic epidermal necrolysis: maternal and foetal outcomes in twenty-two consecutive pregnant HIV infected women. PLoS One. 2015;10:1-11. doi:10.1371/journal.pone.0135501
4. Velter C, Hotz C, Ingen-Housz-Oro S. Stevens-Johnson syndrome during pregnancy: case report of a newborn treated with the culprit drug. JAMA Dermatol. 2018;154:224-225. doi:10.1001/jamadermatol.2017.4607
5. El Daief SG, Das S, Ekekwe G, et al. A successful pregnancy outcome after Stevens-Johnson syndrome. J Obstet Gynaecol (Lahore). 2014;34:445-446. doi:10.3109/01443615.2014.914897
6. Rodriguez G, Trent JT, Mirzabeigi M. Toxic epidermal necrolysis in a mother and fetus. J Am Acad Dermatol. 2006;55(5 suppl):96-98. doi:10.1016/j.jaad.2005.09.023
7. Bermas BL. Safety of rheumatic disease medication use during pregnancy and lactation. UptoDate website. Updated March 24, 2021. Accessed December 16, 2021. https://www.uptodate.com/contents/safety-of-rheumatic-disease-medication-use-during-pregnancy-and-lactation#H11
8. Bastuji-Garin S, Fouchard N, Bertocchi M, et al. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol. 2000;115:149-153. doi:10.1046/j.1523-1747.2000.00061.x
Practice Points
- Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) represent a spectrum of severe mucocutaneous reactions commonly presenting as drug eruptions.
- Pregnant patients affected by SJS/TEN represent a special patient population that requires a multidisciplinary approach for management and treatment.
- The rates of adverse outcomes for pregnant patients with SJS/TEN are low with timely diagnosis, removal of the offending agent, and supportive care as mainstays of treatment.
Dermatologists take to TikTok to share their own ‘hacks’
A young woman is having her lip swabbed with an unknown substance, smiling, on the TikTok video. Seconds later, another young woman, wearing gloves, pushes a hyaluron pen against the first woman’s lips, who, in the next cut, is smiling, happy. “My first syringe down and already 1,000x more confident,” the caption reads.
That video is one of thousands showing hyaluron pen use on TikTok. The pens are sold online and are unapproved – which led to a Food and Drug Administration warning in October 2021 that use could cause bleeding, infection, blood vessel occlusion that could result in blindness or stroke, allergic reactions, and other injuries.
The warning has not stopped many TikTokkers, who also use the medium to promote all sorts of skin and aesthetic products and procedures, a large number unproven, unapproved, or ill advised. which, more often than not, comes from “skinfluencers,” aestheticians, and other laypeople, not board-certified dermatologists.
The suggested “hacks” can be harmless or ineffective, but they also can be misleading, fraudulent, or even dangerous.
Skinfluencers take the lead
TikTok has a reported 1 billion monthly users. Two-thirds are aged 10-29 years, according to data reported in February 2021 in the Journal of the American Academy of Dermatology by David X. Zheng, BA, and colleagues at Case Western Reserve University, Cleveland, and the department of dermatology, Johns Hopkins University, Baltimore.
Visitors consume information in video bits that run from 15 seconds to up to 3 minutes and can follow their favorite TikTokkers, browse for people or hashtags with a search function, or click on content recommended by the platform, which uses algorithms based on the user’s viewing habits to determine what might be of interest.
Some of the biggest “skinfluencers” have millions of followers: Hyram Yarbro, (@skincarebyhyram) for instance, has 6.6 million followers and his own line of skin care products at Sephora. Mr. Yarbro is seen as a no-nonsense debunker of skin care myths, as is British influencer James Welsh, who has 124,000 followers.
“The reason why people trust your average influencer person who’s not a doctor is because they’re relatable,” said Muneeb Shah, MD, a dermatology resident at Atlantic Dermatology in Wilmington, N.C. – known to his 11.4 million TikTok followers as @dermdoctor.
To Sandra Lee, MD, the popularity of nonprofessionals is easy to explain. “You have to think about the fact that a lot of people can’t see dermatologists – they don’t have the money, they don’t have the time to travel there, they don’t have health insurance, or they’re scared of doctors, so they’re willing to try to find an answer, and one of the easiest ways, one of the more entertaining ways to get information, is on social media.”
Dr. Lee is in private practice in Upland, Calif., but is better known as “Dr. Pimple Popper,” through her television show of the same name and her social media accounts, including on TikTok, where she has 14.4 million followers after having started in 2020.
“We’re all looking for that no-down-time, no-expense, no-lines, no-wrinkles, stay-young-forever magic bullet,” said Dr. Lee.
Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, agreed that people are looking for a quick fix. They don’t want to wait 12 weeks for an acne medication or 16 weeks for a biologic to work. “They want something simple, easy, do-it-yourself,” and “natural,” he said.
Laypeople are still the dominant producers – and have the most views – of dermatology content.
Morgan Nguyen, BA, at Northwestern University, Chicago, and colleagues looked at hashtags for the top 10 dermatologic diagnoses and procedures and analyzed the content of the first 40 TikTok videos in each category. About half the videos were produced by an individual, and 39% by a health care provider, according to the study, published in the International Journal of Women’s Dermatology. About 40% of the videos were educational, focusing on skin care, procedures, and disease treatment.
Viewership was highest for videos by laypeople, followed by those produced by business or industry accounts. Those produced by health care providers received only 18% of the views.
The most popular videos were about dermatologic diagnoses, with 2.5 billion views, followed by dermatologic procedures, with 708 million views.
Ms. Nguyen noted in the study that the most liked and most viewed posts were related to #skincare but that board-certified dermatologists produced only 2.5% of the #skincare videos.
Dermatologists take to TikTok
Some dermatologists have started their own TikTok accounts, seeking both to counteract misinformation and provide education.
Dr. Shah has become one of the top influencers on the platform. In a year-end wrap, TikTok put Dr. Shah at No. 7 on its top creators list for 2021.
The dermatology resident said that TikTok is a good tool for reaching patients who might not otherwise interact with dermatologists. He recounted the story of an individual who came into his office with the idea that they had hidradenitis suppurativa.
The person had self-diagnosed after seeing one of Dr. Shah’s TikTok videos on the condition. It was a pleasant surprise, said Dr. Shah. People with hidradenitis suppurativa often avoid treatment, and it’s underdiagnosed and improperly treated, despite an American Academy of Dermatology awareness campaign.
“Dermatologists on social media are almost like the communications department for dermatology,” Dr. Shah commented.
A key to making TikTok work to advance dermatologists’ goals is knowing what makes it unique.
Dr. Lee said she prefers it to Instagram, because TikTok’s algorithms and its younger-skewing audience help her reach a more specific audience.
The algorithm “creates a positive feedback loop in which popular content creators or viral trends are prioritized on the users’ homepages, in turn providing the creators of these videos with an even larger audience,” Mr. Zheng, of University Hospitals Cleveland Medical Center, and coauthors noted in their letter in the Journal of the American Academy of Dermatology.
TikTok also celebrates the everyday – someone doesn’t have to be a celebrity to make something go viral, said Dr. Lee. She believes that TikTok users are more accepting of average people with real problems – which helps when someone is TikTokking about a skin condition.
Doris Day, MD, who goes by @drdorisday on TikTok, agreed with Dr. Lee. “There are so many creative ways you can convey information with it that’s different than what you have on Instagram,” said Dr. Day, who is in private practice in New York. And, she added, “it does really lend itself to getting points out super-fast.”
Dermatologists on TikTok also said they like the “duets” and the “stitch” features, which allow users to add on to an existing video, essentially chiming in or responding to what might have already been posted, in a side-by-side format.
Dr. Shah said he often duets videos that have questionable content. “It allows me to directly respond to people. A lot of times, if something is going really viral and it’s not accurate, you’ll have a response from me or one of the other doctors” within hours or days.
Dr. Shah’s duets are labeled with “DermDoctor Reacts” or “DermDoctor Explains.” In one duet, with more than 2.8 million views, the upper half of the video is someone squeezing a blackhead, while Dr. Shah, in the bottom half, in green scrubs, opines over some hip-hop music: “This is just a blackhead. But once it gets to this point, they do need to be extracted because topical treatments won’t help.”
Dr. Lee – whose TikTok and other accounts capitalize on teens’ obsession with popping pimples – has a duet in which she advised that although popping will leave scars, there are more ideal times to pop, if they must. The duet has at least 21 million views.
Sometimes a TikTok video effectively takes on a trend without being a duet. Nurse practitioner Uy Dam (@uy.np) has a video that demonstrates the dangers of hyaluron pens. He uses both a pen and a needle to inject fluid into a block of jello. The pen delivers a scattershot load of differing depths, while the needle is exact. It’s visual and easy to understand and has at least 1.3 million views.
Still, TikTok, like other forms of social media, is full of misinformation and false accounts, including people who claim to be doctors. “It’s hard for the regular person, myself included, sometimes to be able to root through that and find out whether something is real or not,” said Dr. Lee.
Dr. Friedman said he’s concerned about the lack of accountability. A doctor could lose his or her license for promoting unproven cures, especially if they are harmful. But for influencers, “there’s no accountability for posting information that can actually hurt people.”
TikTok trends gone bad
And some people are being hurt by emulating what they see on TikTok.
Dr. Friedman had a patient with extreme irritant contact dermatitis, “almost like chemical burns to her underarms,” he said. He determined that she saw a video “hack” that recommended using baking soda to stop hyperhidrosis. The patient used so much that it burned her skin.
In 2020, do-it-yourself freckles – with henna or sewing needles impregnated with ink – went viral. Tilly Whitfeld, a 21-year-old reality TV star on Australia’s Big Brother show, told the New York Times that she tried it at home after seeing a TikTok video. She ordered brown tattoo ink online and later found out that it was contaminated with lead, according to the Times. Ms. Whitfeld developed an infection and temporary vision loss and has permanent scarring.
She has since put out a cautionary TikTok video that’s been viewed some 300,000 times.
TikTokkers have also flocked to the idea of using sunscreen to “contour” the face. Selected areas are left without sunscreen to burn or tan. In a duet, a plastic surgeon shakes his head as a young woman explains that “it works.”
Scalp-popping – in which the hair is yanked so hard that it pulls the galea off the skull – has been mostly shut down by TikTok. A search of “scalp popping” brings up the message: “Learn how to recognize harmful challenges and hoaxes.” At-home mole and skin tag removal, pimple-popping, and supposed acne cures such as drinking chlorophyll are all avidly documented and shared on TikTok.
Dr. Shah had a back-and-forth video dialog with someone who had stubbed a toe and then drilled a hole into the nail to drain the hematoma. In a reaction video, Dr. Shah said it was likely to turn into an infection. When it did, the man revealed the infection in a video where he tagged Dr. Shah and later posted a video at the podiatrist’s office having his nail removed, again tagging Dr. Shah.
“I think that pretty much no procedure for skin is good to do at home,” said Dr. Shah, who repeatedly admonishes against mole removal by a nonphysician. He tells followers that “it’s extremely dangerous – not only is it going to cause scarring, but you are potentially discarding a cancerous lesion.”
Unfortunately, most will not follow the advice, said Dr. Shah. That’s especially true of pimple-popping. Aiming for the least harm, he suggests in some TikTok videos that poppers keep the area clean, wear gloves, and consult a physician to get an antibiotic prescription. “You might as well at least guide them in the right direction,” he added.
Dr. Lee believes that lack of access to physicians, insurance, or money may play into how TikTok trends evolve. “Probably those people who injected their lips with this air gun thing, maybe they didn’t have the money necessarily to get filler,” she said.
Also, she noted, while TikTok may try to police its content, creators are incentivized to be outrageous. “The more inflammatory your post is, the more engagement you get.”
Dr. Shah thinks TikTok is self-correcting. “If you’re not being ethical or contradicting yourself, putting out information that’s not accurate, people are going to catch on very quickly,” he said. “The only value, the only currency you have on social media is the trust that you build with people that follow you.”
What it takes to be a TikTokker
For dermatologists, conveying their credentials and experience is one way to build that currency. Dr. Lee advised fellow doctors on TikTok to “showcase your training and how many years it took to become a dermatologist.”
Plunging into TikTok is not for everyone, though. It’s time consuming, said Dr. Lee, who now devotes most of her nonclinical time to TikTok. She creates her own content, leaving others to manage her Instagram account.
Many of those in the medical field who have dived into TikTok are residents, like Dr. Shah. “They are attuned to it and understand it more,” said Dr. Lee. “It’s harder for a lot of us who are older, who really weren’t involved that much in social media at all. It’s very hard to jump in.” There’s a learning curve, and it takes hours to create a single video. “You have to enjoy it and it has to be a part of your life,” she said.
Dr. Shah started experimenting with TikTok at the beginning of the pandemic in 2020 and has never turned back. Fast-talking, curious, and with an infectious sense of fun, he shares tidbits about his personal life – putting his wife in some of his videos – and always seems upbeat.
He said that, as his following grew, users began to see him as an authority figure and started “tagging” him more often, seeking his opinion on other videos. Although still a resident, he believes he has specialized knowledge to share. “Even if you’re not the world’s leading expert in a particular topic, you’re still adding value for the person who doesn’t know much.”
Dr. Shah also occasionally does promotional TikToks, identified as sponsored content. He said he only works with companies that he believes have legitimate products. “You do have to monetize at some point,” he said, noting that many dermatologists, himself included, are trading clinic time for TikTok. “There’s no universe where they can do this for free.”
Product endorsements are likely more rewarding for influencers and other users like Dr. Shah than the remuneration from TikTok, the company. The platform pays user accounts $20 per 1 million views, Dr. Shah said. “Financially, it’s not a big winner for a practicing dermatologist, but the educational outreach is worthwhile.”
To be successful also means understanding what drives viewership.
Using “trending” sounds has “been shown to increase the likelihood of a video amassing millions of views” and may increase engagement with dermatologists’ TikTok videos, wrote Bina Kassamali, BA, and colleagues at the Brigham and Women’s Hospital in Boston and the Ponce Health Science University School of Medicine in Ponce, Puerto Rico, in a letter published in the Journal of the American Academy of Dermatology in July 2021.
Certain content is more likely to engage viewers. In their analysis of top trending dermatologic hashtags, acne-related content was viewed 6.7 billion times, followed by alopecia, with 1.1 billion views. Psoriasis content had 84 million views, putting it eighth on the list of topics.
Dermatologists are still cracking TikTok. They are accumulating more followers on TikTok than on Instagram but have greater engagement on Instagram reels, wrote Mindy D. Szeto, MS, and colleagues at the University of Colorado at Denver, Aurora, and Rocky Vista University in Parker, Colo., in the Journal of the American Academy of Dermatology in April 2021.
Dr. Lee and Dr. Shah had the highest engagement rate on TikTok, according to Ms. Szeto. The engagement rate is calculated as (likes + comments per post)/(total followers) x 100.
“TikTok may currently be the leading avenue for audience education by dermatologist influencers,” they wrote, urging dermatologists to use the platform to answer the call as more of the public “continues to turn to social media for medical advice.”
Dr. Day said she will keep trying to build her TikTok audience. She has just 239 followers, compared with her 44,500 on Instagram. “The more I do TikTok, the more I do any of these mediums, the better I get at it,” she said. “We just have to put a little time and effort into it and try to get more followers and just keep sharing the information.”
Dr. Friedman sees it as a positive that some dermatologists have taken to TikTok to dispel myths and put “good information out there in small bites.” But to be more effective, they need more followers.
“The truth is that 14-year-old is probably going to listen more to a Hyram than a dermatologist,” he said. “Maybe we need to work with these other individuals who know how to take these messages and convert them to a language that can be digested by a 14-year-old, by a 12-year-old, by a 23-year-old. We need to come to the table together and not fight.”
A version of this article first appeared on Medscape.com.
A young woman is having her lip swabbed with an unknown substance, smiling, on the TikTok video. Seconds later, another young woman, wearing gloves, pushes a hyaluron pen against the first woman’s lips, who, in the next cut, is smiling, happy. “My first syringe down and already 1,000x more confident,” the caption reads.
That video is one of thousands showing hyaluron pen use on TikTok. The pens are sold online and are unapproved – which led to a Food and Drug Administration warning in October 2021 that use could cause bleeding, infection, blood vessel occlusion that could result in blindness or stroke, allergic reactions, and other injuries.
The warning has not stopped many TikTokkers, who also use the medium to promote all sorts of skin and aesthetic products and procedures, a large number unproven, unapproved, or ill advised. which, more often than not, comes from “skinfluencers,” aestheticians, and other laypeople, not board-certified dermatologists.
The suggested “hacks” can be harmless or ineffective, but they also can be misleading, fraudulent, or even dangerous.
Skinfluencers take the lead
TikTok has a reported 1 billion monthly users. Two-thirds are aged 10-29 years, according to data reported in February 2021 in the Journal of the American Academy of Dermatology by David X. Zheng, BA, and colleagues at Case Western Reserve University, Cleveland, and the department of dermatology, Johns Hopkins University, Baltimore.
Visitors consume information in video bits that run from 15 seconds to up to 3 minutes and can follow their favorite TikTokkers, browse for people or hashtags with a search function, or click on content recommended by the platform, which uses algorithms based on the user’s viewing habits to determine what might be of interest.
Some of the biggest “skinfluencers” have millions of followers: Hyram Yarbro, (@skincarebyhyram) for instance, has 6.6 million followers and his own line of skin care products at Sephora. Mr. Yarbro is seen as a no-nonsense debunker of skin care myths, as is British influencer James Welsh, who has 124,000 followers.
“The reason why people trust your average influencer person who’s not a doctor is because they’re relatable,” said Muneeb Shah, MD, a dermatology resident at Atlantic Dermatology in Wilmington, N.C. – known to his 11.4 million TikTok followers as @dermdoctor.
To Sandra Lee, MD, the popularity of nonprofessionals is easy to explain. “You have to think about the fact that a lot of people can’t see dermatologists – they don’t have the money, they don’t have the time to travel there, they don’t have health insurance, or they’re scared of doctors, so they’re willing to try to find an answer, and one of the easiest ways, one of the more entertaining ways to get information, is on social media.”
Dr. Lee is in private practice in Upland, Calif., but is better known as “Dr. Pimple Popper,” through her television show of the same name and her social media accounts, including on TikTok, where she has 14.4 million followers after having started in 2020.
“We’re all looking for that no-down-time, no-expense, no-lines, no-wrinkles, stay-young-forever magic bullet,” said Dr. Lee.
Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, agreed that people are looking for a quick fix. They don’t want to wait 12 weeks for an acne medication or 16 weeks for a biologic to work. “They want something simple, easy, do-it-yourself,” and “natural,” he said.
Laypeople are still the dominant producers – and have the most views – of dermatology content.
Morgan Nguyen, BA, at Northwestern University, Chicago, and colleagues looked at hashtags for the top 10 dermatologic diagnoses and procedures and analyzed the content of the first 40 TikTok videos in each category. About half the videos were produced by an individual, and 39% by a health care provider, according to the study, published in the International Journal of Women’s Dermatology. About 40% of the videos were educational, focusing on skin care, procedures, and disease treatment.
Viewership was highest for videos by laypeople, followed by those produced by business or industry accounts. Those produced by health care providers received only 18% of the views.
The most popular videos were about dermatologic diagnoses, with 2.5 billion views, followed by dermatologic procedures, with 708 million views.
Ms. Nguyen noted in the study that the most liked and most viewed posts were related to #skincare but that board-certified dermatologists produced only 2.5% of the #skincare videos.
Dermatologists take to TikTok
Some dermatologists have started their own TikTok accounts, seeking both to counteract misinformation and provide education.
Dr. Shah has become one of the top influencers on the platform. In a year-end wrap, TikTok put Dr. Shah at No. 7 on its top creators list for 2021.
The dermatology resident said that TikTok is a good tool for reaching patients who might not otherwise interact with dermatologists. He recounted the story of an individual who came into his office with the idea that they had hidradenitis suppurativa.
The person had self-diagnosed after seeing one of Dr. Shah’s TikTok videos on the condition. It was a pleasant surprise, said Dr. Shah. People with hidradenitis suppurativa often avoid treatment, and it’s underdiagnosed and improperly treated, despite an American Academy of Dermatology awareness campaign.
“Dermatologists on social media are almost like the communications department for dermatology,” Dr. Shah commented.
A key to making TikTok work to advance dermatologists’ goals is knowing what makes it unique.
Dr. Lee said she prefers it to Instagram, because TikTok’s algorithms and its younger-skewing audience help her reach a more specific audience.
The algorithm “creates a positive feedback loop in which popular content creators or viral trends are prioritized on the users’ homepages, in turn providing the creators of these videos with an even larger audience,” Mr. Zheng, of University Hospitals Cleveland Medical Center, and coauthors noted in their letter in the Journal of the American Academy of Dermatology.
TikTok also celebrates the everyday – someone doesn’t have to be a celebrity to make something go viral, said Dr. Lee. She believes that TikTok users are more accepting of average people with real problems – which helps when someone is TikTokking about a skin condition.
Doris Day, MD, who goes by @drdorisday on TikTok, agreed with Dr. Lee. “There are so many creative ways you can convey information with it that’s different than what you have on Instagram,” said Dr. Day, who is in private practice in New York. And, she added, “it does really lend itself to getting points out super-fast.”
Dermatologists on TikTok also said they like the “duets” and the “stitch” features, which allow users to add on to an existing video, essentially chiming in or responding to what might have already been posted, in a side-by-side format.
Dr. Shah said he often duets videos that have questionable content. “It allows me to directly respond to people. A lot of times, if something is going really viral and it’s not accurate, you’ll have a response from me or one of the other doctors” within hours or days.
Dr. Shah’s duets are labeled with “DermDoctor Reacts” or “DermDoctor Explains.” In one duet, with more than 2.8 million views, the upper half of the video is someone squeezing a blackhead, while Dr. Shah, in the bottom half, in green scrubs, opines over some hip-hop music: “This is just a blackhead. But once it gets to this point, they do need to be extracted because topical treatments won’t help.”
Dr. Lee – whose TikTok and other accounts capitalize on teens’ obsession with popping pimples – has a duet in which she advised that although popping will leave scars, there are more ideal times to pop, if they must. The duet has at least 21 million views.
Sometimes a TikTok video effectively takes on a trend without being a duet. Nurse practitioner Uy Dam (@uy.np) has a video that demonstrates the dangers of hyaluron pens. He uses both a pen and a needle to inject fluid into a block of jello. The pen delivers a scattershot load of differing depths, while the needle is exact. It’s visual and easy to understand and has at least 1.3 million views.
Still, TikTok, like other forms of social media, is full of misinformation and false accounts, including people who claim to be doctors. “It’s hard for the regular person, myself included, sometimes to be able to root through that and find out whether something is real or not,” said Dr. Lee.
Dr. Friedman said he’s concerned about the lack of accountability. A doctor could lose his or her license for promoting unproven cures, especially if they are harmful. But for influencers, “there’s no accountability for posting information that can actually hurt people.”
TikTok trends gone bad
And some people are being hurt by emulating what they see on TikTok.
Dr. Friedman had a patient with extreme irritant contact dermatitis, “almost like chemical burns to her underarms,” he said. He determined that she saw a video “hack” that recommended using baking soda to stop hyperhidrosis. The patient used so much that it burned her skin.
In 2020, do-it-yourself freckles – with henna or sewing needles impregnated with ink – went viral. Tilly Whitfeld, a 21-year-old reality TV star on Australia’s Big Brother show, told the New York Times that she tried it at home after seeing a TikTok video. She ordered brown tattoo ink online and later found out that it was contaminated with lead, according to the Times. Ms. Whitfeld developed an infection and temporary vision loss and has permanent scarring.
She has since put out a cautionary TikTok video that’s been viewed some 300,000 times.
TikTokkers have also flocked to the idea of using sunscreen to “contour” the face. Selected areas are left without sunscreen to burn or tan. In a duet, a plastic surgeon shakes his head as a young woman explains that “it works.”
Scalp-popping – in which the hair is yanked so hard that it pulls the galea off the skull – has been mostly shut down by TikTok. A search of “scalp popping” brings up the message: “Learn how to recognize harmful challenges and hoaxes.” At-home mole and skin tag removal, pimple-popping, and supposed acne cures such as drinking chlorophyll are all avidly documented and shared on TikTok.
Dr. Shah had a back-and-forth video dialog with someone who had stubbed a toe and then drilled a hole into the nail to drain the hematoma. In a reaction video, Dr. Shah said it was likely to turn into an infection. When it did, the man revealed the infection in a video where he tagged Dr. Shah and later posted a video at the podiatrist’s office having his nail removed, again tagging Dr. Shah.
“I think that pretty much no procedure for skin is good to do at home,” said Dr. Shah, who repeatedly admonishes against mole removal by a nonphysician. He tells followers that “it’s extremely dangerous – not only is it going to cause scarring, but you are potentially discarding a cancerous lesion.”
Unfortunately, most will not follow the advice, said Dr. Shah. That’s especially true of pimple-popping. Aiming for the least harm, he suggests in some TikTok videos that poppers keep the area clean, wear gloves, and consult a physician to get an antibiotic prescription. “You might as well at least guide them in the right direction,” he added.
Dr. Lee believes that lack of access to physicians, insurance, or money may play into how TikTok trends evolve. “Probably those people who injected their lips with this air gun thing, maybe they didn’t have the money necessarily to get filler,” she said.
Also, she noted, while TikTok may try to police its content, creators are incentivized to be outrageous. “The more inflammatory your post is, the more engagement you get.”
Dr. Shah thinks TikTok is self-correcting. “If you’re not being ethical or contradicting yourself, putting out information that’s not accurate, people are going to catch on very quickly,” he said. “The only value, the only currency you have on social media is the trust that you build with people that follow you.”
What it takes to be a TikTokker
For dermatologists, conveying their credentials and experience is one way to build that currency. Dr. Lee advised fellow doctors on TikTok to “showcase your training and how many years it took to become a dermatologist.”
Plunging into TikTok is not for everyone, though. It’s time consuming, said Dr. Lee, who now devotes most of her nonclinical time to TikTok. She creates her own content, leaving others to manage her Instagram account.
Many of those in the medical field who have dived into TikTok are residents, like Dr. Shah. “They are attuned to it and understand it more,” said Dr. Lee. “It’s harder for a lot of us who are older, who really weren’t involved that much in social media at all. It’s very hard to jump in.” There’s a learning curve, and it takes hours to create a single video. “You have to enjoy it and it has to be a part of your life,” she said.
Dr. Shah started experimenting with TikTok at the beginning of the pandemic in 2020 and has never turned back. Fast-talking, curious, and with an infectious sense of fun, he shares tidbits about his personal life – putting his wife in some of his videos – and always seems upbeat.
He said that, as his following grew, users began to see him as an authority figure and started “tagging” him more often, seeking his opinion on other videos. Although still a resident, he believes he has specialized knowledge to share. “Even if you’re not the world’s leading expert in a particular topic, you’re still adding value for the person who doesn’t know much.”
Dr. Shah also occasionally does promotional TikToks, identified as sponsored content. He said he only works with companies that he believes have legitimate products. “You do have to monetize at some point,” he said, noting that many dermatologists, himself included, are trading clinic time for TikTok. “There’s no universe where they can do this for free.”
Product endorsements are likely more rewarding for influencers and other users like Dr. Shah than the remuneration from TikTok, the company. The platform pays user accounts $20 per 1 million views, Dr. Shah said. “Financially, it’s not a big winner for a practicing dermatologist, but the educational outreach is worthwhile.”
To be successful also means understanding what drives viewership.
Using “trending” sounds has “been shown to increase the likelihood of a video amassing millions of views” and may increase engagement with dermatologists’ TikTok videos, wrote Bina Kassamali, BA, and colleagues at the Brigham and Women’s Hospital in Boston and the Ponce Health Science University School of Medicine in Ponce, Puerto Rico, in a letter published in the Journal of the American Academy of Dermatology in July 2021.
Certain content is more likely to engage viewers. In their analysis of top trending dermatologic hashtags, acne-related content was viewed 6.7 billion times, followed by alopecia, with 1.1 billion views. Psoriasis content had 84 million views, putting it eighth on the list of topics.
Dermatologists are still cracking TikTok. They are accumulating more followers on TikTok than on Instagram but have greater engagement on Instagram reels, wrote Mindy D. Szeto, MS, and colleagues at the University of Colorado at Denver, Aurora, and Rocky Vista University in Parker, Colo., in the Journal of the American Academy of Dermatology in April 2021.
Dr. Lee and Dr. Shah had the highest engagement rate on TikTok, according to Ms. Szeto. The engagement rate is calculated as (likes + comments per post)/(total followers) x 100.
“TikTok may currently be the leading avenue for audience education by dermatologist influencers,” they wrote, urging dermatologists to use the platform to answer the call as more of the public “continues to turn to social media for medical advice.”
Dr. Day said she will keep trying to build her TikTok audience. She has just 239 followers, compared with her 44,500 on Instagram. “The more I do TikTok, the more I do any of these mediums, the better I get at it,” she said. “We just have to put a little time and effort into it and try to get more followers and just keep sharing the information.”
Dr. Friedman sees it as a positive that some dermatologists have taken to TikTok to dispel myths and put “good information out there in small bites.” But to be more effective, they need more followers.
“The truth is that 14-year-old is probably going to listen more to a Hyram than a dermatologist,” he said. “Maybe we need to work with these other individuals who know how to take these messages and convert them to a language that can be digested by a 14-year-old, by a 12-year-old, by a 23-year-old. We need to come to the table together and not fight.”
A version of this article first appeared on Medscape.com.
A young woman is having her lip swabbed with an unknown substance, smiling, on the TikTok video. Seconds later, another young woman, wearing gloves, pushes a hyaluron pen against the first woman’s lips, who, in the next cut, is smiling, happy. “My first syringe down and already 1,000x more confident,” the caption reads.
That video is one of thousands showing hyaluron pen use on TikTok. The pens are sold online and are unapproved – which led to a Food and Drug Administration warning in October 2021 that use could cause bleeding, infection, blood vessel occlusion that could result in blindness or stroke, allergic reactions, and other injuries.
The warning has not stopped many TikTokkers, who also use the medium to promote all sorts of skin and aesthetic products and procedures, a large number unproven, unapproved, or ill advised. which, more often than not, comes from “skinfluencers,” aestheticians, and other laypeople, not board-certified dermatologists.
The suggested “hacks” can be harmless or ineffective, but they also can be misleading, fraudulent, or even dangerous.
Skinfluencers take the lead
TikTok has a reported 1 billion monthly users. Two-thirds are aged 10-29 years, according to data reported in February 2021 in the Journal of the American Academy of Dermatology by David X. Zheng, BA, and colleagues at Case Western Reserve University, Cleveland, and the department of dermatology, Johns Hopkins University, Baltimore.
Visitors consume information in video bits that run from 15 seconds to up to 3 minutes and can follow their favorite TikTokkers, browse for people or hashtags with a search function, or click on content recommended by the platform, which uses algorithms based on the user’s viewing habits to determine what might be of interest.
Some of the biggest “skinfluencers” have millions of followers: Hyram Yarbro, (@skincarebyhyram) for instance, has 6.6 million followers and his own line of skin care products at Sephora. Mr. Yarbro is seen as a no-nonsense debunker of skin care myths, as is British influencer James Welsh, who has 124,000 followers.
“The reason why people trust your average influencer person who’s not a doctor is because they’re relatable,” said Muneeb Shah, MD, a dermatology resident at Atlantic Dermatology in Wilmington, N.C. – known to his 11.4 million TikTok followers as @dermdoctor.
To Sandra Lee, MD, the popularity of nonprofessionals is easy to explain. “You have to think about the fact that a lot of people can’t see dermatologists – they don’t have the money, they don’t have the time to travel there, they don’t have health insurance, or they’re scared of doctors, so they’re willing to try to find an answer, and one of the easiest ways, one of the more entertaining ways to get information, is on social media.”
Dr. Lee is in private practice in Upland, Calif., but is better known as “Dr. Pimple Popper,” through her television show of the same name and her social media accounts, including on TikTok, where she has 14.4 million followers after having started in 2020.
“We’re all looking for that no-down-time, no-expense, no-lines, no-wrinkles, stay-young-forever magic bullet,” said Dr. Lee.
Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, agreed that people are looking for a quick fix. They don’t want to wait 12 weeks for an acne medication or 16 weeks for a biologic to work. “They want something simple, easy, do-it-yourself,” and “natural,” he said.
Laypeople are still the dominant producers – and have the most views – of dermatology content.
Morgan Nguyen, BA, at Northwestern University, Chicago, and colleagues looked at hashtags for the top 10 dermatologic diagnoses and procedures and analyzed the content of the first 40 TikTok videos in each category. About half the videos were produced by an individual, and 39% by a health care provider, according to the study, published in the International Journal of Women’s Dermatology. About 40% of the videos were educational, focusing on skin care, procedures, and disease treatment.
Viewership was highest for videos by laypeople, followed by those produced by business or industry accounts. Those produced by health care providers received only 18% of the views.
The most popular videos were about dermatologic diagnoses, with 2.5 billion views, followed by dermatologic procedures, with 708 million views.
Ms. Nguyen noted in the study that the most liked and most viewed posts were related to #skincare but that board-certified dermatologists produced only 2.5% of the #skincare videos.
Dermatologists take to TikTok
Some dermatologists have started their own TikTok accounts, seeking both to counteract misinformation and provide education.
Dr. Shah has become one of the top influencers on the platform. In a year-end wrap, TikTok put Dr. Shah at No. 7 on its top creators list for 2021.
The dermatology resident said that TikTok is a good tool for reaching patients who might not otherwise interact with dermatologists. He recounted the story of an individual who came into his office with the idea that they had hidradenitis suppurativa.
The person had self-diagnosed after seeing one of Dr. Shah’s TikTok videos on the condition. It was a pleasant surprise, said Dr. Shah. People with hidradenitis suppurativa often avoid treatment, and it’s underdiagnosed and improperly treated, despite an American Academy of Dermatology awareness campaign.
“Dermatologists on social media are almost like the communications department for dermatology,” Dr. Shah commented.
A key to making TikTok work to advance dermatologists’ goals is knowing what makes it unique.
Dr. Lee said she prefers it to Instagram, because TikTok’s algorithms and its younger-skewing audience help her reach a more specific audience.
The algorithm “creates a positive feedback loop in which popular content creators or viral trends are prioritized on the users’ homepages, in turn providing the creators of these videos with an even larger audience,” Mr. Zheng, of University Hospitals Cleveland Medical Center, and coauthors noted in their letter in the Journal of the American Academy of Dermatology.
TikTok also celebrates the everyday – someone doesn’t have to be a celebrity to make something go viral, said Dr. Lee. She believes that TikTok users are more accepting of average people with real problems – which helps when someone is TikTokking about a skin condition.
Doris Day, MD, who goes by @drdorisday on TikTok, agreed with Dr. Lee. “There are so many creative ways you can convey information with it that’s different than what you have on Instagram,” said Dr. Day, who is in private practice in New York. And, she added, “it does really lend itself to getting points out super-fast.”
Dermatologists on TikTok also said they like the “duets” and the “stitch” features, which allow users to add on to an existing video, essentially chiming in or responding to what might have already been posted, in a side-by-side format.
Dr. Shah said he often duets videos that have questionable content. “It allows me to directly respond to people. A lot of times, if something is going really viral and it’s not accurate, you’ll have a response from me or one of the other doctors” within hours or days.
Dr. Shah’s duets are labeled with “DermDoctor Reacts” or “DermDoctor Explains.” In one duet, with more than 2.8 million views, the upper half of the video is someone squeezing a blackhead, while Dr. Shah, in the bottom half, in green scrubs, opines over some hip-hop music: “This is just a blackhead. But once it gets to this point, they do need to be extracted because topical treatments won’t help.”
Dr. Lee – whose TikTok and other accounts capitalize on teens’ obsession with popping pimples – has a duet in which she advised that although popping will leave scars, there are more ideal times to pop, if they must. The duet has at least 21 million views.
Sometimes a TikTok video effectively takes on a trend without being a duet. Nurse practitioner Uy Dam (@uy.np) has a video that demonstrates the dangers of hyaluron pens. He uses both a pen and a needle to inject fluid into a block of jello. The pen delivers a scattershot load of differing depths, while the needle is exact. It’s visual and easy to understand and has at least 1.3 million views.
Still, TikTok, like other forms of social media, is full of misinformation and false accounts, including people who claim to be doctors. “It’s hard for the regular person, myself included, sometimes to be able to root through that and find out whether something is real or not,” said Dr. Lee.
Dr. Friedman said he’s concerned about the lack of accountability. A doctor could lose his or her license for promoting unproven cures, especially if they are harmful. But for influencers, “there’s no accountability for posting information that can actually hurt people.”
TikTok trends gone bad
And some people are being hurt by emulating what they see on TikTok.
Dr. Friedman had a patient with extreme irritant contact dermatitis, “almost like chemical burns to her underarms,” he said. He determined that she saw a video “hack” that recommended using baking soda to stop hyperhidrosis. The patient used so much that it burned her skin.
In 2020, do-it-yourself freckles – with henna or sewing needles impregnated with ink – went viral. Tilly Whitfeld, a 21-year-old reality TV star on Australia’s Big Brother show, told the New York Times that she tried it at home after seeing a TikTok video. She ordered brown tattoo ink online and later found out that it was contaminated with lead, according to the Times. Ms. Whitfeld developed an infection and temporary vision loss and has permanent scarring.
She has since put out a cautionary TikTok video that’s been viewed some 300,000 times.
TikTokkers have also flocked to the idea of using sunscreen to “contour” the face. Selected areas are left without sunscreen to burn or tan. In a duet, a plastic surgeon shakes his head as a young woman explains that “it works.”
Scalp-popping – in which the hair is yanked so hard that it pulls the galea off the skull – has been mostly shut down by TikTok. A search of “scalp popping” brings up the message: “Learn how to recognize harmful challenges and hoaxes.” At-home mole and skin tag removal, pimple-popping, and supposed acne cures such as drinking chlorophyll are all avidly documented and shared on TikTok.
Dr. Shah had a back-and-forth video dialog with someone who had stubbed a toe and then drilled a hole into the nail to drain the hematoma. In a reaction video, Dr. Shah said it was likely to turn into an infection. When it did, the man revealed the infection in a video where he tagged Dr. Shah and later posted a video at the podiatrist’s office having his nail removed, again tagging Dr. Shah.
“I think that pretty much no procedure for skin is good to do at home,” said Dr. Shah, who repeatedly admonishes against mole removal by a nonphysician. He tells followers that “it’s extremely dangerous – not only is it going to cause scarring, but you are potentially discarding a cancerous lesion.”
Unfortunately, most will not follow the advice, said Dr. Shah. That’s especially true of pimple-popping. Aiming for the least harm, he suggests in some TikTok videos that poppers keep the area clean, wear gloves, and consult a physician to get an antibiotic prescription. “You might as well at least guide them in the right direction,” he added.
Dr. Lee believes that lack of access to physicians, insurance, or money may play into how TikTok trends evolve. “Probably those people who injected their lips with this air gun thing, maybe they didn’t have the money necessarily to get filler,” she said.
Also, she noted, while TikTok may try to police its content, creators are incentivized to be outrageous. “The more inflammatory your post is, the more engagement you get.”
Dr. Shah thinks TikTok is self-correcting. “If you’re not being ethical or contradicting yourself, putting out information that’s not accurate, people are going to catch on very quickly,” he said. “The only value, the only currency you have on social media is the trust that you build with people that follow you.”
What it takes to be a TikTokker
For dermatologists, conveying their credentials and experience is one way to build that currency. Dr. Lee advised fellow doctors on TikTok to “showcase your training and how many years it took to become a dermatologist.”
Plunging into TikTok is not for everyone, though. It’s time consuming, said Dr. Lee, who now devotes most of her nonclinical time to TikTok. She creates her own content, leaving others to manage her Instagram account.
Many of those in the medical field who have dived into TikTok are residents, like Dr. Shah. “They are attuned to it and understand it more,” said Dr. Lee. “It’s harder for a lot of us who are older, who really weren’t involved that much in social media at all. It’s very hard to jump in.” There’s a learning curve, and it takes hours to create a single video. “You have to enjoy it and it has to be a part of your life,” she said.
Dr. Shah started experimenting with TikTok at the beginning of the pandemic in 2020 and has never turned back. Fast-talking, curious, and with an infectious sense of fun, he shares tidbits about his personal life – putting his wife in some of his videos – and always seems upbeat.
He said that, as his following grew, users began to see him as an authority figure and started “tagging” him more often, seeking his opinion on other videos. Although still a resident, he believes he has specialized knowledge to share. “Even if you’re not the world’s leading expert in a particular topic, you’re still adding value for the person who doesn’t know much.”
Dr. Shah also occasionally does promotional TikToks, identified as sponsored content. He said he only works with companies that he believes have legitimate products. “You do have to monetize at some point,” he said, noting that many dermatologists, himself included, are trading clinic time for TikTok. “There’s no universe where they can do this for free.”
Product endorsements are likely more rewarding for influencers and other users like Dr. Shah than the remuneration from TikTok, the company. The platform pays user accounts $20 per 1 million views, Dr. Shah said. “Financially, it’s not a big winner for a practicing dermatologist, but the educational outreach is worthwhile.”
To be successful also means understanding what drives viewership.
Using “trending” sounds has “been shown to increase the likelihood of a video amassing millions of views” and may increase engagement with dermatologists’ TikTok videos, wrote Bina Kassamali, BA, and colleagues at the Brigham and Women’s Hospital in Boston and the Ponce Health Science University School of Medicine in Ponce, Puerto Rico, in a letter published in the Journal of the American Academy of Dermatology in July 2021.
Certain content is more likely to engage viewers. In their analysis of top trending dermatologic hashtags, acne-related content was viewed 6.7 billion times, followed by alopecia, with 1.1 billion views. Psoriasis content had 84 million views, putting it eighth on the list of topics.
Dermatologists are still cracking TikTok. They are accumulating more followers on TikTok than on Instagram but have greater engagement on Instagram reels, wrote Mindy D. Szeto, MS, and colleagues at the University of Colorado at Denver, Aurora, and Rocky Vista University in Parker, Colo., in the Journal of the American Academy of Dermatology in April 2021.
Dr. Lee and Dr. Shah had the highest engagement rate on TikTok, according to Ms. Szeto. The engagement rate is calculated as (likes + comments per post)/(total followers) x 100.
“TikTok may currently be the leading avenue for audience education by dermatologist influencers,” they wrote, urging dermatologists to use the platform to answer the call as more of the public “continues to turn to social media for medical advice.”
Dr. Day said she will keep trying to build her TikTok audience. She has just 239 followers, compared with her 44,500 on Instagram. “The more I do TikTok, the more I do any of these mediums, the better I get at it,” she said. “We just have to put a little time and effort into it and try to get more followers and just keep sharing the information.”
Dr. Friedman sees it as a positive that some dermatologists have taken to TikTok to dispel myths and put “good information out there in small bites.” But to be more effective, they need more followers.
“The truth is that 14-year-old is probably going to listen more to a Hyram than a dermatologist,” he said. “Maybe we need to work with these other individuals who know how to take these messages and convert them to a language that can be digested by a 14-year-old, by a 12-year-old, by a 23-year-old. We need to come to the table together and not fight.”
A version of this article first appeared on Medscape.com.
Telehealth: The 21st century house call
On March 11, 2020, the World Health Organization declared the novel coronavirus disease (COVID-19) to be a global pandemic. Shortly after, federal regulators temporarily relaxed restrictions, raised Medicare payment for telemedicine visits to the same level as in-person visits, and waived or reduced cost sharing for patients. As pandemic-related regulations expire, policymakers are debating the need to address insurance coverage of telemedicine services going forward. Congress should consider the lessons learned over the past 20 months to ensure that health care providers have the flexibility to meet the needs of patients.
One of my early telehealth visits was with a patient in his 80s who spent nearly a month in the hospital after complex abdominal surgery. While at home with his daughter, it was the first visit to assess his progress after discharge from the hospital. We were able to address his concerns, assess his wounds using the video on his computer, and formulate a plan so he could continue to improve. At the end of the call, his daughter mentioned in passing, “Thank God we did not have to go to the office ... that would have been a nightmare.”
The nightmare would have consisted of driving her frail father 45 minutes to our office, spending 15 minutes to park, waiting for 30 minutes to be seen, and finally speaking with the physician for 30 minutes face-to-face. Following the appointment, my patient and his daughter would spend another 10 minutes checking out before the 45-minute drive home. Instead, they spent a few minutes logging on through a computer prior to the 30-minute visit from the comfort of their couch.
The COVID-19 pandemic has resulted in millions of deaths and trillions of dollars in economic loss, as well as changed the norms of social interaction. One of the many ways it impacted our health care system is through the exponential growth of telehealth – the use of telecommunication modalities, such as telephone and real-time video – to connect patients with clinicians for the purpose of providing health care.
Prior to the pandemic, telehealth was limited to populations with limited access to health care. Our practice had never performed telehealth, yet converted nearly exclusively to telehealth at the height of the pandemic. My colleagues and I were concerned about how patients and physicians would respond to the sudden disruption of norms of patient engagement.
To measure the response, we conducted an online survey of over 500 gastroenterologists and nearly 1,500 patients from March to May 2020 to assess their satisfaction with telehealth. Our published results demonstrated that more than 80% of patients and 90% of physicians surveyed were either satisfied or highly satisfied with telehealth. Surprisingly, these trends were true irrespective of age or the reason for a visit. Greater than 80% of patients also indicated that the provider addressed their concerns and that they were willing to participate in telehealth visits in the future.
In a subsequent survey of nearly 3,000 patients who had experience with telehealth and in-person visits, 73% of respondents indicated that they received a similar quality of care through telehealth as compared to in-person visits and 61% stated that the interaction with their physician was also similar. More than half of the patients (54%) were likely to continue using telehealth services after the pandemic mainly because of shorter wait and travel times (75%), flexibility with personal schedule (56%), and ease of scheduling appointments on a desired date (47%).
During the COVID-19 pandemic, access to health care has been limited for a great number of patients, and telehealth has been a useful and necessary tool in overcoming this challenge. Telehealth also promotes the triple aim of improving health care by improving the care experience, reducing cost, and improving patient and population health outcomes. Our findings showed a high level of overall patient and provider satisfaction following telehealth appointments. Telehealth increases access to care by decreasing travel time and cost, limiting missed workdays, and reducing the need to find alternative caregivers, especially among rural communities and people facing financial hardship. For a small subset of people who lack the resources, access to technology, or ability to do video visits, telephone-only visits are an appropriate option and should be preserved and reimbursed in some capacity.
From a patient perspective, convenience and decreased cost are often cited as major reasons for satisfaction with telehealth. This is of particular importance to people with limited mobility, nontraditional work hours, and lower socioeconomic status. For patients who use public transportation or caregivers to travel to appointments, a short appointment may require hours of logistical planning and may come at significant financial cost. Enabling these patients to interact with their providers from home would make accessing the health care system both less expensive and logistically less challenging.
One unexpected benefit of telehealth that I have experienced is the ability to “visit” the patients in their own surroundings. Many telehealth visits have allowed the doctor to make a “house call” and see the patients in their homes, cars, and break rooms. Observing the chaos in a home or an extremely quiet and dark space has given me insight into the role anxiety and depression might play in health conditions – which may have not been appreciated in a visit to my office.
The most memorable meeting was a man who was sitting in his kitchen while smoking a cigarette and drinking a beer for breakfast whose main complaint was heartburn. His life habits were obviously contributing to his heartburn, and this degree of insight would not have been appreciated during a traditional in-person office visit.
Congress is now contemplating the role telehealth will play in health care once the pandemic is over. The main concerns are abuse of telehealth by providers, leading to a dramatic rise in visits due to the ease of care delivery. This in turn can dramatically increase health care costs. The long-term health outcomes of patients seen through telehealth are also unknown and must be studied.
All these concerns are valid and must be addressed in future studies, but it would be a mistake for Congress to revert telehealth back to prepandemic regulations. We must move forward with this important innovation in care delivery.
The adoption of telehealth is one of few silver linings of the COVID-19 pandemic. It will never replace in-person visits but should be preserved as an additional tool we can use when in-person visits are not the best option. The future of U.S. health care must allow for a hybrid model so that patients and providers can continue to benefit from this valuable innovation. Patients, providers, and families will be forever grateful.
Naresh Gunaratnam MD, AGAF is a practicing gastroenterologist with Huron Gastroenterology in Ann Arbor, Mich. He also serves as the chair of data analytics as a member of the Digestive Health Physicians Association executive committee. Dr. Gunaratnam has no conflicts in telehealth. He is the founder of and CMO of a weight loss device company and service.
On March 11, 2020, the World Health Organization declared the novel coronavirus disease (COVID-19) to be a global pandemic. Shortly after, federal regulators temporarily relaxed restrictions, raised Medicare payment for telemedicine visits to the same level as in-person visits, and waived or reduced cost sharing for patients. As pandemic-related regulations expire, policymakers are debating the need to address insurance coverage of telemedicine services going forward. Congress should consider the lessons learned over the past 20 months to ensure that health care providers have the flexibility to meet the needs of patients.
One of my early telehealth visits was with a patient in his 80s who spent nearly a month in the hospital after complex abdominal surgery. While at home with his daughter, it was the first visit to assess his progress after discharge from the hospital. We were able to address his concerns, assess his wounds using the video on his computer, and formulate a plan so he could continue to improve. At the end of the call, his daughter mentioned in passing, “Thank God we did not have to go to the office ... that would have been a nightmare.”
The nightmare would have consisted of driving her frail father 45 minutes to our office, spending 15 minutes to park, waiting for 30 minutes to be seen, and finally speaking with the physician for 30 minutes face-to-face. Following the appointment, my patient and his daughter would spend another 10 minutes checking out before the 45-minute drive home. Instead, they spent a few minutes logging on through a computer prior to the 30-minute visit from the comfort of their couch.
The COVID-19 pandemic has resulted in millions of deaths and trillions of dollars in economic loss, as well as changed the norms of social interaction. One of the many ways it impacted our health care system is through the exponential growth of telehealth – the use of telecommunication modalities, such as telephone and real-time video – to connect patients with clinicians for the purpose of providing health care.
Prior to the pandemic, telehealth was limited to populations with limited access to health care. Our practice had never performed telehealth, yet converted nearly exclusively to telehealth at the height of the pandemic. My colleagues and I were concerned about how patients and physicians would respond to the sudden disruption of norms of patient engagement.
To measure the response, we conducted an online survey of over 500 gastroenterologists and nearly 1,500 patients from March to May 2020 to assess their satisfaction with telehealth. Our published results demonstrated that more than 80% of patients and 90% of physicians surveyed were either satisfied or highly satisfied with telehealth. Surprisingly, these trends were true irrespective of age or the reason for a visit. Greater than 80% of patients also indicated that the provider addressed their concerns and that they were willing to participate in telehealth visits in the future.
In a subsequent survey of nearly 3,000 patients who had experience with telehealth and in-person visits, 73% of respondents indicated that they received a similar quality of care through telehealth as compared to in-person visits and 61% stated that the interaction with their physician was also similar. More than half of the patients (54%) were likely to continue using telehealth services after the pandemic mainly because of shorter wait and travel times (75%), flexibility with personal schedule (56%), and ease of scheduling appointments on a desired date (47%).
During the COVID-19 pandemic, access to health care has been limited for a great number of patients, and telehealth has been a useful and necessary tool in overcoming this challenge. Telehealth also promotes the triple aim of improving health care by improving the care experience, reducing cost, and improving patient and population health outcomes. Our findings showed a high level of overall patient and provider satisfaction following telehealth appointments. Telehealth increases access to care by decreasing travel time and cost, limiting missed workdays, and reducing the need to find alternative caregivers, especially among rural communities and people facing financial hardship. For a small subset of people who lack the resources, access to technology, or ability to do video visits, telephone-only visits are an appropriate option and should be preserved and reimbursed in some capacity.
From a patient perspective, convenience and decreased cost are often cited as major reasons for satisfaction with telehealth. This is of particular importance to people with limited mobility, nontraditional work hours, and lower socioeconomic status. For patients who use public transportation or caregivers to travel to appointments, a short appointment may require hours of logistical planning and may come at significant financial cost. Enabling these patients to interact with their providers from home would make accessing the health care system both less expensive and logistically less challenging.
One unexpected benefit of telehealth that I have experienced is the ability to “visit” the patients in their own surroundings. Many telehealth visits have allowed the doctor to make a “house call” and see the patients in their homes, cars, and break rooms. Observing the chaos in a home or an extremely quiet and dark space has given me insight into the role anxiety and depression might play in health conditions – which may have not been appreciated in a visit to my office.
The most memorable meeting was a man who was sitting in his kitchen while smoking a cigarette and drinking a beer for breakfast whose main complaint was heartburn. His life habits were obviously contributing to his heartburn, and this degree of insight would not have been appreciated during a traditional in-person office visit.
Congress is now contemplating the role telehealth will play in health care once the pandemic is over. The main concerns are abuse of telehealth by providers, leading to a dramatic rise in visits due to the ease of care delivery. This in turn can dramatically increase health care costs. The long-term health outcomes of patients seen through telehealth are also unknown and must be studied.
All these concerns are valid and must be addressed in future studies, but it would be a mistake for Congress to revert telehealth back to prepandemic regulations. We must move forward with this important innovation in care delivery.
The adoption of telehealth is one of few silver linings of the COVID-19 pandemic. It will never replace in-person visits but should be preserved as an additional tool we can use when in-person visits are not the best option. The future of U.S. health care must allow for a hybrid model so that patients and providers can continue to benefit from this valuable innovation. Patients, providers, and families will be forever grateful.
Naresh Gunaratnam MD, AGAF is a practicing gastroenterologist with Huron Gastroenterology in Ann Arbor, Mich. He also serves as the chair of data analytics as a member of the Digestive Health Physicians Association executive committee. Dr. Gunaratnam has no conflicts in telehealth. He is the founder of and CMO of a weight loss device company and service.
On March 11, 2020, the World Health Organization declared the novel coronavirus disease (COVID-19) to be a global pandemic. Shortly after, federal regulators temporarily relaxed restrictions, raised Medicare payment for telemedicine visits to the same level as in-person visits, and waived or reduced cost sharing for patients. As pandemic-related regulations expire, policymakers are debating the need to address insurance coverage of telemedicine services going forward. Congress should consider the lessons learned over the past 20 months to ensure that health care providers have the flexibility to meet the needs of patients.
One of my early telehealth visits was with a patient in his 80s who spent nearly a month in the hospital after complex abdominal surgery. While at home with his daughter, it was the first visit to assess his progress after discharge from the hospital. We were able to address his concerns, assess his wounds using the video on his computer, and formulate a plan so he could continue to improve. At the end of the call, his daughter mentioned in passing, “Thank God we did not have to go to the office ... that would have been a nightmare.”
The nightmare would have consisted of driving her frail father 45 minutes to our office, spending 15 minutes to park, waiting for 30 minutes to be seen, and finally speaking with the physician for 30 minutes face-to-face. Following the appointment, my patient and his daughter would spend another 10 minutes checking out before the 45-minute drive home. Instead, they spent a few minutes logging on through a computer prior to the 30-minute visit from the comfort of their couch.
The COVID-19 pandemic has resulted in millions of deaths and trillions of dollars in economic loss, as well as changed the norms of social interaction. One of the many ways it impacted our health care system is through the exponential growth of telehealth – the use of telecommunication modalities, such as telephone and real-time video – to connect patients with clinicians for the purpose of providing health care.
Prior to the pandemic, telehealth was limited to populations with limited access to health care. Our practice had never performed telehealth, yet converted nearly exclusively to telehealth at the height of the pandemic. My colleagues and I were concerned about how patients and physicians would respond to the sudden disruption of norms of patient engagement.
To measure the response, we conducted an online survey of over 500 gastroenterologists and nearly 1,500 patients from March to May 2020 to assess their satisfaction with telehealth. Our published results demonstrated that more than 80% of patients and 90% of physicians surveyed were either satisfied or highly satisfied with telehealth. Surprisingly, these trends were true irrespective of age or the reason for a visit. Greater than 80% of patients also indicated that the provider addressed their concerns and that they were willing to participate in telehealth visits in the future.
In a subsequent survey of nearly 3,000 patients who had experience with telehealth and in-person visits, 73% of respondents indicated that they received a similar quality of care through telehealth as compared to in-person visits and 61% stated that the interaction with their physician was also similar. More than half of the patients (54%) were likely to continue using telehealth services after the pandemic mainly because of shorter wait and travel times (75%), flexibility with personal schedule (56%), and ease of scheduling appointments on a desired date (47%).
During the COVID-19 pandemic, access to health care has been limited for a great number of patients, and telehealth has been a useful and necessary tool in overcoming this challenge. Telehealth also promotes the triple aim of improving health care by improving the care experience, reducing cost, and improving patient and population health outcomes. Our findings showed a high level of overall patient and provider satisfaction following telehealth appointments. Telehealth increases access to care by decreasing travel time and cost, limiting missed workdays, and reducing the need to find alternative caregivers, especially among rural communities and people facing financial hardship. For a small subset of people who lack the resources, access to technology, or ability to do video visits, telephone-only visits are an appropriate option and should be preserved and reimbursed in some capacity.
From a patient perspective, convenience and decreased cost are often cited as major reasons for satisfaction with telehealth. This is of particular importance to people with limited mobility, nontraditional work hours, and lower socioeconomic status. For patients who use public transportation or caregivers to travel to appointments, a short appointment may require hours of logistical planning and may come at significant financial cost. Enabling these patients to interact with their providers from home would make accessing the health care system both less expensive and logistically less challenging.
One unexpected benefit of telehealth that I have experienced is the ability to “visit” the patients in their own surroundings. Many telehealth visits have allowed the doctor to make a “house call” and see the patients in their homes, cars, and break rooms. Observing the chaos in a home or an extremely quiet and dark space has given me insight into the role anxiety and depression might play in health conditions – which may have not been appreciated in a visit to my office.
The most memorable meeting was a man who was sitting in his kitchen while smoking a cigarette and drinking a beer for breakfast whose main complaint was heartburn. His life habits were obviously contributing to his heartburn, and this degree of insight would not have been appreciated during a traditional in-person office visit.
Congress is now contemplating the role telehealth will play in health care once the pandemic is over. The main concerns are abuse of telehealth by providers, leading to a dramatic rise in visits due to the ease of care delivery. This in turn can dramatically increase health care costs. The long-term health outcomes of patients seen through telehealth are also unknown and must be studied.
All these concerns are valid and must be addressed in future studies, but it would be a mistake for Congress to revert telehealth back to prepandemic regulations. We must move forward with this important innovation in care delivery.
The adoption of telehealth is one of few silver linings of the COVID-19 pandemic. It will never replace in-person visits but should be preserved as an additional tool we can use when in-person visits are not the best option. The future of U.S. health care must allow for a hybrid model so that patients and providers can continue to benefit from this valuable innovation. Patients, providers, and families will be forever grateful.
Naresh Gunaratnam MD, AGAF is a practicing gastroenterologist with Huron Gastroenterology in Ann Arbor, Mich. He also serves as the chair of data analytics as a member of the Digestive Health Physicians Association executive committee. Dr. Gunaratnam has no conflicts in telehealth. He is the founder of and CMO of a weight loss device company and service.
Authorities charge woman after long history of pretending to be a nurse
Online news reports indicate the suspect has a long history of similar deception in other locations in Canada and the United States dating back 30 years.
The Vancouver Police Department (VPD) charged the woman, who goes by the name of Brigitte Cleroux, 49, with fraud over $5,000 and personation with intent. VPD launched an investigation in June after learning that an employee at BC Women’s Hospital had fraudulently identified herself as a nurse while working there between June 2020 and June 2021, according to a VPD press release. At press time, Ms. Cleroux was in custody, and her next court appearance was set for Jan. 5, according to BC court records.
In June, the British Columbia College of Nurses & Midwives (BCCNM) issued a warning that Ms. Cleroux might be using aliases, including Melanie Smith. It stated that it had “received a report that Melanie Smith has held herself out as a registered nurse in British Columbia in order to seek employment in a hospital, dental surgery clinic, and in residential care.” The aliases included Melanie Thompson and Melanie Cleroux.
“This person has never been and is not a registrant of BCCNM and is not entitled to practice as a registered nurse in British Columbia.”
“Our detectives worked collaboratively with the Ottawa Police Service, which was conducting a parallel investigation into the same suspect,” said Constable Tania Visintin. “We don’t yet know how many people in Vancouver may have received treatment from the fraudulent nurse, but we’re working with the Provincial Health Services Authority to identify patients who may have had contact with her.”
Ottawa Police had charged Ms. Cleroux in September with more serious offenses of assault with a weapon and criminal negligence causing bodily harm along with “personation to gain advantage,” obtaining by false pretense, and using a forged document.
The charges followed an investigation into “personation, criminal negligence and fraud-related incidents after falsely gaining employment and conducting duties as a nurse at a medical and dental clinic in Ottawa. Some of those duties included the administration of medications, including injections, to patients,” police said in a statement.
“The investigation began when police were told that a woman had used aliases and assumed the identifies of registered nurses that she fraudulently obtained.” Police said they believed there might be other clinics and victims.
The College of Nurses of Ontario also issued a warning about Ms. Cleroux and a list of seven other aliases under the Ottawa region heading.
Ms. Cleroux’s past includes reports of a long string of deception dating back about three decades and including incidents in Florida and Colorado. Ms. Cleroux was in nursing school in Colorado but only competed 2 years of a 4-year nursing course and was never certified as a nurse, according to CBC Radio-Canada.
A version of this article first appeared on Medscape.com.
Online news reports indicate the suspect has a long history of similar deception in other locations in Canada and the United States dating back 30 years.
The Vancouver Police Department (VPD) charged the woman, who goes by the name of Brigitte Cleroux, 49, with fraud over $5,000 and personation with intent. VPD launched an investigation in June after learning that an employee at BC Women’s Hospital had fraudulently identified herself as a nurse while working there between June 2020 and June 2021, according to a VPD press release. At press time, Ms. Cleroux was in custody, and her next court appearance was set for Jan. 5, according to BC court records.
In June, the British Columbia College of Nurses & Midwives (BCCNM) issued a warning that Ms. Cleroux might be using aliases, including Melanie Smith. It stated that it had “received a report that Melanie Smith has held herself out as a registered nurse in British Columbia in order to seek employment in a hospital, dental surgery clinic, and in residential care.” The aliases included Melanie Thompson and Melanie Cleroux.
“This person has never been and is not a registrant of BCCNM and is not entitled to practice as a registered nurse in British Columbia.”
“Our detectives worked collaboratively with the Ottawa Police Service, which was conducting a parallel investigation into the same suspect,” said Constable Tania Visintin. “We don’t yet know how many people in Vancouver may have received treatment from the fraudulent nurse, but we’re working with the Provincial Health Services Authority to identify patients who may have had contact with her.”
Ottawa Police had charged Ms. Cleroux in September with more serious offenses of assault with a weapon and criminal negligence causing bodily harm along with “personation to gain advantage,” obtaining by false pretense, and using a forged document.
The charges followed an investigation into “personation, criminal negligence and fraud-related incidents after falsely gaining employment and conducting duties as a nurse at a medical and dental clinic in Ottawa. Some of those duties included the administration of medications, including injections, to patients,” police said in a statement.
“The investigation began when police were told that a woman had used aliases and assumed the identifies of registered nurses that she fraudulently obtained.” Police said they believed there might be other clinics and victims.
The College of Nurses of Ontario also issued a warning about Ms. Cleroux and a list of seven other aliases under the Ottawa region heading.
Ms. Cleroux’s past includes reports of a long string of deception dating back about three decades and including incidents in Florida and Colorado. Ms. Cleroux was in nursing school in Colorado but only competed 2 years of a 4-year nursing course and was never certified as a nurse, according to CBC Radio-Canada.
A version of this article first appeared on Medscape.com.
Online news reports indicate the suspect has a long history of similar deception in other locations in Canada and the United States dating back 30 years.
The Vancouver Police Department (VPD) charged the woman, who goes by the name of Brigitte Cleroux, 49, with fraud over $5,000 and personation with intent. VPD launched an investigation in June after learning that an employee at BC Women’s Hospital had fraudulently identified herself as a nurse while working there between June 2020 and June 2021, according to a VPD press release. At press time, Ms. Cleroux was in custody, and her next court appearance was set for Jan. 5, according to BC court records.
In June, the British Columbia College of Nurses & Midwives (BCCNM) issued a warning that Ms. Cleroux might be using aliases, including Melanie Smith. It stated that it had “received a report that Melanie Smith has held herself out as a registered nurse in British Columbia in order to seek employment in a hospital, dental surgery clinic, and in residential care.” The aliases included Melanie Thompson and Melanie Cleroux.
“This person has never been and is not a registrant of BCCNM and is not entitled to practice as a registered nurse in British Columbia.”
“Our detectives worked collaboratively with the Ottawa Police Service, which was conducting a parallel investigation into the same suspect,” said Constable Tania Visintin. “We don’t yet know how many people in Vancouver may have received treatment from the fraudulent nurse, but we’re working with the Provincial Health Services Authority to identify patients who may have had contact with her.”
Ottawa Police had charged Ms. Cleroux in September with more serious offenses of assault with a weapon and criminal negligence causing bodily harm along with “personation to gain advantage,” obtaining by false pretense, and using a forged document.
The charges followed an investigation into “personation, criminal negligence and fraud-related incidents after falsely gaining employment and conducting duties as a nurse at a medical and dental clinic in Ottawa. Some of those duties included the administration of medications, including injections, to patients,” police said in a statement.
“The investigation began when police were told that a woman had used aliases and assumed the identifies of registered nurses that she fraudulently obtained.” Police said they believed there might be other clinics and victims.
The College of Nurses of Ontario also issued a warning about Ms. Cleroux and a list of seven other aliases under the Ottawa region heading.
Ms. Cleroux’s past includes reports of a long string of deception dating back about three decades and including incidents in Florida and Colorado. Ms. Cleroux was in nursing school in Colorado but only competed 2 years of a 4-year nursing course and was never certified as a nurse, according to CBC Radio-Canada.
A version of this article first appeared on Medscape.com.
Infectious disease pop quiz: Clinical challenge #6 for the ObGyn
Which vaccines are contraindicated in pregnancy?
Continue to the answer...
Live virus vaccines should not be used in pregnancy because of the possibility of teratogenic effects. Live agents include the measles, mumps, and rubella (MMR) vaccine; live influenza vaccine (FluMist); oral polio vaccine; BCG (bacille Calmette-Guerin) vaccine; yellow fever vaccine; and smallpox vaccine.
- Duff P. Maternal and perinatal infections: bacterial. In: Landon MB, Galan HL, Jauniaux ERM, et al. Gabbe’s Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021:1124-1146.
- Duff P. Maternal and fetal infections. In: Resnik R, Lockwood CJ, Moore TJ, et al. Creasy & Resnik’s Maternal-Fetal Medicine: Principles and Practice. 8th ed. Elsevier; 2019:862-919.
Dr. Edwards is a Resident in the Department of Medicine, University of Florida College of Medicine, Gainesville.
Dr. Duff is Professor of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville.
The authors report no financial relationships relevant to this article.
Dr. Edwards is a Resident in the Department of Medicine, University of Florida College of Medicine, Gainesville.
Dr. Duff is Professor of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville.
The authors report no financial relationships relevant to this article.
Dr. Edwards is a Resident in the Department of Medicine, University of Florida College of Medicine, Gainesville.
Dr. Duff is Professor of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville.
The authors report no financial relationships relevant to this article.
Which vaccines are contraindicated in pregnancy?
Continue to the answer...
Live virus vaccines should not be used in pregnancy because of the possibility of teratogenic effects. Live agents include the measles, mumps, and rubella (MMR) vaccine; live influenza vaccine (FluMist); oral polio vaccine; BCG (bacille Calmette-Guerin) vaccine; yellow fever vaccine; and smallpox vaccine.
Which vaccines are contraindicated in pregnancy?
Continue to the answer...
Live virus vaccines should not be used in pregnancy because of the possibility of teratogenic effects. Live agents include the measles, mumps, and rubella (MMR) vaccine; live influenza vaccine (FluMist); oral polio vaccine; BCG (bacille Calmette-Guerin) vaccine; yellow fever vaccine; and smallpox vaccine.
- Duff P. Maternal and perinatal infections: bacterial. In: Landon MB, Galan HL, Jauniaux ERM, et al. Gabbe’s Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021:1124-1146.
- Duff P. Maternal and fetal infections. In: Resnik R, Lockwood CJ, Moore TJ, et al. Creasy & Resnik’s Maternal-Fetal Medicine: Principles and Practice. 8th ed. Elsevier; 2019:862-919.
- Duff P. Maternal and perinatal infections: bacterial. In: Landon MB, Galan HL, Jauniaux ERM, et al. Gabbe’s Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021:1124-1146.
- Duff P. Maternal and fetal infections. In: Resnik R, Lockwood CJ, Moore TJ, et al. Creasy & Resnik’s Maternal-Fetal Medicine: Principles and Practice. 8th ed. Elsevier; 2019:862-919.