The Diagnosis: Monsel Solution Reaction

Exogenous substances can cause interesting incongruities in cutaneous biopsies of which pathologists and dermatologists should be cognizant. Exogenous lesions are caused by externally introduced foreign bodies, substances, or materials, such as sterile compressed sponges, aluminum chloride hexahydrate and anhydrous ethyl alcohol, silica, paraffin, and Monsel solution. Monsel solution reaction is a florid fibrohistiocytic proliferation stimulated by the application of Monsel solution. Monsel solution is a ferric subsulfate that often is used to achieve hemostasis after shave biopsies. Hemostasis is thought to result from the ability of ferric ions to denature and agglutinate proteins such as fibrinogen.^1,2 Application of Monsel solution likely causes ferrugination of fibrin, dermal collagen, and striated muscle fibers. Some ferruginated collagen fibers are eliminated through the epidermis as the epidermis regenerates, while some fibers become calcified. Siderophages (iron-containing macrophages) are present in these areas. The ferrugination of collagen fibers becomes less pronounced as the biopsy sites heal and the iron pigment subsequently is absorbed by macrophages. Ferruginated skeletal muscles can act as foreign bodies and may elicit granulomatous reactions.²

It is currently unclear why fibrohistiocytic responses occur in some instances but not others. Iron stains (eg, Perls Prussian blue stain) make interpretation clear, provided the pathologist is familiar with Monsel solution. The primary differential diagnosis of these lesions centers on heavily pigmented melanocytic proliferations. It is critical to review prior biopsy sections or to have definite knowledge of the prior biopsy diagnosis. Histologically, the epidermis may demonstrate nonspecific reactive changes such as hyperkeratosis with foci of irregular acanthosis. The prominent features are present in the dermis where there is a proliferation of spindle- and polyhedral-shaped cells that may show cytologic atypia and occasional mitotic figures. The cells contain refractile brown pigment scattered in the dermis and deposited on collagen fibers (quiz images). Occasional large black or brown encrustations may be identified. Monsel-containing cells may indiscernibly blend with foci of more blatantly fibrohistiocytic differentiation, in which case iron stains are strongly positive (Figure 1). If the clinician uses Monsel solution for hemostasis during the removal of a nevomelanocytic neoplasm, it might be necessary to use melanin stains or immunohistochemistry on the reexcision specimen to distinguish between residual nevomelanocytic and fibrohistiocytic cells.³

Common blue nevus is a benign, typically intradermal melanocytic lesion. It most frequently occurs in young adults and has a predilection for females. Clinically, it can be found anywhere on the body as a single, asymptomatic, well-circumscribed, blue-black, dome-shaped papule measuring less than 1 cm in diameter. Histologically, it is characterized by pigmented, dendritic, spindle-shaped melanocytes that typically are separated by thick collagen bundles (Figure 2). The melanocytes typically have small nuclei with occasional basophilic nucleolus. Melanocytes typically are diffusely positive for melanocytic markers including human melanoma black (HMB) 45, S-100, Melan-A, and microphthalmia transcription factor 1. In contrast to most other benign melanocytic nevi, HMB-45 strongly stains the entire lesion in blue nevi.⁴

Desmoplastic melanoma accounts for 1% to 4% of all melanomas. The median age at diagnosis is 62 years and, as in other types of melanoma, men are more commonly affected.⁵ Clinically, desmoplastic melanoma typically presents on the head and neck as a painless indurated plaque, though it can present as a small papule or nodule. Nearly half of desmoplastic melanomas lack obvious pigmentation, which may lead to the misdiagnosis of basal cell carcinoma or a scar. Histologically, desmoplastic melanomas are composed of spindled melanocytes separated by collagen fibers or fibrous stroma (Figure 3). Histology displays variable cytologic atypia and stromal fibrosis. Characteristically there are small islands of lymphocytes and plasma cells within or at the edge of the tumor. The spindle cells stain positive with S-100 and Sry-related HMg-box gene 10, SOX10. Type IV collagen and laminin often are expressed in desmoplastic melanoma. In contrast to many other subtypes of melanoma, HMB-45 and Melan-A usually are negative.⁶

Animal-type melanoma is a rare neoplasm that differs from other subtypes of melanoma both clinically and histologically. Most frequently, animal-type melanoma affects younger adults (median age, 27 years) and arises on the arms and legs, head and neck, or trunk; men and women are affected equally.7 It most commonly presents with a blue or blue-black nodule with a blue-white veil or irregular white areas. Histologically, animal-type melanoma is a predominantly dermal-based melanocytic proliferation with heavily pigmented epithelioid and spindled melanocytes (Figure 4). The pigmentation pattern ranges widely from fine, granular, light brown deposits to coarse dark brown deposits with malignant cells often arranged in fascicles or sheets. Frequently, there is periadnexal and perieccrine spread. Often, there is epidermal hyperplasia above the dermis. As with conventional melanoma, the immunohistochemistry of animal-type melanoma is positive for S-100 protein, HMB-45, SOX10, and Melan-A.⁷

Recurrent nevi typically arise within 6 months of a previously biopsied melanocytic nevus. Most recurrent nevi originate from common banal nevi (most often a compound nevus). Recurrent nevi also may arise from congenital, atypical/dysplastic, and Spitz nevi. Most often they are found on the back of women aged 20 to 30 years.⁸ Clinically, they manifest as a macular area of scar with variegated hyperpigmentation and hypopigmentation as well as linear streaking. They may demonstrate variable diffuse, stippled, and halo pigmentation patterns. Classically, recurrent nevi present with a trizonal histologic pattern. Within the epidermis there is a proliferation of melanocytes along the dermoepidermal junction, which may show varying degrees of atypia and pagetoid migration. The melanocytes often are described as epithelioid with round nuclei and even chromatin (Figure 5). The atypical features should be confined to the epidermis overlying the prior biopsy site. Within the dermis there is dense dermal collagen and fibrosis with vertically oriented blood vessels. Finally, features of the original nevus may be seen at the base of the lesion. Although immunohistochemistry may be helpful in some cases, an appropriate clinical history and comparison to the prior biopsy can be invaluable.⁸

Host tissue reactions resulting in artefactual changes caused by foreign bodies or substances may confound the untrained eye. Monsel solution reaction may be confused for a blue nevus, desmoplastic melanoma, animal-type melanoma, and a residual/recurrent nevus. This confusion could lead to serious diagnostic errors that could cause an unfavorable outcome for the patient. It is critical to know the salient points in the patient's clinical history. Knowledge of the Monsel solution reaction and other exogenous lesions as well as the subsequent unique tissue reaction patterns can aid in facilitating an accurate and prompt pathologic diagnosis.

The Diagnosis: Monsel Solution Reaction

Exogenous substances can cause interesting incongruities in cutaneous biopsies of which pathologists and dermatologists should be cognizant. Exogenous lesions are caused by externally introduced foreign bodies, substances, or materials, such as sterile compressed sponges, aluminum chloride hexahydrate and anhydrous ethyl alcohol, silica, paraffin, and Monsel solution. Monsel solution reaction is a florid fibrohistiocytic proliferation stimulated by the application of Monsel solution. Monsel solution is a ferric subsulfate that often is used to achieve hemostasis after shave biopsies. Hemostasis is thought to result from the ability of ferric ions to denature and agglutinate proteins such as fibrinogen.^1,2 Application of Monsel solution likely causes ferrugination of fibrin, dermal collagen, and striated muscle fibers. Some ferruginated collagen fibers are eliminated through the epidermis as the epidermis regenerates, while some fibers become calcified. Siderophages (iron-containing macrophages) are present in these areas. The ferrugination of collagen fibers becomes less pronounced as the biopsy sites heal and the iron pigment subsequently is absorbed by macrophages. Ferruginated skeletal muscles can act as foreign bodies and may elicit granulomatous reactions.²

It is currently unclear why fibrohistiocytic responses occur in some instances but not others. Iron stains (eg, Perls Prussian blue stain) make interpretation clear, provided the pathologist is familiar with Monsel solution. The primary differential diagnosis of these lesions centers on heavily pigmented melanocytic proliferations. It is critical to review prior biopsy sections or to have definite knowledge of the prior biopsy diagnosis. Histologically, the epidermis may demonstrate nonspecific reactive changes such as hyperkeratosis with foci of irregular acanthosis. The prominent features are present in the dermis where there is a proliferation of spindle- and polyhedral-shaped cells that may show cytologic atypia and occasional mitotic figures. The cells contain refractile brown pigment scattered in the dermis and deposited on collagen fibers (quiz images). Occasional large black or brown encrustations may be identified. Monsel-containing cells may indiscernibly blend with foci of more blatantly fibrohistiocytic differentiation, in which case iron stains are strongly positive (Figure 1). If the clinician uses Monsel solution for hemostasis during the removal of a nevomelanocytic neoplasm, it might be necessary to use melanin stains or immunohistochemistry on the reexcision specimen to distinguish between residual nevomelanocytic and fibrohistiocytic cells.³

Common blue nevus is a benign, typically intradermal melanocytic lesion. It most frequently occurs in young adults and has a predilection for females. Clinically, it can be found anywhere on the body as a single, asymptomatic, well-circumscribed, blue-black, dome-shaped papule measuring less than 1 cm in diameter. Histologically, it is characterized by pigmented, dendritic, spindle-shaped melanocytes that typically are separated by thick collagen bundles (Figure 2). The melanocytes typically have small nuclei with occasional basophilic nucleolus. Melanocytes typically are diffusely positive for melanocytic markers including human melanoma black (HMB) 45, S-100, Melan-A, and microphthalmia transcription factor 1. In contrast to most other benign melanocytic nevi, HMB-45 strongly stains the entire lesion in blue nevi.⁴

Desmoplastic melanoma accounts for 1% to 4% of all melanomas. The median age at diagnosis is 62 years and, as in other types of melanoma, men are more commonly affected.⁵ Clinically, desmoplastic melanoma typically presents on the head and neck as a painless indurated plaque, though it can present as a small papule or nodule. Nearly half of desmoplastic melanomas lack obvious pigmentation, which may lead to the misdiagnosis of basal cell carcinoma or a scar. Histologically, desmoplastic melanomas are composed of spindled melanocytes separated by collagen fibers or fibrous stroma (Figure 3). Histology displays variable cytologic atypia and stromal fibrosis. Characteristically there are small islands of lymphocytes and plasma cells within or at the edge of the tumor. The spindle cells stain positive with S-100 and Sry-related HMg-box gene 10, SOX10. Type IV collagen and laminin often are expressed in desmoplastic melanoma. In contrast to many other subtypes of melanoma, HMB-45 and Melan-A usually are negative.⁶

Animal-type melanoma is a rare neoplasm that differs from other subtypes of melanoma both clinically and histologically. Most frequently, animal-type melanoma affects younger adults (median age, 27 years) and arises on the arms and legs, head and neck, or trunk; men and women are affected equally.7 It most commonly presents with a blue or blue-black nodule with a blue-white veil or irregular white areas. Histologically, animal-type melanoma is a predominantly dermal-based melanocytic proliferation with heavily pigmented epithelioid and spindled melanocytes (Figure 4). The pigmentation pattern ranges widely from fine, granular, light brown deposits to coarse dark brown deposits with malignant cells often arranged in fascicles or sheets. Frequently, there is periadnexal and perieccrine spread. Often, there is epidermal hyperplasia above the dermis. As with conventional melanoma, the immunohistochemistry of animal-type melanoma is positive for S-100 protein, HMB-45, SOX10, and Melan-A.⁷

Recurrent nevi typically arise within 6 months of a previously biopsied melanocytic nevus. Most recurrent nevi originate from common banal nevi (most often a compound nevus). Recurrent nevi also may arise from congenital, atypical/dysplastic, and Spitz nevi. Most often they are found on the back of women aged 20 to 30 years.⁸ Clinically, they manifest as a macular area of scar with variegated hyperpigmentation and hypopigmentation as well as linear streaking. They may demonstrate variable diffuse, stippled, and halo pigmentation patterns. Classically, recurrent nevi present with a trizonal histologic pattern. Within the epidermis there is a proliferation of melanocytes along the dermoepidermal junction, which may show varying degrees of atypia and pagetoid migration. The melanocytes often are described as epithelioid with round nuclei and even chromatin (Figure 5). The atypical features should be confined to the epidermis overlying the prior biopsy site. Within the dermis there is dense dermal collagen and fibrosis with vertically oriented blood vessels. Finally, features of the original nevus may be seen at the base of the lesion. Although immunohistochemistry may be helpful in some cases, an appropriate clinical history and comparison to the prior biopsy can be invaluable.⁸

Host tissue reactions resulting in artefactual changes caused by foreign bodies or substances may confound the untrained eye. Monsel solution reaction may be confused for a blue nevus, desmoplastic melanoma, animal-type melanoma, and a residual/recurrent nevus. This confusion could lead to serious diagnostic errors that could cause an unfavorable outcome for the patient. It is critical to know the salient points in the patient's clinical history. Knowledge of the Monsel solution reaction and other exogenous lesions as well as the subsequent unique tissue reaction patterns can aid in facilitating an accurate and prompt pathologic diagnosis.

The Diagnosis: Monsel Solution Reaction

Exogenous substances can cause interesting incongruities in cutaneous biopsies of which pathologists and dermatologists should be cognizant. Exogenous lesions are caused by externally introduced foreign bodies, substances, or materials, such as sterile compressed sponges, aluminum chloride hexahydrate and anhydrous ethyl alcohol, silica, paraffin, and Monsel solution. Monsel solution reaction is a florid fibrohistiocytic proliferation stimulated by the application of Monsel solution. Monsel solution is a ferric subsulfate that often is used to achieve hemostasis after shave biopsies. Hemostasis is thought to result from the ability of ferric ions to denature and agglutinate proteins such as fibrinogen.^1,2 Application of Monsel solution likely causes ferrugination of fibrin, dermal collagen, and striated muscle fibers. Some ferruginated collagen fibers are eliminated through the epidermis as the epidermis regenerates, while some fibers become calcified. Siderophages (iron-containing macrophages) are present in these areas. The ferrugination of collagen fibers becomes less pronounced as the biopsy sites heal and the iron pigment subsequently is absorbed by macrophages. Ferruginated skeletal muscles can act as foreign bodies and may elicit granulomatous reactions.²

It is currently unclear why fibrohistiocytic responses occur in some instances but not others. Iron stains (eg, Perls Prussian blue stain) make interpretation clear, provided the pathologist is familiar with Monsel solution. The primary differential diagnosis of these lesions centers on heavily pigmented melanocytic proliferations. It is critical to review prior biopsy sections or to have definite knowledge of the prior biopsy diagnosis. Histologically, the epidermis may demonstrate nonspecific reactive changes such as hyperkeratosis with foci of irregular acanthosis. The prominent features are present in the dermis where there is a proliferation of spindle- and polyhedral-shaped cells that may show cytologic atypia and occasional mitotic figures. The cells contain refractile brown pigment scattered in the dermis and deposited on collagen fibers (quiz images). Occasional large black or brown encrustations may be identified. Monsel-containing cells may indiscernibly blend with foci of more blatantly fibrohistiocytic differentiation, in which case iron stains are strongly positive (Figure 1). If the clinician uses Monsel solution for hemostasis during the removal of a nevomelanocytic neoplasm, it might be necessary to use melanin stains or immunohistochemistry on the reexcision specimen to distinguish between residual nevomelanocytic and fibrohistiocytic cells.³

Common blue nevus is a benign, typically intradermal melanocytic lesion. It most frequently occurs in young adults and has a predilection for females. Clinically, it can be found anywhere on the body as a single, asymptomatic, well-circumscribed, blue-black, dome-shaped papule measuring less than 1 cm in diameter. Histologically, it is characterized by pigmented, dendritic, spindle-shaped melanocytes that typically are separated by thick collagen bundles (Figure 2). The melanocytes typically have small nuclei with occasional basophilic nucleolus. Melanocytes typically are diffusely positive for melanocytic markers including human melanoma black (HMB) 45, S-100, Melan-A, and microphthalmia transcription factor 1. In contrast to most other benign melanocytic nevi, HMB-45 strongly stains the entire lesion in blue nevi.⁴

Desmoplastic melanoma accounts for 1% to 4% of all melanomas. The median age at diagnosis is 62 years and, as in other types of melanoma, men are more commonly affected.⁵ Clinically, desmoplastic melanoma typically presents on the head and neck as a painless indurated plaque, though it can present as a small papule or nodule. Nearly half of desmoplastic melanomas lack obvious pigmentation, which may lead to the misdiagnosis of basal cell carcinoma or a scar. Histologically, desmoplastic melanomas are composed of spindled melanocytes separated by collagen fibers or fibrous stroma (Figure 3). Histology displays variable cytologic atypia and stromal fibrosis. Characteristically there are small islands of lymphocytes and plasma cells within or at the edge of the tumor. The spindle cells stain positive with S-100 and Sry-related HMg-box gene 10, SOX10. Type IV collagen and laminin often are expressed in desmoplastic melanoma. In contrast to many other subtypes of melanoma, HMB-45 and Melan-A usually are negative.⁶

Animal-type melanoma is a rare neoplasm that differs from other subtypes of melanoma both clinically and histologically. Most frequently, animal-type melanoma affects younger adults (median age, 27 years) and arises on the arms and legs, head and neck, or trunk; men and women are affected equally.7 It most commonly presents with a blue or blue-black nodule with a blue-white veil or irregular white areas. Histologically, animal-type melanoma is a predominantly dermal-based melanocytic proliferation with heavily pigmented epithelioid and spindled melanocytes (Figure 4). The pigmentation pattern ranges widely from fine, granular, light brown deposits to coarse dark brown deposits with malignant cells often arranged in fascicles or sheets. Frequently, there is periadnexal and perieccrine spread. Often, there is epidermal hyperplasia above the dermis. As with conventional melanoma, the immunohistochemistry of animal-type melanoma is positive for S-100 protein, HMB-45, SOX10, and Melan-A.⁷

Recurrent nevi typically arise within 6 months of a previously biopsied melanocytic nevus. Most recurrent nevi originate from common banal nevi (most often a compound nevus). Recurrent nevi also may arise from congenital, atypical/dysplastic, and Spitz nevi. Most often they are found on the back of women aged 20 to 30 years.⁸ Clinically, they manifest as a macular area of scar with variegated hyperpigmentation and hypopigmentation as well as linear streaking. They may demonstrate variable diffuse, stippled, and halo pigmentation patterns. Classically, recurrent nevi present with a trizonal histologic pattern. Within the epidermis there is a proliferation of melanocytes along the dermoepidermal junction, which may show varying degrees of atypia and pagetoid migration. The melanocytes often are described as epithelioid with round nuclei and even chromatin (Figure 5). The atypical features should be confined to the epidermis overlying the prior biopsy site. Within the dermis there is dense dermal collagen and fibrosis with vertically oriented blood vessels. Finally, features of the original nevus may be seen at the base of the lesion. Although immunohistochemistry may be helpful in some cases, an appropriate clinical history and comparison to the prior biopsy can be invaluable.⁸

Host tissue reactions resulting in artefactual changes caused by foreign bodies or substances may confound the untrained eye. Monsel solution reaction may be confused for a blue nevus, desmoplastic melanoma, animal-type melanoma, and a residual/recurrent nevus. This confusion could lead to serious diagnostic errors that could cause an unfavorable outcome for the patient. It is critical to know the salient points in the patient's clinical history. Knowledge of the Monsel solution reaction and other exogenous lesions as well as the subsequent unique tissue reaction patterns can aid in facilitating an accurate and prompt pathologic diagnosis.

CHICAGO – Most psoriasis therapies in the pipeline are biologics, including several interleukin (IL)-23 inhibitors and a promising dual inhibitor of IL-17A and IL-17F, so dermatologists are likely to gain a few more options for treating psoriasis patients who have not responded well to or tolerated existing therapies.

“The IL-23 blockers are ideal for patients who want a few injections,” Mark Lebwohl, MD, professor of dermatology at the Icahn School of Medicine at Mount Sinai, New York, and chair of the department of dermatology of the Mount Sinai Health System, said after the American Academy of Dermatology summer meeting. He discussed clinical trial results for risankizumab, mirikizumab, certolizumab pegol (which was recently approved for psoriasis), bimekizumab, as well as tildrakizumab, which has been approved by the Food and Drug Administration, but has not yet been released.

 

Tildrakizumab: The FDA approved tildrakizumab (Ilumya), a selective IL-23p19 inhibitor, for treatment of moderate to severe plaque psoriasis in March 2018 based on data from the reSURFACE 1 and reSURFACE 2 trials. After initial doses at weeks 0 and 4, patients received a 100-mg subcutaneous injection dose every 12 weeks. Results of reSURFACE 1 showed that 14% of trial participants achieved a Psoriasis Area and Severity Index (PASI) score of 100 with tildrakizumab at week 12, compared with 1% of those receiving a placebo. Similarly, 35% achieved a PASI 90 and 64% achieved a PASI 75 with the drug, compared with 3% and 6%, respectively, in the placebo group. Findings for reSURFACE 2 were similar; in a pooled analysis, a quarter of the 371 patients reached PASI 100 by week 28, 36% reached PASI 90-PASI 99, 24% reached PASI 75-PASI 89, and 10% reached PASI 50-PASI 74. Efficacy remained high 2 years after treatment, although body weight affected the efficacy. “The authors concluded that PASI and PGA [Physician Global Assessment] responses were numerically greater in patients with lower versus higher body weight,” Dr. Lebwohl said at the meeting.

Tildrakizumab also has an “overall clean safety profile,” he said. Among all patients treated in the trials, the rate of severe infections, malignancies and major adverse cardiac events did not significantly differ from placebo.*

Risankizumab: Also an IL-23 inhibitor, risankizumab, under FDA review for treatment of moderate to severe plaque psoriasis, outperformed both ustekinumab and adalimumab in pivotal phase 3 trials reported in October 2017. In the two ultlMMa trials, 75% of 598 total patients achieved a PASI 90 score after 16 weeks of treatment, compared with 2%-5% of placebo participants and 42%-48% of those on ustekinumab. In ultlMMa-1, just over a third of patients treated with achieved PASI 100, and just over half did in ultlMMa-2, compared with 12% and 24% of those on ustekinumab, respectively.

At 1 year, the proportion of those with PASI 90 rose to 82% in ultlMMa-1 and 81% in ultlMMa-2, with over half the participants achieving PASI 100 in both studies. The risankizumab trial findings were “among highest efficacy results reported to date, with impressive durability of response on and off drug,” Dr. Lebwohl said. “Preliminary safety is encouraging,” but “long-term data are required.”

Mirikizumab: Although not as far along in clinical trials, mirikizumab is another IL-23 inhibitor with “interesting and impressive preliminary results,” Dr. Lebwohl said. In a phase 2 trial of 205 participants whose baseline demographics indicated more severe psoriasis, 67% achieved PASI 90 at week 16 with a 300-mg dose (administered every 8 weeks). Doses of 100 mg and 30 mg resulted in 59% and 29% of participants achieving PASI 90 at week 16.

“The most common treatment emergent adverse events included upper respiratory tract infection [including viral], injection site pain, hypertension and diarrhea,” Dr. Lebwohl said. Patients are now being recruited for two phase 3 studies of mirikizumab (OASIS-1 and OASIS-2).

Certolizumab pegol: Certolizumab pegol is a tumor necrosis factor blocker approved in 2013 for treatment of psoriatic arthritis, and for moderate to severe plaque psoriasis in May 2018. In a pooled data analysis of three phase 3 trials (CIMPASI-1, CIMPASI-2, and CIMPACT), 52.3% of participants taking 400 mg subcutaneously every 2 weeks and 44.5% of those taking 200 mg every 2 weeks achieved PASI 90 at week 16, compared with 1.6% of those on placebo. In addition, a trial evaluating maternal transfer of certolizumab to the fetus via placenta found minimal drug concentration levels in the umbilical cord and infant’s plasma. “Certolizumab is ideal for women of childbearing potential,” Dr. Lebwohl said after the meeting.

Bimekizumab: This is a dual inhibitor of IL-17A and IL-17F being studied for treatment of mild psoriasis but “is very promising for psoriatic arthritis, as well as psoriasis,” Dr. Lebwohl said. In the phase 2b BE ABLE 1 trial, up to 79% of patients receiving bimekizumab achieved PASI 90 at week 12, and up to 46% of psoriatic arthritis patients had at least a 50% improvement in joint symptoms, compared with 7% of those on placebo.

Dr. Lebwohl is a consultant for Allergan, Boehringer-Ingelheim, Leo and Promius Pharma, and is an employee of Mount Sinai, which receives research funds from Abbvie, Amgen, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen/Johnson & Johnson, Kadmon, Medimmune/AstraZeneca, Novartis, Pfizer, and ViDac Pharma.

*Correction, 8/6/18: An earlier version of this article misstated the adverse event data for tildrakizumab.

CHICAGO – Most psoriasis therapies in the pipeline are biologics, including several interleukin (IL)-23 inhibitors and a promising dual inhibitor of IL-17A and IL-17F, so dermatologists are likely to gain a few more options for treating psoriasis patients who have not responded well to or tolerated existing therapies.

“The IL-23 blockers are ideal for patients who want a few injections,” Mark Lebwohl, MD, professor of dermatology at the Icahn School of Medicine at Mount Sinai, New York, and chair of the department of dermatology of the Mount Sinai Health System, said after the American Academy of Dermatology summer meeting. He discussed clinical trial results for risankizumab, mirikizumab, certolizumab pegol (which was recently approved for psoriasis), bimekizumab, as well as tildrakizumab, which has been approved by the Food and Drug Administration, but has not yet been released.

 

Tildrakizumab: The FDA approved tildrakizumab (Ilumya), a selective IL-23p19 inhibitor, for treatment of moderate to severe plaque psoriasis in March 2018 based on data from the reSURFACE 1 and reSURFACE 2 trials. After initial doses at weeks 0 and 4, patients received a 100-mg subcutaneous injection dose every 12 weeks. Results of reSURFACE 1 showed that 14% of trial participants achieved a Psoriasis Area and Severity Index (PASI) score of 100 with tildrakizumab at week 12, compared with 1% of those receiving a placebo. Similarly, 35% achieved a PASI 90 and 64% achieved a PASI 75 with the drug, compared with 3% and 6%, respectively, in the placebo group. Findings for reSURFACE 2 were similar; in a pooled analysis, a quarter of the 371 patients reached PASI 100 by week 28, 36% reached PASI 90-PASI 99, 24% reached PASI 75-PASI 89, and 10% reached PASI 50-PASI 74. Efficacy remained high 2 years after treatment, although body weight affected the efficacy. “The authors concluded that PASI and PGA [Physician Global Assessment] responses were numerically greater in patients with lower versus higher body weight,” Dr. Lebwohl said at the meeting.

Tildrakizumab also has an “overall clean safety profile,” he said. Among all patients treated in the trials, the rate of severe infections, malignancies and major adverse cardiac events did not significantly differ from placebo.*

Risankizumab: Also an IL-23 inhibitor, risankizumab, under FDA review for treatment of moderate to severe plaque psoriasis, outperformed both ustekinumab and adalimumab in pivotal phase 3 trials reported in October 2017. In the two ultlMMa trials, 75% of 598 total patients achieved a PASI 90 score after 16 weeks of treatment, compared with 2%-5% of placebo participants and 42%-48% of those on ustekinumab. In ultlMMa-1, just over a third of patients treated with achieved PASI 100, and just over half did in ultlMMa-2, compared with 12% and 24% of those on ustekinumab, respectively.

At 1 year, the proportion of those with PASI 90 rose to 82% in ultlMMa-1 and 81% in ultlMMa-2, with over half the participants achieving PASI 100 in both studies. The risankizumab trial findings were “among highest efficacy results reported to date, with impressive durability of response on and off drug,” Dr. Lebwohl said. “Preliminary safety is encouraging,” but “long-term data are required.”

Mirikizumab: Although not as far along in clinical trials, mirikizumab is another IL-23 inhibitor with “interesting and impressive preliminary results,” Dr. Lebwohl said. In a phase 2 trial of 205 participants whose baseline demographics indicated more severe psoriasis, 67% achieved PASI 90 at week 16 with a 300-mg dose (administered every 8 weeks). Doses of 100 mg and 30 mg resulted in 59% and 29% of participants achieving PASI 90 at week 16.

“The most common treatment emergent adverse events included upper respiratory tract infection [including viral], injection site pain, hypertension and diarrhea,” Dr. Lebwohl said. Patients are now being recruited for two phase 3 studies of mirikizumab (OASIS-1 and OASIS-2).

Certolizumab pegol: Certolizumab pegol is a tumor necrosis factor blocker approved in 2013 for treatment of psoriatic arthritis, and for moderate to severe plaque psoriasis in May 2018. In a pooled data analysis of three phase 3 trials (CIMPASI-1, CIMPASI-2, and CIMPACT), 52.3% of participants taking 400 mg subcutaneously every 2 weeks and 44.5% of those taking 200 mg every 2 weeks achieved PASI 90 at week 16, compared with 1.6% of those on placebo. In addition, a trial evaluating maternal transfer of certolizumab to the fetus via placenta found minimal drug concentration levels in the umbilical cord and infant’s plasma. “Certolizumab is ideal for women of childbearing potential,” Dr. Lebwohl said after the meeting.

Bimekizumab: This is a dual inhibitor of IL-17A and IL-17F being studied for treatment of mild psoriasis but “is very promising for psoriatic arthritis, as well as psoriasis,” Dr. Lebwohl said. In the phase 2b BE ABLE 1 trial, up to 79% of patients receiving bimekizumab achieved PASI 90 at week 12, and up to 46% of psoriatic arthritis patients had at least a 50% improvement in joint symptoms, compared with 7% of those on placebo.

Dr. Lebwohl is a consultant for Allergan, Boehringer-Ingelheim, Leo and Promius Pharma, and is an employee of Mount Sinai, which receives research funds from Abbvie, Amgen, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen/Johnson & Johnson, Kadmon, Medimmune/AstraZeneca, Novartis, Pfizer, and ViDac Pharma.

*Correction, 8/6/18: An earlier version of this article misstated the adverse event data for tildrakizumab.

CHICAGO – Most psoriasis therapies in the pipeline are biologics, including several interleukin (IL)-23 inhibitors and a promising dual inhibitor of IL-17A and IL-17F, so dermatologists are likely to gain a few more options for treating psoriasis patients who have not responded well to or tolerated existing therapies.

“The IL-23 blockers are ideal for patients who want a few injections,” Mark Lebwohl, MD, professor of dermatology at the Icahn School of Medicine at Mount Sinai, New York, and chair of the department of dermatology of the Mount Sinai Health System, said after the American Academy of Dermatology summer meeting. He discussed clinical trial results for risankizumab, mirikizumab, certolizumab pegol (which was recently approved for psoriasis), bimekizumab, as well as tildrakizumab, which has been approved by the Food and Drug Administration, but has not yet been released.

 

Tildrakizumab: The FDA approved tildrakizumab (Ilumya), a selective IL-23p19 inhibitor, for treatment of moderate to severe plaque psoriasis in March 2018 based on data from the reSURFACE 1 and reSURFACE 2 trials. After initial doses at weeks 0 and 4, patients received a 100-mg subcutaneous injection dose every 12 weeks. Results of reSURFACE 1 showed that 14% of trial participants achieved a Psoriasis Area and Severity Index (PASI) score of 100 with tildrakizumab at week 12, compared with 1% of those receiving a placebo. Similarly, 35% achieved a PASI 90 and 64% achieved a PASI 75 with the drug, compared with 3% and 6%, respectively, in the placebo group. Findings for reSURFACE 2 were similar; in a pooled analysis, a quarter of the 371 patients reached PASI 100 by week 28, 36% reached PASI 90-PASI 99, 24% reached PASI 75-PASI 89, and 10% reached PASI 50-PASI 74. Efficacy remained high 2 years after treatment, although body weight affected the efficacy. “The authors concluded that PASI and PGA [Physician Global Assessment] responses were numerically greater in patients with lower versus higher body weight,” Dr. Lebwohl said at the meeting.

Tildrakizumab also has an “overall clean safety profile,” he said. Among all patients treated in the trials, the rate of severe infections, malignancies and major adverse cardiac events did not significantly differ from placebo.*

Risankizumab: Also an IL-23 inhibitor, risankizumab, under FDA review for treatment of moderate to severe plaque psoriasis, outperformed both ustekinumab and adalimumab in pivotal phase 3 trials reported in October 2017. In the two ultlMMa trials, 75% of 598 total patients achieved a PASI 90 score after 16 weeks of treatment, compared with 2%-5% of placebo participants and 42%-48% of those on ustekinumab. In ultlMMa-1, just over a third of patients treated with achieved PASI 100, and just over half did in ultlMMa-2, compared with 12% and 24% of those on ustekinumab, respectively.

At 1 year, the proportion of those with PASI 90 rose to 82% in ultlMMa-1 and 81% in ultlMMa-2, with over half the participants achieving PASI 100 in both studies. The risankizumab trial findings were “among highest efficacy results reported to date, with impressive durability of response on and off drug,” Dr. Lebwohl said. “Preliminary safety is encouraging,” but “long-term data are required.”

Mirikizumab: Although not as far along in clinical trials, mirikizumab is another IL-23 inhibitor with “interesting and impressive preliminary results,” Dr. Lebwohl said. In a phase 2 trial of 205 participants whose baseline demographics indicated more severe psoriasis, 67% achieved PASI 90 at week 16 with a 300-mg dose (administered every 8 weeks). Doses of 100 mg and 30 mg resulted in 59% and 29% of participants achieving PASI 90 at week 16.

“The most common treatment emergent adverse events included upper respiratory tract infection [including viral], injection site pain, hypertension and diarrhea,” Dr. Lebwohl said. Patients are now being recruited for two phase 3 studies of mirikizumab (OASIS-1 and OASIS-2).

Certolizumab pegol: Certolizumab pegol is a tumor necrosis factor blocker approved in 2013 for treatment of psoriatic arthritis, and for moderate to severe plaque psoriasis in May 2018. In a pooled data analysis of three phase 3 trials (CIMPASI-1, CIMPASI-2, and CIMPACT), 52.3% of participants taking 400 mg subcutaneously every 2 weeks and 44.5% of those taking 200 mg every 2 weeks achieved PASI 90 at week 16, compared with 1.6% of those on placebo. In addition, a trial evaluating maternal transfer of certolizumab to the fetus via placenta found minimal drug concentration levels in the umbilical cord and infant’s plasma. “Certolizumab is ideal for women of childbearing potential,” Dr. Lebwohl said after the meeting.

Bimekizumab: This is a dual inhibitor of IL-17A and IL-17F being studied for treatment of mild psoriasis but “is very promising for psoriatic arthritis, as well as psoriasis,” Dr. Lebwohl said. In the phase 2b BE ABLE 1 trial, up to 79% of patients receiving bimekizumab achieved PASI 90 at week 12, and up to 46% of psoriatic arthritis patients had at least a 50% improvement in joint symptoms, compared with 7% of those on placebo.

Dr. Lebwohl is a consultant for Allergan, Boehringer-Ingelheim, Leo and Promius Pharma, and is an employee of Mount Sinai, which receives research funds from Abbvie, Amgen, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen/Johnson & Johnson, Kadmon, Medimmune/AstraZeneca, Novartis, Pfizer, and ViDac Pharma.

*Correction, 8/6/18: An earlier version of this article misstated the adverse event data for tildrakizumab.

What does your patient need to know preoperatively?

Patients should be educated on all aspects of the procedure as well as the expected postoperative course of healing. Manage patient expectations in advance to minimize any surprises for everyone involved. Swelling and bruising are not uncommon in the immediate postoperative phase, and for surgery near the eyes, both may be worse, making it prudent for patients to schedule any procedures after big events or vacations.

The sutured wound initially can appear lumpy, bumpy, and pink, and it may take potentially 3 to 6 months, or even longer, for the scar to fully mature depending on the type of repair performed. Sutured wounds require activity restrictions, which is especially important for young active patients as well as patients who may have labor-intensive occupations. I often recommend 1 to 2 weeks before resuming most forms of strenuous exercise and/or physical labor. Skin grafts may require even longer limitations. Although the overall risk for infection is low (approximately 1%), patients should be instructed to monitor for purulent drainage, fever, and worsening pain and redness, and to inform the dermatologist immediately of any concerning symptoms.

What is your go-to approach for wound closure?

My motto is: Simplest is often best. For the patient who prioritizes returning to full activity as soon as possible, the wound may be able to heal by secondary intention in select anatomic locations, and this approach can often yield excellent cosmetic results. If wound closure with sutures is indicated, then I use the following treatment algorithm:

1. Primary closure is used if I can close a wound in a linear fashion without distorting free margins, especially if I can hide the lines within cosmetic subunit junctions and/or relaxed skin tension lines.
2. Local flap is used for defects when repair in a linear fashion is not always ideal for various reasons. Recruit local skin with various flap options for the best color and texture match. This approach may be more involved but often provides the best long-term cosmetic outcome; however, it usually results in a longer recovery time and may even require staged procedures.
3. Graft usually is our last preferred option because it may appear as a sewn-in patch; however, in certain anatomic locations and in the right patient, skin grafts also can yield acceptable cosmetic results.

I give trainees the following surgical technique pearls:  

• Use buried vertical mattress sutures to achieve eversion of wound edges with deep sutures
• Dermal pulley as well as epidermal pulley sutures can offset tension wonderfully, especially in high-tension areas such as the back and scalp
• Placement of a running subcuticular suture in place of epidermal stitches on the trunk and extremities can prevent track marks

How do you keep patients compliant with wound care instructions?

Two keys to high patient compliance with wound care are making instructions as simple as possible and providing detailed written instructions. We instruct patients to keep the pressure dressing in place for 48 hours. Once removed, we recommend patients clean the wound with regular soap and water daily, followed by application of petrolatum ointment. For hard-to-reach areas or on non-hair-bearing skin, my surgical assistants apply adhesive strips over the sutures, eliminating the need for daily wound care. For full-thickness skin grafts, we commonly place a bolster pressure dressing that stays in place until the patient returns to our clinic for a postoperative visit. We provide every patient with detailed written instructions as a patient handout that is specific to the type of wound closure performed.

What do you do if the patient refuses your recommendation for wound closure?

It is important to explain all wound closure options to the patient and the risks and benefits of each. I always show patients the proposed plan using a mirror and/or textbook images so that they can better understand the process. In rare cases when the patient refuses the preferred method of closure, we ensure that he/she understands the advantages and disadvantages of the proposed procedure and why the recommendation was made. If the patient still refuses, we document our lengthy discussion in the medical record. For patients who refuse our recommended plan of sutures and opt to heal by secondary intention, we will see these patients almost weekly to ensure appropriate healing as well as provide further recommendations such as a delayed repair if there is any evidence of functional impairment and/or notable cosmetic implications. A patient completely refusing a planned repair is rare.

More commonly, patients request a "simpler" repair, even if the cosmetic outcome may be suboptimal. For example, some elderly patients with large nasal defects do not want to undergo a staged flap, even though it would give a superior cosmetic result. Instead, we do the best we can with a skin graft or single-stage flap.

What resources do you provide to patients for wound care instructions?

We recommend that physicians prepare comprehensive handouts on wound care instructions that address both short-term and long-term expectations, provide instructions regarding follow-up, and encourage good sun protection behaviors. Some physicians post videos demonstrating proper wound care on their websites, which may be another useful tool.
 
Acknowledgment
The author thanks Daniel Condie, MD (Dallas, Texas), for his contributions.

Suggested Readings

Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: part I. cutting tissue: incising, excising, and undermining. J Am Acad Dermatol. 2015;72:377-387.

Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: part II. repairing tissue: suturing. J Am Acad Dermatol. 2015;72:389-402.

What does your patient need to know preoperatively?

Patients should be educated on all aspects of the procedure as well as the expected postoperative course of healing. Manage patient expectations in advance to minimize any surprises for everyone involved. Swelling and bruising are not uncommon in the immediate postoperative phase, and for surgery near the eyes, both may be worse, making it prudent for patients to schedule any procedures after big events or vacations.

The sutured wound initially can appear lumpy, bumpy, and pink, and it may take potentially 3 to 6 months, or even longer, for the scar to fully mature depending on the type of repair performed. Sutured wounds require activity restrictions, which is especially important for young active patients as well as patients who may have labor-intensive occupations. I often recommend 1 to 2 weeks before resuming most forms of strenuous exercise and/or physical labor. Skin grafts may require even longer limitations. Although the overall risk for infection is low (approximately 1%), patients should be instructed to monitor for purulent drainage, fever, and worsening pain and redness, and to inform the dermatologist immediately of any concerning symptoms.

What is your go-to approach for wound closure?

My motto is: Simplest is often best. For the patient who prioritizes returning to full activity as soon as possible, the wound may be able to heal by secondary intention in select anatomic locations, and this approach can often yield excellent cosmetic results. If wound closure with sutures is indicated, then I use the following treatment algorithm:

1. Primary closure is used if I can close a wound in a linear fashion without distorting free margins, especially if I can hide the lines within cosmetic subunit junctions and/or relaxed skin tension lines.
2. Local flap is used for defects when repair in a linear fashion is not always ideal for various reasons. Recruit local skin with various flap options for the best color and texture match. This approach may be more involved but often provides the best long-term cosmetic outcome; however, it usually results in a longer recovery time and may even require staged procedures.
3. Graft usually is our last preferred option because it may appear as a sewn-in patch; however, in certain anatomic locations and in the right patient, skin grafts also can yield acceptable cosmetic results.

I give trainees the following surgical technique pearls:  

• Use buried vertical mattress sutures to achieve eversion of wound edges with deep sutures
• Dermal pulley as well as epidermal pulley sutures can offset tension wonderfully, especially in high-tension areas such as the back and scalp
• Placement of a running subcuticular suture in place of epidermal stitches on the trunk and extremities can prevent track marks

How do you keep patients compliant with wound care instructions?

Two keys to high patient compliance with wound care are making instructions as simple as possible and providing detailed written instructions. We instruct patients to keep the pressure dressing in place for 48 hours. Once removed, we recommend patients clean the wound with regular soap and water daily, followed by application of petrolatum ointment. For hard-to-reach areas or on non-hair-bearing skin, my surgical assistants apply adhesive strips over the sutures, eliminating the need for daily wound care. For full-thickness skin grafts, we commonly place a bolster pressure dressing that stays in place until the patient returns to our clinic for a postoperative visit. We provide every patient with detailed written instructions as a patient handout that is specific to the type of wound closure performed.

What do you do if the patient refuses your recommendation for wound closure?

It is important to explain all wound closure options to the patient and the risks and benefits of each. I always show patients the proposed plan using a mirror and/or textbook images so that they can better understand the process. In rare cases when the patient refuses the preferred method of closure, we ensure that he/she understands the advantages and disadvantages of the proposed procedure and why the recommendation was made. If the patient still refuses, we document our lengthy discussion in the medical record. For patients who refuse our recommended plan of sutures and opt to heal by secondary intention, we will see these patients almost weekly to ensure appropriate healing as well as provide further recommendations such as a delayed repair if there is any evidence of functional impairment and/or notable cosmetic implications. A patient completely refusing a planned repair is rare.

More commonly, patients request a "simpler" repair, even if the cosmetic outcome may be suboptimal. For example, some elderly patients with large nasal defects do not want to undergo a staged flap, even though it would give a superior cosmetic result. Instead, we do the best we can with a skin graft or single-stage flap.

What resources do you provide to patients for wound care instructions?

We recommend that physicians prepare comprehensive handouts on wound care instructions that address both short-term and long-term expectations, provide instructions regarding follow-up, and encourage good sun protection behaviors. Some physicians post videos demonstrating proper wound care on their websites, which may be another useful tool.
 
Acknowledgment
The author thanks Daniel Condie, MD (Dallas, Texas), for his contributions.

Suggested Readings

Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: part I. cutting tissue: incising, excising, and undermining. J Am Acad Dermatol. 2015;72:377-387.

Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: part II. repairing tissue: suturing. J Am Acad Dermatol. 2015;72:389-402.

What does your patient need to know preoperatively?

Patients should be educated on all aspects of the procedure as well as the expected postoperative course of healing. Manage patient expectations in advance to minimize any surprises for everyone involved. Swelling and bruising are not uncommon in the immediate postoperative phase, and for surgery near the eyes, both may be worse, making it prudent for patients to schedule any procedures after big events or vacations.

The sutured wound initially can appear lumpy, bumpy, and pink, and it may take potentially 3 to 6 months, or even longer, for the scar to fully mature depending on the type of repair performed. Sutured wounds require activity restrictions, which is especially important for young active patients as well as patients who may have labor-intensive occupations. I often recommend 1 to 2 weeks before resuming most forms of strenuous exercise and/or physical labor. Skin grafts may require even longer limitations. Although the overall risk for infection is low (approximately 1%), patients should be instructed to monitor for purulent drainage, fever, and worsening pain and redness, and to inform the dermatologist immediately of any concerning symptoms.

What is your go-to approach for wound closure?

My motto is: Simplest is often best. For the patient who prioritizes returning to full activity as soon as possible, the wound may be able to heal by secondary intention in select anatomic locations, and this approach can often yield excellent cosmetic results. If wound closure with sutures is indicated, then I use the following treatment algorithm:

1. Primary closure is used if I can close a wound in a linear fashion without distorting free margins, especially if I can hide the lines within cosmetic subunit junctions and/or relaxed skin tension lines.
2. Local flap is used for defects when repair in a linear fashion is not always ideal for various reasons. Recruit local skin with various flap options for the best color and texture match. This approach may be more involved but often provides the best long-term cosmetic outcome; however, it usually results in a longer recovery time and may even require staged procedures.
3. Graft usually is our last preferred option because it may appear as a sewn-in patch; however, in certain anatomic locations and in the right patient, skin grafts also can yield acceptable cosmetic results.

I give trainees the following surgical technique pearls:  

• Use buried vertical mattress sutures to achieve eversion of wound edges with deep sutures
• Dermal pulley as well as epidermal pulley sutures can offset tension wonderfully, especially in high-tension areas such as the back and scalp
• Placement of a running subcuticular suture in place of epidermal stitches on the trunk and extremities can prevent track marks

How do you keep patients compliant with wound care instructions?

Two keys to high patient compliance with wound care are making instructions as simple as possible and providing detailed written instructions. We instruct patients to keep the pressure dressing in place for 48 hours. Once removed, we recommend patients clean the wound with regular soap and water daily, followed by application of petrolatum ointment. For hard-to-reach areas or on non-hair-bearing skin, my surgical assistants apply adhesive strips over the sutures, eliminating the need for daily wound care. For full-thickness skin grafts, we commonly place a bolster pressure dressing that stays in place until the patient returns to our clinic for a postoperative visit. We provide every patient with detailed written instructions as a patient handout that is specific to the type of wound closure performed.

What do you do if the patient refuses your recommendation for wound closure?

It is important to explain all wound closure options to the patient and the risks and benefits of each. I always show patients the proposed plan using a mirror and/or textbook images so that they can better understand the process. In rare cases when the patient refuses the preferred method of closure, we ensure that he/she understands the advantages and disadvantages of the proposed procedure and why the recommendation was made. If the patient still refuses, we document our lengthy discussion in the medical record. For patients who refuse our recommended plan of sutures and opt to heal by secondary intention, we will see these patients almost weekly to ensure appropriate healing as well as provide further recommendations such as a delayed repair if there is any evidence of functional impairment and/or notable cosmetic implications. A patient completely refusing a planned repair is rare.

More commonly, patients request a "simpler" repair, even if the cosmetic outcome may be suboptimal. For example, some elderly patients with large nasal defects do not want to undergo a staged flap, even though it would give a superior cosmetic result. Instead, we do the best we can with a skin graft or single-stage flap.

What resources do you provide to patients for wound care instructions?

We recommend that physicians prepare comprehensive handouts on wound care instructions that address both short-term and long-term expectations, provide instructions regarding follow-up, and encourage good sun protection behaviors. Some physicians post videos demonstrating proper wound care on their websites, which may be another useful tool.
 
Acknowledgment
The author thanks Daniel Condie, MD (Dallas, Texas), for his contributions.

Suggested Readings

Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: part I. cutting tissue: incising, excising, and undermining. J Am Acad Dermatol. 2015;72:377-387.

Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: part II. repairing tissue: suturing. J Am Acad Dermatol. 2015;72:389-402.

The Diagnosis: Acute Contact Dermatitis

Dermoscopy demonstrated caterpillar hairs (Figure) and established the diagnosis of acute contact dermatitis due to a caterpillar. Upon further questioning, the patient recalled that something dustlike fell on the left cheek as she walked under some trees. The clinical and dermoscopic findings suggested a diagnosis of caterpillar dermatitis (family Limacodidae or Lymantriinae, order Lepidoptera). During the life cycle from young larvae to mature larvae, the quantities of the toxic thorns and hairs increase from 60,000 to 80,000 to 2,000,000 to 3,000,000. The toxic hairs measure 0.5 to 2.0 mm in length. They drop from the mature larvae's skin during desquamation as well as from the cocoon curing maturation to a moth. The hairs appear tubular and arrowlike with terminal spines.¹ The larvae are called "the fiery hot" in Chinese, which vividly describes the swelling and sensation of burning with immediate contact.

Eruption severity and distribution depend on exposure modality and intensity. Exposed body parts, including the face, neck, forearms, interdigital spaces, and dorsal aspects of the hands, most commonly are involved. The eruption can be immediate or delayed, occurring hours or even days after the first contact.2 Itching is intense and continuous, with intermittent worsening. Clinically, the eruption manifests with rose to bright red, round macules and papules. Although rare, skin manifestations can be accompanied by systemic symptoms, such as malaise, fever, and anaphylaxis syndrome.³ The cutaneous lesions may last for 3 to 4 days and subside, leaving a brownish macule.^1,4

The differential diagnosis includes acute herpes simplex, which presents as grouped vesicles on an erythematous base with itching or burning, and recurrences in the same location are common. Acute Sweet syndrome may appear as erythematous or edematous painful plaques with fever and neutrophilia. Acute urticaria appears as wheals with severe pruritus, and individual lesions can resolve within several hours. Insect bites often appear as itching or painful erythema or papules.

We sterilized the lesion with alcohol, removed the thorns as much as possible with ophthalmic forceps under the guidance of dermoscopy, and prescribed chloramphenicol ointment 1% twice daily. Our patient was completely cured within 24 hours with no systemic symptoms or pigmentation.

This case directly showed a novel usage of dermoscopy in diagnosis and therapy, especially in acute contact dermatitis. Small irritants such as caterpillar thorns and hairs easily can be observed and removed by dermoscopy devices with higher magnification.

The Diagnosis: Acute Contact Dermatitis

Dermoscopy demonstrated caterpillar hairs (Figure) and established the diagnosis of acute contact dermatitis due to a caterpillar. Upon further questioning, the patient recalled that something dustlike fell on the left cheek as she walked under some trees. The clinical and dermoscopic findings suggested a diagnosis of caterpillar dermatitis (family Limacodidae or Lymantriinae, order Lepidoptera). During the life cycle from young larvae to mature larvae, the quantities of the toxic thorns and hairs increase from 60,000 to 80,000 to 2,000,000 to 3,000,000. The toxic hairs measure 0.5 to 2.0 mm in length. They drop from the mature larvae's skin during desquamation as well as from the cocoon curing maturation to a moth. The hairs appear tubular and arrowlike with terminal spines.¹ The larvae are called "the fiery hot" in Chinese, which vividly describes the swelling and sensation of burning with immediate contact.

Eruption severity and distribution depend on exposure modality and intensity. Exposed body parts, including the face, neck, forearms, interdigital spaces, and dorsal aspects of the hands, most commonly are involved. The eruption can be immediate or delayed, occurring hours or even days after the first contact.2 Itching is intense and continuous, with intermittent worsening. Clinically, the eruption manifests with rose to bright red, round macules and papules. Although rare, skin manifestations can be accompanied by systemic symptoms, such as malaise, fever, and anaphylaxis syndrome.³ The cutaneous lesions may last for 3 to 4 days and subside, leaving a brownish macule.^1,4

The differential diagnosis includes acute herpes simplex, which presents as grouped vesicles on an erythematous base with itching or burning, and recurrences in the same location are common. Acute Sweet syndrome may appear as erythematous or edematous painful plaques with fever and neutrophilia. Acute urticaria appears as wheals with severe pruritus, and individual lesions can resolve within several hours. Insect bites often appear as itching or painful erythema or papules.

We sterilized the lesion with alcohol, removed the thorns as much as possible with ophthalmic forceps under the guidance of dermoscopy, and prescribed chloramphenicol ointment 1% twice daily. Our patient was completely cured within 24 hours with no systemic symptoms or pigmentation.

This case directly showed a novel usage of dermoscopy in diagnosis and therapy, especially in acute contact dermatitis. Small irritants such as caterpillar thorns and hairs easily can be observed and removed by dermoscopy devices with higher magnification.

The Diagnosis: Acute Contact Dermatitis

Dermoscopy demonstrated caterpillar hairs (Figure) and established the diagnosis of acute contact dermatitis due to a caterpillar. Upon further questioning, the patient recalled that something dustlike fell on the left cheek as she walked under some trees. The clinical and dermoscopic findings suggested a diagnosis of caterpillar dermatitis (family Limacodidae or Lymantriinae, order Lepidoptera). During the life cycle from young larvae to mature larvae, the quantities of the toxic thorns and hairs increase from 60,000 to 80,000 to 2,000,000 to 3,000,000. The toxic hairs measure 0.5 to 2.0 mm in length. They drop from the mature larvae's skin during desquamation as well as from the cocoon curing maturation to a moth. The hairs appear tubular and arrowlike with terminal spines.¹ The larvae are called "the fiery hot" in Chinese, which vividly describes the swelling and sensation of burning with immediate contact.

Eruption severity and distribution depend on exposure modality and intensity. Exposed body parts, including the face, neck, forearms, interdigital spaces, and dorsal aspects of the hands, most commonly are involved. The eruption can be immediate or delayed, occurring hours or even days after the first contact.2 Itching is intense and continuous, with intermittent worsening. Clinically, the eruption manifests with rose to bright red, round macules and papules. Although rare, skin manifestations can be accompanied by systemic symptoms, such as malaise, fever, and anaphylaxis syndrome.³ The cutaneous lesions may last for 3 to 4 days and subside, leaving a brownish macule.^1,4

The differential diagnosis includes acute herpes simplex, which presents as grouped vesicles on an erythematous base with itching or burning, and recurrences in the same location are common. Acute Sweet syndrome may appear as erythematous or edematous painful plaques with fever and neutrophilia. Acute urticaria appears as wheals with severe pruritus, and individual lesions can resolve within several hours. Insect bites often appear as itching or painful erythema or papules.

We sterilized the lesion with alcohol, removed the thorns as much as possible with ophthalmic forceps under the guidance of dermoscopy, and prescribed chloramphenicol ointment 1% twice daily. Our patient was completely cured within 24 hours with no systemic symptoms or pigmentation.

This case directly showed a novel usage of dermoscopy in diagnosis and therapy, especially in acute contact dermatitis. Small irritants such as caterpillar thorns and hairs easily can be observed and removed by dermoscopy devices with higher magnification.

The American Recovery and Reinvestment Act of 2009 introduced the Health Information Technology for Economic and Clinical Health (HITECH) Act and allocated $19.2 billion to promote the implementation of an electronic medical record (EMR) by hospitals as well as physicians in private practices.¹ The EMR stores longitudinal health information and constructs a comprehensive picture of a patient's medical history.^2,3 Following its debut, the US Department of Health & Human Services set forth meaningful use (MU) criteria,¹ which aimed to increase quality of care, safety, and efficiency. Meaningful use criteria also sought to decrease health disparities; improve coordination of care; engage patients in their care; refine population and public health measures; and finally ensure accessibility, privacy, and security of patient data.^1,2

The EMR offers potential gains at multiple levels of the patient-physician-public health hierarchy: a decrease in medical errors and duplicate services, timely access to test results and records, timely notification of patients in need for preventive services, and preservation of medical records in the event of an environmental disaster.^1-3 Furthermore, physicians can take advantage of informational reciprocity with other providers, gain remote access to medical records, be reminded of need for service, e-prescribe, monitor for drug interactions, and utilize clinical information for research purposes.^1,3 Lastly, public health organizations can use EMRs to improve outcomes by employing surveillance measures and creating patient registries that serve to protect the society at large.¹

Although it seems that the broad-scale implementation of EMRs will undoubtedly enhance the quality of patient care in the years to come, many obstacles must be overcome to reach this potential. Certification of EMR systems and implementation of confidentiality measures that are compatible with the Health Insurance Portability and Accountability Act are the forerunning concerns, and the interconnectivity of EMR systems becomes more important as MU enters its later stages (eg, increased electronic transmission of patient data during phases of care, reliance on e-prescribing, population-level analysis of patient data to improve health outcomes). Additionally, the cost to implement and maintain an EMR deters many physicians in smaller practices from shouldering the charges, as they do not necessarily see increased productivity with this technology.² Last but not least, unintended consequences of EMR implementation can involve the dangers of upcoding and overdocumentation.¹

Dermatology is a visually dominant field serving a high volume of patients that require both medical and surgical care. These factors do not preclude the implementation of EMRs in our specialty but rather necessitate the utilization of a system specifically designed to cater to the needs of specialists in dermatology. This editorial will address some fundamental considerations in implementing an EMR in dermatology; discuss what platforms and patient interfaces are most practical; reiterate the importance of interoperability; and highlight the implications of this powerful tool in education, research, training, and monitoring quality of care.

Implementation and Specific Considerations in Dermatology

One of the biggest areas of concern in adopting an EMR is the associated financial burden.^2-5 Although government incentives of MU cover a part of the initial cost of purchasing an EMR, expert maintenance costs, changes in workflow dynamics, and a steep learning curve can translate into lost productivity and revenue, discouraging many dermatologists from implementing an EMR.^3,5 Furthermore, physicians who are nearing the end of their careers may not realize the longer-term benefits of implementing an EMR and therefore may decline to do so despite the disincentives of lower Medicare reimbursements.² In fact, when juxtaposing the upfront cost of implementing an EMR against the expected increase in revenue after its implementation, there are general concerns that there will be a net loss on the part of the provider, which is a barrier to adoption of EMRs.³

Beyond the cost-benefit analysis, dermatologists often report multiple lesions in different anatomic sites or identify multiple biopsy sites that have been conveniently recorded on body templates included in their paper-based examination forms. Converting that information into words to be entered into an EMR can be excruciatingly time consuming and not easily comprehensible upon follow-up visits with the patient, which again results in decreased efficiency and productivity.⁴ Therefore, selecting a dermatology-compatible EMR that aims to make this transition easier is of utmost importance. One developer introduced an EMR with a touch interface containing a human body in all its facets that can be rotated, zoomed, and marked multiple times for accurate and convenient recording of lesions and intended procedure sites. This system automatically produces codes for examinations and procedures; facilitates e-prescription and ordering of laboratory results; prints pathology requests and consent forms; and includes information for patient education regarding their care. For example, the physical examination section of an H&P (history and physical examination) can be generated with a few taps on the screen, translating into increased efficiency and productivity.

The visual nature of dermatology demands the use of images, and as such, photographs have become integral in the diagnosis and follow-up of dermatology patients. Digital and dermatoscopic images not only help to eliminate unnecessary biopsies but also can promote early detection and management of malignancies.⁶ Thus, the capability to link photographs to a patient's medical record using an EMR is an invaluable gain. However, employing this feature in clinical practice has ethical implications that must be addressed, given that taking photographs can evoke an avoidable fear in patients regarding unlawful dissemination or unnecessary exposure of these images to physicians who do not need to access them.⁶ Thus, guidelines must be set for uploading, de-identifying, and annotating patient photographs, and only physicians involved in the care of the patient should be allocated access.^4,6

EMR Platforms

When computers were first introduced into examination rooms, many physicians were reluctant, as computers were thought to disconnect physicians from patients, arousing a sense of remoteness and further depersonalizing the encounter as physicians spent more time typing and less time making meaningful eye contact with patients.⁵ The practice of dermatology requires patient-centered communication that serves to enhance the quality of care while at the same time allowing physicians to fulfill professional competencies and reduce medical errors, which may ultimately translate into patient satisfaction.⁷ In fact, when the patient-physician relationship is interrupted, patients are more likely to pursue legal action in the wake of a bad treatment outcome.⁵

Employing a tablet-friendly EMR can help circumvent (or at least minimize) this problem by providing the physician with a light, user-friendly device that eliminates the need for laptops or desktop computers.⁴ Going one step further, the utilization of tablets eliminates the need for accessory digital cameras, as most tablets come with built-in high-resolution cameras for capturing clinical photographs and immediately linking them to the patient's medical record. Lastly, tablet technology allows physicians to access consent forms while in the examination room with the patient to more readily obtain a signature for procedural or research consent.^4,8

Interoperability, MU, and Quality of Care

The real goal in nationwide implementation of EMR technology is to accomplish MU criteria. Different EMRs should not only allow data to be imported and exported but ideally should be compatible and interoperable with one another.² The myriad of different EMR platforms available impedes maximal functionality as MU moves into its final stage. For example, if an academic dermatology program in the setting of a larger hospital is required to use the generic hospital EMR, the dermatologist's specific needs may not be effectively met; on the other hand, if a dermatology-specific EMR is implemented, access to the hospital's larger database of patient information may be sacrificed. Optimal EMR systems should be designed to allow specificity for a given specialty while being able to receive and integrate laboratory values, dermatopathology and radiology results, and notes from consultations by other physicians. Such integration may reduce duplicate services, increase patient satisfaction, and fulfill MU criteria. In fact, the fear of many physicians, especially those in a field such as dermatology, are the unwanted costs that come with implementation of an EMR system that will soon become impractical due to compatibility issues.² As a result, until a system that can meet the needs of multiple specialties is developed, dermatologists and other physicians upgrading to an EMR should consider implementing a system that is compatible with nearby hospitals, other specialists' offices, and diagnostic centers to maximize interoperability at the local level.^2,3

Electronic medical record systems that interoperate also provide the ability to set forth performance measures for physicians aimed at improving quality of care. As our health care system moves toward a pay-for-performance model, EMRs will become a tool to determine if standards of care have been met, unnecessary diagnostic tests have been avoided, and unwanted outcomes have been minimized. These measures will usher in a new era of medicine in which physicians strive to improve the care provided to their patients and receive increases in their reimbursements, while patient outcomes and satisfaction are improved.⁹

Academics, Education, Research, and Residency

The practicality of EMRs in dermatology may best be appreciated in academic settings. Electronic medical records serve as a repository of coded information that is neatly organized and can be rapidly searched, allowing for use as a powerful research tool. As an example, physicians can use EMR systems to identify patients with specific qualifications and study outcome variables over time.^2,3 Additionally, with the rise of interoperable systems, we can expect a new dawn in medical research as more information becomes available to clinical investigators, opening doors to endless possibilities for evidence-based care.^2,3,8

Another advantage of EMRs is their utility in residency programs that are charged with the task of ensuring resident competency via exposure to a comprehensive host of clinical encounters. An EMR system uniquely allows residents and attending dermatologists to monitor adequate exposure to general, pediatric, complex medical, procedural, and dermatopathologic cases, and to track the number of procedures performed by the residents by directly linking the information into the Accreditation Council for Graduate Medical Education procedure log.

Furthermore, due to the dominance of digital and dermatoscopic images in the field, interoperable EMRs could be used to construct a database of clinical and dermatopathologic specimens that not only can be used in educating residents but also may serve as a powerful reference tool in the diagnosis of complex and rare cases.8 Another often unrecognized advantage of EMRs is their utility in teledermatology. With the interoperable EMRs within academic institutions, teledermatology can be used locally and nationally for rapid consultation with high diagnostic validity,¹⁰ which has the burgeoning potential of providing patients with quicker time to diagnosis considering the dermatologist shortage in various parts of the country.

Lastly, the implementation of EMRs in residency programs has the additional benefit of exposing residents and medical students to emerging technology early on in their careers and fosters a degree of familiarity and comfort that may lead to implementation of EMRs in their future practices.² For dermatologists in-training, early exposure to these technologies also may serve as a way to develop an interactive interview style and adapt to the presence of EMRs in examination rooms without sacrificing quality of care and meaningful patient interaction.⁷

Conclusion

Electronic medical records are already becoming an integral part of many hospitals and private dermatology practices. Although EMRs provide potential benefits that can be expected to ultimately outweigh the associated costs in larger settings such as hospitals, residency programs, and multidisciplinary practices, EMRs may not be immediately beneficial to physicians in private practices or those approaching the end of their careers. Although a perfect system may be unattainable, development of interoperable systems designed to meet the needs of specialties such as dermatology are essential in attaining a comprehensive patient medical profile, improving quality of care, minimizing costs, reducing medical errors, and maximizing patient satisfaction.

The American Recovery and Reinvestment Act of 2009 introduced the Health Information Technology for Economic and Clinical Health (HITECH) Act and allocated $19.2 billion to promote the implementation of an electronic medical record (EMR) by hospitals as well as physicians in private practices.¹ The EMR stores longitudinal health information and constructs a comprehensive picture of a patient's medical history.^2,3 Following its debut, the US Department of Health & Human Services set forth meaningful use (MU) criteria,¹ which aimed to increase quality of care, safety, and efficiency. Meaningful use criteria also sought to decrease health disparities; improve coordination of care; engage patients in their care; refine population and public health measures; and finally ensure accessibility, privacy, and security of patient data.^1,2

The EMR offers potential gains at multiple levels of the patient-physician-public health hierarchy: a decrease in medical errors and duplicate services, timely access to test results and records, timely notification of patients in need for preventive services, and preservation of medical records in the event of an environmental disaster.^1-3 Furthermore, physicians can take advantage of informational reciprocity with other providers, gain remote access to medical records, be reminded of need for service, e-prescribe, monitor for drug interactions, and utilize clinical information for research purposes.^1,3 Lastly, public health organizations can use EMRs to improve outcomes by employing surveillance measures and creating patient registries that serve to protect the society at large.¹

Although it seems that the broad-scale implementation of EMRs will undoubtedly enhance the quality of patient care in the years to come, many obstacles must be overcome to reach this potential. Certification of EMR systems and implementation of confidentiality measures that are compatible with the Health Insurance Portability and Accountability Act are the forerunning concerns, and the interconnectivity of EMR systems becomes more important as MU enters its later stages (eg, increased electronic transmission of patient data during phases of care, reliance on e-prescribing, population-level analysis of patient data to improve health outcomes). Additionally, the cost to implement and maintain an EMR deters many physicians in smaller practices from shouldering the charges, as they do not necessarily see increased productivity with this technology.² Last but not least, unintended consequences of EMR implementation can involve the dangers of upcoding and overdocumentation.¹

Dermatology is a visually dominant field serving a high volume of patients that require both medical and surgical care. These factors do not preclude the implementation of EMRs in our specialty but rather necessitate the utilization of a system specifically designed to cater to the needs of specialists in dermatology. This editorial will address some fundamental considerations in implementing an EMR in dermatology; discuss what platforms and patient interfaces are most practical; reiterate the importance of interoperability; and highlight the implications of this powerful tool in education, research, training, and monitoring quality of care.

Implementation and Specific Considerations in Dermatology

One of the biggest areas of concern in adopting an EMR is the associated financial burden.^2-5 Although government incentives of MU cover a part of the initial cost of purchasing an EMR, expert maintenance costs, changes in workflow dynamics, and a steep learning curve can translate into lost productivity and revenue, discouraging many dermatologists from implementing an EMR.^3,5 Furthermore, physicians who are nearing the end of their careers may not realize the longer-term benefits of implementing an EMR and therefore may decline to do so despite the disincentives of lower Medicare reimbursements.² In fact, when juxtaposing the upfront cost of implementing an EMR against the expected increase in revenue after its implementation, there are general concerns that there will be a net loss on the part of the provider, which is a barrier to adoption of EMRs.³

Beyond the cost-benefit analysis, dermatologists often report multiple lesions in different anatomic sites or identify multiple biopsy sites that have been conveniently recorded on body templates included in their paper-based examination forms. Converting that information into words to be entered into an EMR can be excruciatingly time consuming and not easily comprehensible upon follow-up visits with the patient, which again results in decreased efficiency and productivity.⁴ Therefore, selecting a dermatology-compatible EMR that aims to make this transition easier is of utmost importance. One developer introduced an EMR with a touch interface containing a human body in all its facets that can be rotated, zoomed, and marked multiple times for accurate and convenient recording of lesions and intended procedure sites. This system automatically produces codes for examinations and procedures; facilitates e-prescription and ordering of laboratory results; prints pathology requests and consent forms; and includes information for patient education regarding their care. For example, the physical examination section of an H&P (history and physical examination) can be generated with a few taps on the screen, translating into increased efficiency and productivity.

The visual nature of dermatology demands the use of images, and as such, photographs have become integral in the diagnosis and follow-up of dermatology patients. Digital and dermatoscopic images not only help to eliminate unnecessary biopsies but also can promote early detection and management of malignancies.⁶ Thus, the capability to link photographs to a patient's medical record using an EMR is an invaluable gain. However, employing this feature in clinical practice has ethical implications that must be addressed, given that taking photographs can evoke an avoidable fear in patients regarding unlawful dissemination or unnecessary exposure of these images to physicians who do not need to access them.⁶ Thus, guidelines must be set for uploading, de-identifying, and annotating patient photographs, and only physicians involved in the care of the patient should be allocated access.^4,6

EMR Platforms

When computers were first introduced into examination rooms, many physicians were reluctant, as computers were thought to disconnect physicians from patients, arousing a sense of remoteness and further depersonalizing the encounter as physicians spent more time typing and less time making meaningful eye contact with patients.⁵ The practice of dermatology requires patient-centered communication that serves to enhance the quality of care while at the same time allowing physicians to fulfill professional competencies and reduce medical errors, which may ultimately translate into patient satisfaction.⁷ In fact, when the patient-physician relationship is interrupted, patients are more likely to pursue legal action in the wake of a bad treatment outcome.⁵

Employing a tablet-friendly EMR can help circumvent (or at least minimize) this problem by providing the physician with a light, user-friendly device that eliminates the need for laptops or desktop computers.⁴ Going one step further, the utilization of tablets eliminates the need for accessory digital cameras, as most tablets come with built-in high-resolution cameras for capturing clinical photographs and immediately linking them to the patient's medical record. Lastly, tablet technology allows physicians to access consent forms while in the examination room with the patient to more readily obtain a signature for procedural or research consent.^4,8

Interoperability, MU, and Quality of Care

The real goal in nationwide implementation of EMR technology is to accomplish MU criteria. Different EMRs should not only allow data to be imported and exported but ideally should be compatible and interoperable with one another.² The myriad of different EMR platforms available impedes maximal functionality as MU moves into its final stage. For example, if an academic dermatology program in the setting of a larger hospital is required to use the generic hospital EMR, the dermatologist's specific needs may not be effectively met; on the other hand, if a dermatology-specific EMR is implemented, access to the hospital's larger database of patient information may be sacrificed. Optimal EMR systems should be designed to allow specificity for a given specialty while being able to receive and integrate laboratory values, dermatopathology and radiology results, and notes from consultations by other physicians. Such integration may reduce duplicate services, increase patient satisfaction, and fulfill MU criteria. In fact, the fear of many physicians, especially those in a field such as dermatology, are the unwanted costs that come with implementation of an EMR system that will soon become impractical due to compatibility issues.² As a result, until a system that can meet the needs of multiple specialties is developed, dermatologists and other physicians upgrading to an EMR should consider implementing a system that is compatible with nearby hospitals, other specialists' offices, and diagnostic centers to maximize interoperability at the local level.^2,3

Electronic medical record systems that interoperate also provide the ability to set forth performance measures for physicians aimed at improving quality of care. As our health care system moves toward a pay-for-performance model, EMRs will become a tool to determine if standards of care have been met, unnecessary diagnostic tests have been avoided, and unwanted outcomes have been minimized. These measures will usher in a new era of medicine in which physicians strive to improve the care provided to their patients and receive increases in their reimbursements, while patient outcomes and satisfaction are improved.⁹

Academics, Education, Research, and Residency

The practicality of EMRs in dermatology may best be appreciated in academic settings. Electronic medical records serve as a repository of coded information that is neatly organized and can be rapidly searched, allowing for use as a powerful research tool. As an example, physicians can use EMR systems to identify patients with specific qualifications and study outcome variables over time.^2,3 Additionally, with the rise of interoperable systems, we can expect a new dawn in medical research as more information becomes available to clinical investigators, opening doors to endless possibilities for evidence-based care.^2,3,8

Another advantage of EMRs is their utility in residency programs that are charged with the task of ensuring resident competency via exposure to a comprehensive host of clinical encounters. An EMR system uniquely allows residents and attending dermatologists to monitor adequate exposure to general, pediatric, complex medical, procedural, and dermatopathologic cases, and to track the number of procedures performed by the residents by directly linking the information into the Accreditation Council for Graduate Medical Education procedure log.

Furthermore, due to the dominance of digital and dermatoscopic images in the field, interoperable EMRs could be used to construct a database of clinical and dermatopathologic specimens that not only can be used in educating residents but also may serve as a powerful reference tool in the diagnosis of complex and rare cases.8 Another often unrecognized advantage of EMRs is their utility in teledermatology. With the interoperable EMRs within academic institutions, teledermatology can be used locally and nationally for rapid consultation with high diagnostic validity,¹⁰ which has the burgeoning potential of providing patients with quicker time to diagnosis considering the dermatologist shortage in various parts of the country.

Lastly, the implementation of EMRs in residency programs has the additional benefit of exposing residents and medical students to emerging technology early on in their careers and fosters a degree of familiarity and comfort that may lead to implementation of EMRs in their future practices.² For dermatologists in-training, early exposure to these technologies also may serve as a way to develop an interactive interview style and adapt to the presence of EMRs in examination rooms without sacrificing quality of care and meaningful patient interaction.⁷

Conclusion

Electronic medical records are already becoming an integral part of many hospitals and private dermatology practices. Although EMRs provide potential benefits that can be expected to ultimately outweigh the associated costs in larger settings such as hospitals, residency programs, and multidisciplinary practices, EMRs may not be immediately beneficial to physicians in private practices or those approaching the end of their careers. Although a perfect system may be unattainable, development of interoperable systems designed to meet the needs of specialties such as dermatology are essential in attaining a comprehensive patient medical profile, improving quality of care, minimizing costs, reducing medical errors, and maximizing patient satisfaction.

The American Recovery and Reinvestment Act of 2009 introduced the Health Information Technology for Economic and Clinical Health (HITECH) Act and allocated $19.2 billion to promote the implementation of an electronic medical record (EMR) by hospitals as well as physicians in private practices.¹ The EMR stores longitudinal health information and constructs a comprehensive picture of a patient's medical history.^2,3 Following its debut, the US Department of Health & Human Services set forth meaningful use (MU) criteria,¹ which aimed to increase quality of care, safety, and efficiency. Meaningful use criteria also sought to decrease health disparities; improve coordination of care; engage patients in their care; refine population and public health measures; and finally ensure accessibility, privacy, and security of patient data.^1,2

The EMR offers potential gains at multiple levels of the patient-physician-public health hierarchy: a decrease in medical errors and duplicate services, timely access to test results and records, timely notification of patients in need for preventive services, and preservation of medical records in the event of an environmental disaster.^1-3 Furthermore, physicians can take advantage of informational reciprocity with other providers, gain remote access to medical records, be reminded of need for service, e-prescribe, monitor for drug interactions, and utilize clinical information for research purposes.^1,3 Lastly, public health organizations can use EMRs to improve outcomes by employing surveillance measures and creating patient registries that serve to protect the society at large.¹

Although it seems that the broad-scale implementation of EMRs will undoubtedly enhance the quality of patient care in the years to come, many obstacles must be overcome to reach this potential. Certification of EMR systems and implementation of confidentiality measures that are compatible with the Health Insurance Portability and Accountability Act are the forerunning concerns, and the interconnectivity of EMR systems becomes more important as MU enters its later stages (eg, increased electronic transmission of patient data during phases of care, reliance on e-prescribing, population-level analysis of patient data to improve health outcomes). Additionally, the cost to implement and maintain an EMR deters many physicians in smaller practices from shouldering the charges, as they do not necessarily see increased productivity with this technology.² Last but not least, unintended consequences of EMR implementation can involve the dangers of upcoding and overdocumentation.¹

Dermatology is a visually dominant field serving a high volume of patients that require both medical and surgical care. These factors do not preclude the implementation of EMRs in our specialty but rather necessitate the utilization of a system specifically designed to cater to the needs of specialists in dermatology. This editorial will address some fundamental considerations in implementing an EMR in dermatology; discuss what platforms and patient interfaces are most practical; reiterate the importance of interoperability; and highlight the implications of this powerful tool in education, research, training, and monitoring quality of care.

Implementation and Specific Considerations in Dermatology

One of the biggest areas of concern in adopting an EMR is the associated financial burden.^2-5 Although government incentives of MU cover a part of the initial cost of purchasing an EMR, expert maintenance costs, changes in workflow dynamics, and a steep learning curve can translate into lost productivity and revenue, discouraging many dermatologists from implementing an EMR.^3,5 Furthermore, physicians who are nearing the end of their careers may not realize the longer-term benefits of implementing an EMR and therefore may decline to do so despite the disincentives of lower Medicare reimbursements.² In fact, when juxtaposing the upfront cost of implementing an EMR against the expected increase in revenue after its implementation, there are general concerns that there will be a net loss on the part of the provider, which is a barrier to adoption of EMRs.³

Beyond the cost-benefit analysis, dermatologists often report multiple lesions in different anatomic sites or identify multiple biopsy sites that have been conveniently recorded on body templates included in their paper-based examination forms. Converting that information into words to be entered into an EMR can be excruciatingly time consuming and not easily comprehensible upon follow-up visits with the patient, which again results in decreased efficiency and productivity.⁴ Therefore, selecting a dermatology-compatible EMR that aims to make this transition easier is of utmost importance. One developer introduced an EMR with a touch interface containing a human body in all its facets that can be rotated, zoomed, and marked multiple times for accurate and convenient recording of lesions and intended procedure sites. This system automatically produces codes for examinations and procedures; facilitates e-prescription and ordering of laboratory results; prints pathology requests and consent forms; and includes information for patient education regarding their care. For example, the physical examination section of an H&P (history and physical examination) can be generated with a few taps on the screen, translating into increased efficiency and productivity.

The visual nature of dermatology demands the use of images, and as such, photographs have become integral in the diagnosis and follow-up of dermatology patients. Digital and dermatoscopic images not only help to eliminate unnecessary biopsies but also can promote early detection and management of malignancies.⁶ Thus, the capability to link photographs to a patient's medical record using an EMR is an invaluable gain. However, employing this feature in clinical practice has ethical implications that must be addressed, given that taking photographs can evoke an avoidable fear in patients regarding unlawful dissemination or unnecessary exposure of these images to physicians who do not need to access them.⁶ Thus, guidelines must be set for uploading, de-identifying, and annotating patient photographs, and only physicians involved in the care of the patient should be allocated access.^4,6

EMR Platforms

When computers were first introduced into examination rooms, many physicians were reluctant, as computers were thought to disconnect physicians from patients, arousing a sense of remoteness and further depersonalizing the encounter as physicians spent more time typing and less time making meaningful eye contact with patients.⁵ The practice of dermatology requires patient-centered communication that serves to enhance the quality of care while at the same time allowing physicians to fulfill professional competencies and reduce medical errors, which may ultimately translate into patient satisfaction.⁷ In fact, when the patient-physician relationship is interrupted, patients are more likely to pursue legal action in the wake of a bad treatment outcome.⁵

Employing a tablet-friendly EMR can help circumvent (or at least minimize) this problem by providing the physician with a light, user-friendly device that eliminates the need for laptops or desktop computers.⁴ Going one step further, the utilization of tablets eliminates the need for accessory digital cameras, as most tablets come with built-in high-resolution cameras for capturing clinical photographs and immediately linking them to the patient's medical record. Lastly, tablet technology allows physicians to access consent forms while in the examination room with the patient to more readily obtain a signature for procedural or research consent.^4,8

Interoperability, MU, and Quality of Care

The real goal in nationwide implementation of EMR technology is to accomplish MU criteria. Different EMRs should not only allow data to be imported and exported but ideally should be compatible and interoperable with one another.² The myriad of different EMR platforms available impedes maximal functionality as MU moves into its final stage. For example, if an academic dermatology program in the setting of a larger hospital is required to use the generic hospital EMR, the dermatologist's specific needs may not be effectively met; on the other hand, if a dermatology-specific EMR is implemented, access to the hospital's larger database of patient information may be sacrificed. Optimal EMR systems should be designed to allow specificity for a given specialty while being able to receive and integrate laboratory values, dermatopathology and radiology results, and notes from consultations by other physicians. Such integration may reduce duplicate services, increase patient satisfaction, and fulfill MU criteria. In fact, the fear of many physicians, especially those in a field such as dermatology, are the unwanted costs that come with implementation of an EMR system that will soon become impractical due to compatibility issues.² As a result, until a system that can meet the needs of multiple specialties is developed, dermatologists and other physicians upgrading to an EMR should consider implementing a system that is compatible with nearby hospitals, other specialists' offices, and diagnostic centers to maximize interoperability at the local level.^2,3

Electronic medical record systems that interoperate also provide the ability to set forth performance measures for physicians aimed at improving quality of care. As our health care system moves toward a pay-for-performance model, EMRs will become a tool to determine if standards of care have been met, unnecessary diagnostic tests have been avoided, and unwanted outcomes have been minimized. These measures will usher in a new era of medicine in which physicians strive to improve the care provided to their patients and receive increases in their reimbursements, while patient outcomes and satisfaction are improved.⁹

Academics, Education, Research, and Residency

The practicality of EMRs in dermatology may best be appreciated in academic settings. Electronic medical records serve as a repository of coded information that is neatly organized and can be rapidly searched, allowing for use as a powerful research tool. As an example, physicians can use EMR systems to identify patients with specific qualifications and study outcome variables over time.^2,3 Additionally, with the rise of interoperable systems, we can expect a new dawn in medical research as more information becomes available to clinical investigators, opening doors to endless possibilities for evidence-based care.^2,3,8

Another advantage of EMRs is their utility in residency programs that are charged with the task of ensuring resident competency via exposure to a comprehensive host of clinical encounters. An EMR system uniquely allows residents and attending dermatologists to monitor adequate exposure to general, pediatric, complex medical, procedural, and dermatopathologic cases, and to track the number of procedures performed by the residents by directly linking the information into the Accreditation Council for Graduate Medical Education procedure log.

Furthermore, due to the dominance of digital and dermatoscopic images in the field, interoperable EMRs could be used to construct a database of clinical and dermatopathologic specimens that not only can be used in educating residents but also may serve as a powerful reference tool in the diagnosis of complex and rare cases.8 Another often unrecognized advantage of EMRs is their utility in teledermatology. With the interoperable EMRs within academic institutions, teledermatology can be used locally and nationally for rapid consultation with high diagnostic validity,¹⁰ which has the burgeoning potential of providing patients with quicker time to diagnosis considering the dermatologist shortage in various parts of the country.

Lastly, the implementation of EMRs in residency programs has the additional benefit of exposing residents and medical students to emerging technology early on in their careers and fosters a degree of familiarity and comfort that may lead to implementation of EMRs in their future practices.² For dermatologists in-training, early exposure to these technologies also may serve as a way to develop an interactive interview style and adapt to the presence of EMRs in examination rooms without sacrificing quality of care and meaningful patient interaction.⁷

Conclusion

Electronic medical records are already becoming an integral part of many hospitals and private dermatology practices. Although EMRs provide potential benefits that can be expected to ultimately outweigh the associated costs in larger settings such as hospitals, residency programs, and multidisciplinary practices, EMRs may not be immediately beneficial to physicians in private practices or those approaching the end of their careers. Although a perfect system may be unattainable, development of interoperable systems designed to meet the needs of specialties such as dermatology are essential in attaining a comprehensive patient medical profile, improving quality of care, minimizing costs, reducing medical errors, and maximizing patient satisfaction.

I recently picked up my daughter from summer camp, and on the 5-hour drive home she kept texting people back and forth. I asked her if they were other campers or counselors she’d befriended.

cyano66/Thinkstock

She said yes, they were other campers she’d met, but was horrified that I thought some might be counselors. Counselors, understandably, aren’t allowed to have any contact with kids outside of camp. Not by text, Instagram, Facebook, or any other modern social contrivances.

That probably should have occurred to me before I even asked. It makes sense.

I keep a similar policy with patients.

Nothing against them: The majority are decent people, and there are a few I could easily see being social friends with – meeting for dinner, going to a basketball game ... but I won’t.

Like the kids and counselors at camp, I need to keep a distance between myself and patients. I don’t have any social media accounts, anyway, but I keep the relationship confined to my office.

Keeping an emotional distance with patients makes it easier to do this job. While we may genuinely care about them and are trying to help, it’s important to be objective. Seeing them through the lens of friendship might affect the decision-making process.

The divider of professionalism is there for a good reason, across many fields. It allows us to try and think clearly, to give good and bad news, and make diagnostic and treatment decisions as rationally as possible, based on scientific evidence and each individual’s circumstances.

It’s what makes good medicine possible. I wouldn’t want it to be any other way.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I recently picked up my daughter from summer camp, and on the 5-hour drive home she kept texting people back and forth. I asked her if they were other campers or counselors she’d befriended.

cyano66/Thinkstock

She said yes, they were other campers she’d met, but was horrified that I thought some might be counselors. Counselors, understandably, aren’t allowed to have any contact with kids outside of camp. Not by text, Instagram, Facebook, or any other modern social contrivances.

That probably should have occurred to me before I even asked. It makes sense.

I keep a similar policy with patients.

Nothing against them: The majority are decent people, and there are a few I could easily see being social friends with – meeting for dinner, going to a basketball game ... but I won’t.

Like the kids and counselors at camp, I need to keep a distance between myself and patients. I don’t have any social media accounts, anyway, but I keep the relationship confined to my office.

Keeping an emotional distance with patients makes it easier to do this job. While we may genuinely care about them and are trying to help, it’s important to be objective. Seeing them through the lens of friendship might affect the decision-making process.

The divider of professionalism is there for a good reason, across many fields. It allows us to try and think clearly, to give good and bad news, and make diagnostic and treatment decisions as rationally as possible, based on scientific evidence and each individual’s circumstances.

It’s what makes good medicine possible. I wouldn’t want it to be any other way.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I recently picked up my daughter from summer camp, and on the 5-hour drive home she kept texting people back and forth. I asked her if they were other campers or counselors she’d befriended.

cyano66/Thinkstock

She said yes, they were other campers she’d met, but was horrified that I thought some might be counselors. Counselors, understandably, aren’t allowed to have any contact with kids outside of camp. Not by text, Instagram, Facebook, or any other modern social contrivances.

That probably should have occurred to me before I even asked. It makes sense.

I keep a similar policy with patients.

Nothing against them: The majority are decent people, and there are a few I could easily see being social friends with – meeting for dinner, going to a basketball game ... but I won’t.

Like the kids and counselors at camp, I need to keep a distance between myself and patients. I don’t have any social media accounts, anyway, but I keep the relationship confined to my office.

Keeping an emotional distance with patients makes it easier to do this job. While we may genuinely care about them and are trying to help, it’s important to be objective. Seeing them through the lens of friendship might affect the decision-making process.

The divider of professionalism is there for a good reason, across many fields. It allows us to try and think clearly, to give good and bad news, and make diagnostic and treatment decisions as rationally as possible, based on scientific evidence and each individual’s circumstances.

It’s what makes good medicine possible. I wouldn’t want it to be any other way.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In medical school, they taught us to learn the patient’s chief complaint.

Steve Debenport/Getty Images

In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.

Sandra

“How are your parents?”

“Getting older. I’m over their house every day. It’s always something.

“My husband had a stroke this year. Our daughter – she’s a nurse – made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’

“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”

Sandra’s moles are normal. Who is taking care of her?

Grigoriy

“I’ve had a hard life,” says Grigoriy, apropos of nothing.

“How?”

“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. “They kept me in a cell of one room for 15 years.”

“Why did they put you in jail?”

“I was my father’s son.”

Phil

Phil is in for his annual. He looks robust, but thinner.

“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found that I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterward, I’d feel awful. They were right.

“I lost 20 pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.

Fred

Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.

“It may be viral,” I say.

“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”

“I’m not sure …”

“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”

I tell Fred to wash carefully. Some things can’t be rescheduled.

Emily

Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.

Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.

Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.

Brenda

Brenda comes for 6-month skin checks. Usually with her husband Glen, but not today.

“Glen’s not so well,” Brenda says. The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.

“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”

Tom

“It’s been a tough year. Eddie died. You saw him years ago, I think.”

I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.

“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’

“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.

“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”

Frank

Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.

“I guess it’s stress,” Frank says.

“How about avoiding stress?” I ask, with a smile.

Frank breaks down and weeps.

“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot 4 years ago. Then it grew. It’s already stage four. Our kids are teenagers.”

Frank breaks down again. He apologizes again. “I’m so sorry for being like this.” Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”

I am sorry, too. Very sorry, indeed. Like all doctors, I want to help. Sometimes I can help the skin, temper the presenting complaint. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.


 

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

In medical school, they taught us to learn the patient’s chief complaint.

Steve Debenport/Getty Images

In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.

Sandra

“How are your parents?”

“Getting older. I’m over their house every day. It’s always something.

“My husband had a stroke this year. Our daughter – she’s a nurse – made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’

“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”

Sandra’s moles are normal. Who is taking care of her?

Grigoriy

“I’ve had a hard life,” says Grigoriy, apropos of nothing.

“How?”

“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. “They kept me in a cell of one room for 15 years.”

“Why did they put you in jail?”

“I was my father’s son.”

Phil

Phil is in for his annual. He looks robust, but thinner.

“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found that I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterward, I’d feel awful. They were right.

“I lost 20 pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.

Fred

Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.

“It may be viral,” I say.

“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”

“I’m not sure …”

“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”

I tell Fred to wash carefully. Some things can’t be rescheduled.

Emily

Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.

Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.

Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.

Brenda

Brenda comes for 6-month skin checks. Usually with her husband Glen, but not today.

“Glen’s not so well,” Brenda says. The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.

“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”

Tom

“It’s been a tough year. Eddie died. You saw him years ago, I think.”

I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.

“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’

“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.

“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”

Frank

Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.

“I guess it’s stress,” Frank says.

“How about avoiding stress?” I ask, with a smile.

Frank breaks down and weeps.

“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot 4 years ago. Then it grew. It’s already stage four. Our kids are teenagers.”

Frank breaks down again. He apologizes again. “I’m so sorry for being like this.” Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”

I am sorry, too. Very sorry, indeed. Like all doctors, I want to help. Sometimes I can help the skin, temper the presenting complaint. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.


 

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

In medical school, they taught us to learn the patient’s chief complaint.

Steve Debenport/Getty Images

In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.

Sandra

“How are your parents?”

“Getting older. I’m over their house every day. It’s always something.

“My husband had a stroke this year. Our daughter – she’s a nurse – made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’

“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”

Sandra’s moles are normal. Who is taking care of her?

Grigoriy

“I’ve had a hard life,” says Grigoriy, apropos of nothing.

“How?”

“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. “They kept me in a cell of one room for 15 years.”

“Why did they put you in jail?”

“I was my father’s son.”

Phil

Phil is in for his annual. He looks robust, but thinner.

“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found that I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterward, I’d feel awful. They were right.

“I lost 20 pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.

Fred

Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.

“It may be viral,” I say.

“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”

“I’m not sure …”

“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”

I tell Fred to wash carefully. Some things can’t be rescheduled.

Emily

Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.

Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.

Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.

Brenda

Brenda comes for 6-month skin checks. Usually with her husband Glen, but not today.

“Glen’s not so well,” Brenda says. The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.

“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”

Tom

“It’s been a tough year. Eddie died. You saw him years ago, I think.”

I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.

“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’

“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.

“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”

Frank

Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.

“I guess it’s stress,” Frank says.

“How about avoiding stress?” I ask, with a smile.

Frank breaks down and weeps.

“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot 4 years ago. Then it grew. It’s already stage four. Our kids are teenagers.”

Frank breaks down again. He apologizes again. “I’m so sorry for being like this.” Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”

I am sorry, too. Very sorry, indeed. Like all doctors, I want to help. Sometimes I can help the skin, temper the presenting complaint. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.


 

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Every cancer diagnosis starts out as anything but. That’s what I was thinking when I met Sue Marcus (not her real name) in the emergency department one Friday afternoon.

“You know,” she said in a matter of fact manner. “I think I might have the flu.”

“Yes,” I said. “You might.”

“I was in Vegas a week ago, and the person next to me was sick.”

“It’s definitely possible. That’s one of the things we’ll test for.”

“I mean ... what else can it be?”

I had information Sue didn’t yet. All her blood counts were disturbingly low. On top of that, the lab had picked up several atypical appearing cells. They could be reactive, in the setting of infection, or they could be blasts – a new diagnosis of leukemia.

I paused.

“I’m going to say this now, so you know what we are looking for. There’s a lot more information we still need.”

“But?”

“But, another possibility is that it is cancer.”

“Cancer?”

“Leukemia, maybe.”

I explained the next steps. We would have flow cytometry by that night, but it’s not a perfect test. We were limited, actually, by logistics. It was a Friday night. We would do a bone marrow biopsy on Monday. It would be several days before we’d know with certainty.

That evening, the hematology fellow and I looked at the slide under the microscope. We agreed with the lab.

“That’s a blast, isn’t it?”

“Yes, I think it is.”

But they were not completely classic, and they were sporadic. It wasn’t enough to say for sure. Meanwhile, Sue, understandably, wanted answers.

“What did you see? Is it cancer, or not?”

There was flow cytometry that night, showing an abnormal population of cells. And then, finally, there was a bone marrow biopsy clinching the diagnosis.

We explained what the path ahead looked like: Hospitalization for a month. Chemotherapy, then a repeat bone marrow biopsy to look for response. Then more chemotherapy. Chances of remission. Long-term implications.

As we gathered more information, Sue’s questions evolved.

“Is it curable?”

“Can I go back to work?”

And one day, a week into treatment, she asked, “Am I going to die?”

Over my last 3 years as an internal medicine resident, I’ve been humbled by how often patients turned to me for answers to some of the most difficult questions I could imagine. Sometimes, the questions seemed purely factual, but often, they took a more existential bent: How should I spend my last months? What should I do now? Patients have asked me if they are going to die, along with when, how, and even why.

I’ve wrestled with how to communicate candidly, treading a delicate balance between being as up-front as possible while also recognizing the uncertainty inherent in predicting. I’ve struggled with walking the tightrope of delivering bad news while also emphasizing compassion and support.

I chose hematology and oncology in part because of the gravity of these interactions. I enjoy being a primary doctor for a complex, sick, patient population who are grappling with physically and emotionally challenging illness. I value longitudinal relationships with patients I know well. I found the medicine of hematology and oncology interdisciplinary, the details high stakes, and the big questions always at play. If it was meaningful work I sought, cancer became the ultimate question that mattered.

The changing landscape of cancer care is making these conversations substantially more difficult. A central tenet of medicine is truthfulness: setting the stage for what is going on and what to anticipate. It’s explaining the nuances of the upcoming treatment options, while also addressing what a person’s life may look like down the road. It’s understanding what matters most to a patient, understanding what therapeutic choices we can offer – and then trying to reconcile them, as best as we can.

This has always been hard. But it’s getting harder. The options we have to treat cancer are expanding rapidly as immunotherapy competes with the basics of chemotherapy, radiation, and surgery. We work alongside researchers looking to change the paradigm, collecting information on outcomes and side effects as we go along. We are learning and we are applying what we learn – in real time – on real people willing to try.

How can we speak honestly about a prognosis when our data are limited and our tools are in continuous flux? How can we prepare someone for what lies ahead when we are still trying to grasp what today looks like?

All the while, medical uncertainties are amplified by a complex system with many moving parts. It’s a system in which some patients cannot afford care, in which insurance companies may deny necessary treatment, and where families may come together or fall apart in the face of incredible adversity. There are factors outside the scope of pure medicine that make the path ahead all the hazier and navigating it all the more challenging.

In July, I began my hematology and oncology fellowship. I am caring for patients with a range of cancers, and all of that goes along with the weight of those diagnoses. Learning the most up-to-date management in a constantly evolving landscape will be an ongoing skill. That my patients allow me into their most vulnerable moments – and trust me with them – is a gift.

For patients like Sue, there sometimes remain more questions than answers. She recently underwent her third round of chemotherapy and endured multiple blood clots. With her insurance covering only limited interventions, she is deciding what to focus on and where to receive her care. Her story, like many others, continues to be written.

I am deeply aware of the difficulties that are a part of the world of cancer – and the heartbreak. How can we hold up scans triumphantly showing no recurrence in some patients while others suffer one failed treatment after another? When should we push for more therapy and when should we shift our efforts toward comfort? What should we prioritize – medically and personally – if time is limited?

These questions are hard, but I cannot think of any that are more meaningful.

This is a column about patients and uncertainty as I pursue my hematology and oncology fellowship and grapple with these questions. I look forward to sharing them with you each month.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Every cancer diagnosis starts out as anything but. That’s what I was thinking when I met Sue Marcus (not her real name) in the emergency department one Friday afternoon.

“You know,” she said in a matter of fact manner. “I think I might have the flu.”

“Yes,” I said. “You might.”

“I was in Vegas a week ago, and the person next to me was sick.”

“It’s definitely possible. That’s one of the things we’ll test for.”

“I mean ... what else can it be?”

I had information Sue didn’t yet. All her blood counts were disturbingly low. On top of that, the lab had picked up several atypical appearing cells. They could be reactive, in the setting of infection, or they could be blasts – a new diagnosis of leukemia.

I paused.

“I’m going to say this now, so you know what we are looking for. There’s a lot more information we still need.”

“But?”

“But, another possibility is that it is cancer.”

“Cancer?”

“Leukemia, maybe.”

I explained the next steps. We would have flow cytometry by that night, but it’s not a perfect test. We were limited, actually, by logistics. It was a Friday night. We would do a bone marrow biopsy on Monday. It would be several days before we’d know with certainty.

That evening, the hematology fellow and I looked at the slide under the microscope. We agreed with the lab.

“That’s a blast, isn’t it?”

“Yes, I think it is.”

But they were not completely classic, and they were sporadic. It wasn’t enough to say for sure. Meanwhile, Sue, understandably, wanted answers.

“What did you see? Is it cancer, or not?”

There was flow cytometry that night, showing an abnormal population of cells. And then, finally, there was a bone marrow biopsy clinching the diagnosis.

We explained what the path ahead looked like: Hospitalization for a month. Chemotherapy, then a repeat bone marrow biopsy to look for response. Then more chemotherapy. Chances of remission. Long-term implications.

As we gathered more information, Sue’s questions evolved.

“Is it curable?”

“Can I go back to work?”

And one day, a week into treatment, she asked, “Am I going to die?”

Over my last 3 years as an internal medicine resident, I’ve been humbled by how often patients turned to me for answers to some of the most difficult questions I could imagine. Sometimes, the questions seemed purely factual, but often, they took a more existential bent: How should I spend my last months? What should I do now? Patients have asked me if they are going to die, along with when, how, and even why.

I’ve wrestled with how to communicate candidly, treading a delicate balance between being as up-front as possible while also recognizing the uncertainty inherent in predicting. I’ve struggled with walking the tightrope of delivering bad news while also emphasizing compassion and support.

I chose hematology and oncology in part because of the gravity of these interactions. I enjoy being a primary doctor for a complex, sick, patient population who are grappling with physically and emotionally challenging illness. I value longitudinal relationships with patients I know well. I found the medicine of hematology and oncology interdisciplinary, the details high stakes, and the big questions always at play. If it was meaningful work I sought, cancer became the ultimate question that mattered.

The changing landscape of cancer care is making these conversations substantially more difficult. A central tenet of medicine is truthfulness: setting the stage for what is going on and what to anticipate. It’s explaining the nuances of the upcoming treatment options, while also addressing what a person’s life may look like down the road. It’s understanding what matters most to a patient, understanding what therapeutic choices we can offer – and then trying to reconcile them, as best as we can.

This has always been hard. But it’s getting harder. The options we have to treat cancer are expanding rapidly as immunotherapy competes with the basics of chemotherapy, radiation, and surgery. We work alongside researchers looking to change the paradigm, collecting information on outcomes and side effects as we go along. We are learning and we are applying what we learn – in real time – on real people willing to try.

How can we speak honestly about a prognosis when our data are limited and our tools are in continuous flux? How can we prepare someone for what lies ahead when we are still trying to grasp what today looks like?

All the while, medical uncertainties are amplified by a complex system with many moving parts. It’s a system in which some patients cannot afford care, in which insurance companies may deny necessary treatment, and where families may come together or fall apart in the face of incredible adversity. There are factors outside the scope of pure medicine that make the path ahead all the hazier and navigating it all the more challenging.

In July, I began my hematology and oncology fellowship. I am caring for patients with a range of cancers, and all of that goes along with the weight of those diagnoses. Learning the most up-to-date management in a constantly evolving landscape will be an ongoing skill. That my patients allow me into their most vulnerable moments – and trust me with them – is a gift.

For patients like Sue, there sometimes remain more questions than answers. She recently underwent her third round of chemotherapy and endured multiple blood clots. With her insurance covering only limited interventions, she is deciding what to focus on and where to receive her care. Her story, like many others, continues to be written.

I am deeply aware of the difficulties that are a part of the world of cancer – and the heartbreak. How can we hold up scans triumphantly showing no recurrence in some patients while others suffer one failed treatment after another? When should we push for more therapy and when should we shift our efforts toward comfort? What should we prioritize – medically and personally – if time is limited?

These questions are hard, but I cannot think of any that are more meaningful.

This is a column about patients and uncertainty as I pursue my hematology and oncology fellowship and grapple with these questions. I look forward to sharing them with you each month.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Every cancer diagnosis starts out as anything but. That’s what I was thinking when I met Sue Marcus (not her real name) in the emergency department one Friday afternoon.

“You know,” she said in a matter of fact manner. “I think I might have the flu.”

“Yes,” I said. “You might.”

“I was in Vegas a week ago, and the person next to me was sick.”

“It’s definitely possible. That’s one of the things we’ll test for.”

“I mean ... what else can it be?”

I had information Sue didn’t yet. All her blood counts were disturbingly low. On top of that, the lab had picked up several atypical appearing cells. They could be reactive, in the setting of infection, or they could be blasts – a new diagnosis of leukemia.

I paused.

“I’m going to say this now, so you know what we are looking for. There’s a lot more information we still need.”

“But?”

“But, another possibility is that it is cancer.”

“Cancer?”

“Leukemia, maybe.”

I explained the next steps. We would have flow cytometry by that night, but it’s not a perfect test. We were limited, actually, by logistics. It was a Friday night. We would do a bone marrow biopsy on Monday. It would be several days before we’d know with certainty.

That evening, the hematology fellow and I looked at the slide under the microscope. We agreed with the lab.

“That’s a blast, isn’t it?”

“Yes, I think it is.”

But they were not completely classic, and they were sporadic. It wasn’t enough to say for sure. Meanwhile, Sue, understandably, wanted answers.

“What did you see? Is it cancer, or not?”

There was flow cytometry that night, showing an abnormal population of cells. And then, finally, there was a bone marrow biopsy clinching the diagnosis.

We explained what the path ahead looked like: Hospitalization for a month. Chemotherapy, then a repeat bone marrow biopsy to look for response. Then more chemotherapy. Chances of remission. Long-term implications.

As we gathered more information, Sue’s questions evolved.

“Is it curable?”

“Can I go back to work?”

And one day, a week into treatment, she asked, “Am I going to die?”

Over my last 3 years as an internal medicine resident, I’ve been humbled by how often patients turned to me for answers to some of the most difficult questions I could imagine. Sometimes, the questions seemed purely factual, but often, they took a more existential bent: How should I spend my last months? What should I do now? Patients have asked me if they are going to die, along with when, how, and even why.

I’ve wrestled with how to communicate candidly, treading a delicate balance between being as up-front as possible while also recognizing the uncertainty inherent in predicting. I’ve struggled with walking the tightrope of delivering bad news while also emphasizing compassion and support.

I chose hematology and oncology in part because of the gravity of these interactions. I enjoy being a primary doctor for a complex, sick, patient population who are grappling with physically and emotionally challenging illness. I value longitudinal relationships with patients I know well. I found the medicine of hematology and oncology interdisciplinary, the details high stakes, and the big questions always at play. If it was meaningful work I sought, cancer became the ultimate question that mattered.

The changing landscape of cancer care is making these conversations substantially more difficult. A central tenet of medicine is truthfulness: setting the stage for what is going on and what to anticipate. It’s explaining the nuances of the upcoming treatment options, while also addressing what a person’s life may look like down the road. It’s understanding what matters most to a patient, understanding what therapeutic choices we can offer – and then trying to reconcile them, as best as we can.

This has always been hard. But it’s getting harder. The options we have to treat cancer are expanding rapidly as immunotherapy competes with the basics of chemotherapy, radiation, and surgery. We work alongside researchers looking to change the paradigm, collecting information on outcomes and side effects as we go along. We are learning and we are applying what we learn – in real time – on real people willing to try.

How can we speak honestly about a prognosis when our data are limited and our tools are in continuous flux? How can we prepare someone for what lies ahead when we are still trying to grasp what today looks like?

All the while, medical uncertainties are amplified by a complex system with many moving parts. It’s a system in which some patients cannot afford care, in which insurance companies may deny necessary treatment, and where families may come together or fall apart in the face of incredible adversity. There are factors outside the scope of pure medicine that make the path ahead all the hazier and navigating it all the more challenging.

In July, I began my hematology and oncology fellowship. I am caring for patients with a range of cancers, and all of that goes along with the weight of those diagnoses. Learning the most up-to-date management in a constantly evolving landscape will be an ongoing skill. That my patients allow me into their most vulnerable moments – and trust me with them – is a gift.

For patients like Sue, there sometimes remain more questions than answers. She recently underwent her third round of chemotherapy and endured multiple blood clots. With her insurance covering only limited interventions, she is deciding what to focus on and where to receive her care. Her story, like many others, continues to be written.

I am deeply aware of the difficulties that are a part of the world of cancer – and the heartbreak. How can we hold up scans triumphantly showing no recurrence in some patients while others suffer one failed treatment after another? When should we push for more therapy and when should we shift our efforts toward comfort? What should we prioritize – medically and personally – if time is limited?

These questions are hard, but I cannot think of any that are more meaningful.

This is a column about patients and uncertainty as I pursue my hematology and oncology fellowship and grapple with these questions. I look forward to sharing them with you each month.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Click here to access August 2018 Advances In Hematology and Oncology Digital Edition.

Table of Contents

• VHA Practice Guideline Recommendations for Diffuse Gliomas
• Positivity Rates in Head and Neck Cancer in the VA
• Prevalence of Cancer in Thyroid Nodules in a Veteran Population
• Fatal Drug-Resistant Invasive Infection in a 56-Year-Old Immunosuppressed Man
• Immune Checkpoint Inhibitors for Urothelial Cancer: An Update on New Therapies
• Research News: RCC. Adrenal Tumors, Myeloma Therapy, Cancer Clusters, Hodgkin Lymphoma
• Coordination of Prostate Cance Care Between Primary Care and Oncology
• Open Clinical Trials for Patients With Lung Cancers

Click here to access August 2018 Advances In Hematology and Oncology Digital Edition.

Table of Contents

• VHA Practice Guideline Recommendations for Diffuse Gliomas
• Positivity Rates in Head and Neck Cancer in the VA
• Prevalence of Cancer in Thyroid Nodules in a Veteran Population
• Fatal Drug-Resistant Invasive Infection in a 56-Year-Old Immunosuppressed Man
• Immune Checkpoint Inhibitors for Urothelial Cancer: An Update on New Therapies
• Research News: RCC. Adrenal Tumors, Myeloma Therapy, Cancer Clusters, Hodgkin Lymphoma
• Coordination of Prostate Cance Care Between Primary Care and Oncology
• Open Clinical Trials for Patients With Lung Cancers

Click here to access August 2018 Advances In Hematology and Oncology Digital Edition.

Table of Contents

• VHA Practice Guideline Recommendations for Diffuse Gliomas
• Positivity Rates in Head and Neck Cancer in the VA
• Prevalence of Cancer in Thyroid Nodules in a Veteran Population
• Fatal Drug-Resistant Invasive Infection in a 56-Year-Old Immunosuppressed Man
• Immune Checkpoint Inhibitors for Urothelial Cancer: An Update on New Therapies
• Research News: RCC. Adrenal Tumors, Myeloma Therapy, Cancer Clusters, Hodgkin Lymphoma
• Coordination of Prostate Cance Care Between Primary Care and Oncology
• Open Clinical Trials for Patients With Lung Cancers

The rupture rate for breast implants is about 10% at 10 years after insertion. That means women aged ≥ 70 years have a greater risk of rupture. For women who had breast augmentation or reconstruction before the advent of fifth-generation implants, there are no specific recommendations regarding follow-up and very little guidance in the literature about management for those who have had implants after radiation, say clinicians from Mayo Clinic.

They report on a 74-year-old patient who was treated for breast cancer in 1987 and 1988. She underwent lumpectomy, adjuvant unilateral radiation, a right simple mastectomy, left modified radical mastectomy, and implant-based reconstruction. Nearly 30 years later, she felt an asymmetry in 1 breast. Magnetic resonance imaging and ultrasound revealed that both implants had ruptured.

It is well known, the clinicians say, that complications of postmastectomy radiotherapy include capsular contracture, infection, and loss of prosthesis in implant-based reconstruction. Studies have shown that fibrosis, a hallmark of chronic radiation therapy, can show up even several years after radiotherapy—underscoring the importance of long-term follow-up for these patients. Moreover, the fact that the consequences of silicone on irradiated mastectomy flaps is unknown posed a further challenge.

While the cause of their patient’s implant rupture is unknown, the clinicians say it is “very likely” that delayed-onset fibrosis and capsular contracture secondary to radiation played a role. Such complications, though rare, should be kept in mind, the clinicians advise, when evaluating patients who had radiation and implants.

Source:

Molinar VE, Sabbagh MD, Manrique OJ. BMJ Case Rep. 2018; pii: bcr-2018-224578.
doi: 10.1136/bcr-2018-224578.

The rupture rate for breast implants is about 10% at 10 years after insertion. That means women aged ≥ 70 years have a greater risk of rupture. For women who had breast augmentation or reconstruction before the advent of fifth-generation implants, there are no specific recommendations regarding follow-up and very little guidance in the literature about management for those who have had implants after radiation, say clinicians from Mayo Clinic.

They report on a 74-year-old patient who was treated for breast cancer in 1987 and 1988. She underwent lumpectomy, adjuvant unilateral radiation, a right simple mastectomy, left modified radical mastectomy, and implant-based reconstruction. Nearly 30 years later, she felt an asymmetry in 1 breast. Magnetic resonance imaging and ultrasound revealed that both implants had ruptured.

It is well known, the clinicians say, that complications of postmastectomy radiotherapy include capsular contracture, infection, and loss of prosthesis in implant-based reconstruction. Studies have shown that fibrosis, a hallmark of chronic radiation therapy, can show up even several years after radiotherapy—underscoring the importance of long-term follow-up for these patients. Moreover, the fact that the consequences of silicone on irradiated mastectomy flaps is unknown posed a further challenge.

While the cause of their patient’s implant rupture is unknown, the clinicians say it is “very likely” that delayed-onset fibrosis and capsular contracture secondary to radiation played a role. Such complications, though rare, should be kept in mind, the clinicians advise, when evaluating patients who had radiation and implants.

Source:

Molinar VE, Sabbagh MD, Manrique OJ. BMJ Case Rep. 2018; pii: bcr-2018-224578.
doi: 10.1136/bcr-2018-224578.

The rupture rate for breast implants is about 10% at 10 years after insertion. That means women aged ≥ 70 years have a greater risk of rupture. For women who had breast augmentation or reconstruction before the advent of fifth-generation implants, there are no specific recommendations regarding follow-up and very little guidance in the literature about management for those who have had implants after radiation, say clinicians from Mayo Clinic.

They report on a 74-year-old patient who was treated for breast cancer in 1987 and 1988. She underwent lumpectomy, adjuvant unilateral radiation, a right simple mastectomy, left modified radical mastectomy, and implant-based reconstruction. Nearly 30 years later, she felt an asymmetry in 1 breast. Magnetic resonance imaging and ultrasound revealed that both implants had ruptured.

It is well known, the clinicians say, that complications of postmastectomy radiotherapy include capsular contracture, infection, and loss of prosthesis in implant-based reconstruction. Studies have shown that fibrosis, a hallmark of chronic radiation therapy, can show up even several years after radiotherapy—underscoring the importance of long-term follow-up for these patients. Moreover, the fact that the consequences of silicone on irradiated mastectomy flaps is unknown posed a further challenge.

While the cause of their patient’s implant rupture is unknown, the clinicians say it is “very likely” that delayed-onset fibrosis and capsular contracture secondary to radiation played a role. Such complications, though rare, should be kept in mind, the clinicians advise, when evaluating patients who had radiation and implants.

Source:

Molinar VE, Sabbagh MD, Manrique OJ. BMJ Case Rep. 2018; pii: bcr-2018-224578.
doi: 10.1136/bcr-2018-224578.