High-resolution ultrasound with Doppler (HRUD) is an emerging imaging modality that enables noninvasive visualization of hair follicles, perifollicular structures, and vascular changes. Recent studies have identified characteristic ultrasonographic findings in both non-scarring and scarring alopecias, expanding the role of ultrasound in their clinical evaluation. This narrative review summarizes HRUD principles, sonoanatomy of the hair, scanning techniques, indications, and representative imaging findings in alopecias. PubMed and Scopus were searched to identify publications describing HRUD applications in alopecias, and ultrasonographic images and illustrative cases from the authors' collections were included to demonstrate key findings. Across alopecias, HRUD demonstrates recognizable imaging patterns that may support diagnosis and clinical assessment. Reported findings include follicular miniaturization in pattern alopecia, drop-like follicular widening in alopecia areata, perifollicular inflammatory changes and increased vascularization in scarring alopecias, follicular fusion in folliculitis decalvans, and fistulous tracts in dissecting cellulitis of the scalp. HRUD may also facilitate assessment of disease activity, treatment response, and clinicopathologic correlations. In conclusion, HRUD provides clinically useful structural and vascular information in alopecias and may complement clinical examination and trichoscopy. Standardization of imaging protocols and further clinical studies may help define its role in diagnosis, monitoring, and research.
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly used beyond approved metabolic indications, including for elective weight loss and aesthetic optimization. Dermatologists may encounter both requests to prescribe these agents and downstream consequences such as facial volume loss and telogen effluvium. Although prescribing these medications for hidradenitis suppurative or psoriasis can be medically rationalized and helpful, elective prescribing raises ethical concerns related to nonmaleficence, scope of practice, prescribing cascades, patient autonomy, justice, and stewardship of limited resources. We discuss the ethical responsibilities of dermatologists considering GLP-1 RA prescribing for cosmetic purposes and propose practical guardrails for balancing patient preferences with professional judgment and avoidance of iatrogenic harm.
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have generated growing interest in dermatology for their potential anti-inflammatory and immunomodulatory effects on skin disease, in addition to their metabolic benefits. As their use expands beyond established indications for type 2 diabetes and obesity, important ethical challenges have emerged. This review explores the ethical considerations surrounding GLP-1 RA use in dermatology through the principles of autonomy, beneficence, non maleficence, and justice. Notable issues include disparities in access and affordability, compounded formulations, social media misinformation, scope-of-practice considerations in prescribing, and informed consent. Evidence suggests that racial, ethnic, socioeconomic, and insurance-related disparities limit access to GLP-1 RAs, while increasing off-label and cosmetic use may worsen medication shortages and inequitable distribution. Compounded agents may improve access but introduce concerns about product quality, safety, counterfeit medications, and inadequate patient counseling. Social media and direct-to-consumer marketing contribute to misinformation, unrealistic outcome expectations, and demand-driven shortages. Emerging dermatologic evidence supports potential benefits of GLP-1 RAs for hidradenitis suppurativa and psoriasis, raising questions about appropriate prescribing authority and side effect monitoring responsibilities for dermatologists. Limited long term safety data for off-label GLP-1 RA use highlights the importance of transparent patient counseling and shared decision-making when prescribing these agents. As GLP-1 RA use continues to expand, dermatologists must balance potential therapeutic benefits with broader societal considerations. Ethical stewardship through evidence based prescribing, informed consent, adverse effect monitoring, patient education, and advocacy for equitable treatment access is essential to maximizing patient benefit, minimizing harm, and preserving fair access.
Prediction markets increasingly allow participants to take financial positions on biomedical outcomes, including clinical trial results and US Food and Drug Administration decisions. Dermatologists may possess specialized expertise that helps them interpret emerging therapeutic data, but physician participation raises concerns about conflicts of interest, material nonpublic information, patient trust, and professional responsibility. These concerns are particularly relevant for physicians involved in clinical trials, regulatory activities, peer review, or industry consulting. We discuss the ethical implications of physician participation in prediction markets and propose principles to distinguish acceptable use of publicly available information from inappropriate trading based on privileged professional knowledge.
Background Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are increasingly prescribed for type 2 diabetes mellitus and obesity, with expanding therapeutic applications. Although gastrointestinal adverse events are the most recognized toxicities, Cutaneous adverse events constitute a large burden of total adverse reactions. Objective To review the prevalence, clinical features, mechanisms, and management of non-immunologic Injection Site and Dermatologic Reactions associated with GLP-1RAs. Methods A review of clinical trials, pharmacovigilance studies, and case reports and series was performed. In addition, adverse event reports for tirzepatide, semaglutide, liraglutide, exenatide, dulaglutide, and lixisenatide were extracted from the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS). Injection-site events were combined with skin-related adverse events to generate an adjusted "Skin and Injection-Site Reactions" category for comparison across agents. Results Among 442,567 FAERS reports, 137,412 (31.0%) involved skin and injection-site reactions, representing the third most frequently reported adverse event category. Exenatide demonstrated the highest proportion of skin and injection-site reports (53.1%), followed by dulaglutide (33.5%), tirzepatide (32.6%), liraglutide (17.1%), semaglutide (12.2%), and lixisenatide (6.9%). Common reactions included pain, bleeding, erythema, bruising, mass, pruritus, and swelling. Additional adverse events included dysesthesias, nodules, granulomatous reactions, bruising, and hyperhidrosis. Most reactions were mild to moderate and generally managed symptomatically without requiring treatment discontinuation. Conclusions Non-immunologic cutaneous adverse events comprise a substantial proportion of reported GLP-1RA-associated adverse events with differing rates among individual agents. Recognition of these reactions and appropriate supportive management may improve patient outcomes. Prospective studies are needed to better define their adverse event risk rates, mechanisms, and optimal management strategies.
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have transformed the management of obesity, type 2 diabetes mellitus, and cardiometabolic disease through effects on weight reduction, glycemic control, and systemic inflammation. Their varied immunometabolic actions have generated increasing interest in dermatology, where chronic inflammatory skin diseases frequently coexist with obesity, insulin resistance, metabolic syndrome, and cardiovascular disease. Emerging evidence from clinical trials, observational studies, and real-world analyses suggests that GLP-1RAs may improve outcomes in psoriasis and hidradenitis suppurativa while simultaneously reducing the burden of associated metabolic and cardiovascular comorbidities. In psoriasis, combination therapy with tirzepatide has demonstrated enhanced skin clearance, substantial weight loss, and reduced risk of psoriatic arthritis. In hidradenitis suppurativa, GLP-1RAs have been associated with improvements in cardiometabolic outcomes and reductions in systemic complications. Collectively, these findings support an evolving paradigm in which the greatest therapeutic utility of GLP-1RAs in dermatology may lie not in direct modulation of cutaneous inflammation but in addressing the metabolic dysfunction and chronic systemic inflammation that drive disease severity and multimorbidity. We review the current clinical evidence and propose a conceptual framework positioning GLP-1RAs as immune-metabolic therapies that target the systemic comorbidities of inflammatory skin disease, which may provide future opportunities for cutaneous disease modification and integrated dermatologic care.
The introduction of dermatology's specialty-specific Standardized Letter of Evaluation (SLOE) for the 2026-2027 residency cycle aims to improve fairness, comparability, and reduce bias in applicant assessment. Although standardization may reduce differences in writing style and interpretation, it does not eliminate subjectivity and may redistribute how and where bias affects the process. Rating inflation, ceiling effects, and interrater variability have been reported in dermatology and other specialties, while evidence that standardized ratings predict residency performance remains limited; furthermore, standardizing evaluation does not standardize opportunity: ratings of research, professionalism, and communication may reflect differences in mentorship, resources, clinical exposure, and evaluator relationships. Programs should, therefore, avoid interpreting small numerical differences as precise measures of ability and instead consider SLOEs within a holistic review. Ethical implementation will require ongoing assessment of rating inflation, interrater variability, demographic disparities, and predictive validity. Ultimately, the SLOE's value will depend on whether it improves comparability and transparency without creating false precision or masking unequal opportunities.
Isotretinoin is an effective acne therapy but highly regulated due to its potential teratogenicity and serious side effects. Isotretinoin distribution is currently monitored through the Food and Drug Administration- (FDA)-mandated iPLEDGE Risk Evaluation and Mitigation Strategy System (REMS). Safe prescribing depends not only on FDA and physician oversight, but also on patients taking the medication as prescribed and adhering to established safeguards, such as frequent pregnancy tests and routine monitoring. Concerns regarding nonadherence or potential medication diversion in the setting of apparent treatment failures raise ethical tensions, particularly if the provider cannot definitively assess how the medication is being used. We outline the ethical obligations of providers when there is credible suspicion for isotretinoin nonadherence or diversion.
Yellow nail syndrome (YNS) is a rare disorder defined by the triad of yellow nail discoloration, lymphedema, and respiratory tract disease. Only two of the three signs should be present to diagnose YNS; however, this can be challenging as patients often do not exhibit all three signs concurrently. The association between YNS and malignancy has led to the hypothesis that YNS may be paraneoplastic. Treatment may include oral vitamin E for nail discoloration, serial thoracenteses for pleural effusions, and compression garments along with bandaging for lymphedema.
As parental leave becomes increasingly common in dermatology residency programs, ethical questions arise regarding redistribution of clinical responsibilities. We examine whether requiring co-residents to cover additional on-call duties during colleagues' parental leave is ethically justified using the principles of autonomy, justice, beneficence, nonmaleficence, and honesty. While residents have an autonomous right to parental leave, programs should recognize the impact on co-residents. Temporary redistribution of duties may be necessary to maintain patient care, but justice requires that added workloads be distributed fairly and mitigated to avoid burnout, compromised education, and threats to patient safety. Residency programs should implement transparent parental leave policies, engage residents in policy development, and adopt equitable scheduling strategies rather than relying solely on peer coverage. Ethical parental leave policies should balance support for residents taking leave with fairness to their colleagues while maintaining resident well-being, educational quality, and patient care.
Dermatologist-inventors have ethical responsibilities extending beyond demonstrating that an innovation is helpful, accurate, and safe. Diagnostic technologies can be a positive influence on access to care, healthcare equity, and patient trust, particularly when these technologies are intended for rural and resource-limited communities. Ethical development of novel dermatologic diagnostic technologies requires consideration of beneficence, justice, transparency, accessibility, and responsible commercialization. Physician-inventors should evaluate whether a technology addresses a meaningful clinical need, performs adequately across diverse patient populations, and can be integrated into real-world clinical settings. Accessibility should also be considered during the design process rather than after development. Eliminating unnecessary cold-chain requirements may improve the feasibility of distributing diagnostic technologies to rural and low-resource settings where refrigeration and temperature-controlled transportation might be limited. These design strategies should be supported by appropriate analytical and clinical validation to ensure that accessibility does not compromise diagnostic performance. Such validations could lead to perpetuating inequities in underserved communities, where low cost technologies are most likely to have the biggest impact.
Genital herpes is a common, recurrent, chronic sexually transmitted infection that is frequently encountered in dermatologic practice, and in which the psychosocial burden often exceeds the physical manifestations, as many affected individuals are asymptomatic or experience only mild symptoms. Shame, fear of rejection, anger, depression, and anxiety surrounding disclosure can diminish quality of life more than the physical manifestations of the herpes infection. These concerns are compounded by practical threats to confidentiality, especially for adolescents whose explanation-of-benefits statements are insured under a parent's plan. Using two cases, we examine the ethical tensions that a diagnosis of genital herpes can create for the dermatologist. In the first, a patient requests omission of the diagnosis from her record; in the second, the same patient declines to notify an identifiable partner. In genital herpes, ethical management requires balancing confidentiality against truthful documentation and the interests of identifiable partners, while attending to stigma, relational autonomy, truthfulness, beneficence, informed consent, and psychologic morbidity alongside antiviral therapy.
Carcinoid syndrome refers to the signs and symptoms a patient experiences secondary to a carcinoid tumor or another well-differentiated neuroendocrine tumor, which secretes serotonin and other peptides that enter the bloodstream; only 10% of patients with carcinoid tumors experience carcinoid syndrome. Common findings include facial flushing, tachycardia, and shortness of breath. Carcinoid tumors usually originate in the gastrointestinal tract. They are slow growing but can metastasize to the liver, lymph nodes, and elsewhere. Primary or metastatic cutaneous carcinoid tumors present as pink, fast-growing dermal or subcutaneous nodules. The diagnostic workup includes a thorough history and physical examination of the entire body, including a urinary 24-hour 5-hydroxyindoleacetic acid and serum chromogranin A tests. Management of carcinoid syndrome initially includes the use of somatostatin analogs, diet, medication regulation, and clinical monitoring. More aggressive treatment, such as peptide receptor radionuclide therapy or everolimus, a mechanistic target of rapamycin (mTOR), may be required.
Glucagon-like peptide-1 receptor agonists and related incretin therapies have moved rapidly from second-line diabetes agents to widely prescribed cardiometabolic medications, and dermatologists increasingly encounter patients who are already taking them. Obesity is common among dermatology patients and is particularly prevalent in psoriasis and hidradenitis suppurativa, yet most eligible patients are not receiving glucagon-like peptide-1 receptor agonist therapy, and nearly all prescriptions originate outside dermatology. This positions dermatologists at the intersection of two distinct clinical questions: how to manage the cutaneous consequences of therapy in patients already receiving these agents, and when to raise the possibility of treatment in patients who may benefit. This narrative review examines patient selection, including the metabolic and inflammatory phenotypes most likely to see dermatologic benefit, and the practical demands of therapy that influence whether treatment succeeds. It reviews the dermatology-relevant adverse effects that patients most often notice, including facial volume loss, hair shedding, and gastrointestinal intolerance, along with a monitoring approach suited to the dermatology visit. Throughout, it argues that shared decision-making offers a useful framework for an area where the evidence is still evolving and where treatment can reshape how patients look and feel.
"Tanmaxxing" is an emerging online trend that promotes intentional UV exposure with minimal sun protection to achieve a darker tan. This beauty trend encourages participants to become as tan or dark as possible. Although traditional tanning culture is well documented, newer platforms such as Instagram and TikTok enable promotional materials to reach larger, younger audiences. They have recently not only begun promoting avoidance of sunscreens but also endorse the use of tanning oils. Engagement-based algorithms boost provocative videos of creators promoting sun-seeking behaviors, such as indoor tanning. These videos typically minimize or omit the risks, whereas the creators financially benefit from the participation of impressionable audiences. We outline the ethical implications of leveraging social media algorithms to promote tanmaxxing, exploring autonomy and adolescent vulnerability, and propose solutions to better protect adolescents and young adults from the normalization of preventable harm.
Smoking has been associated with increased disease severity, poorer treatment response, and adverse outcomes in several dermatologic conditions, including hidradenitis suppurativa (HS), psoriasis, cutaneous lupus erythematosus, and chronic wounds. Although smoking cessation counseling is traditionally viewed as the responsibility of primary care clinicians, dermatologists frequently encounter patients whose skin disease may be influenced by tobacco use. This raises an important ethical question: when does counseling regarding lifestyle behaviors fall within the scope of dermatologic practice? Herein, we discuss the ethical justification for dermatologists to engage in smoking cessation counseling through the principles of beneficence, autonomy, and justice. Beneficence supports counseling when tobacco use is relevant to disease severity, treatment response, procedural outcomes, or prevention. At the same time, counseling must respect patient autonomy and avoid approaches that may contribute to emotional distress, perceived judgment, or damage to the therapeutic alliance. Justice further requires recognition of the social and structural barriers that can make smoking cessation difficult for many patients. More broadly, smoking serves as a model for addressing other modifiable health behaviors that may affect skin health, including obesity, alcohol use, and vaccination status. Dermatologists are not obligated to comprehensively manage all lifestyle factors; however, they have an ethical/professional responsibility to discuss behaviors that have meaningful implications for patient outcomes.
Authors of fiction are unique. They develop the characters of their novels for their readers, with the main character of a book being the protagonist. Other important characters include the antagonist and the deuteragonist. This paper focuses on fiction novels in which one of the key characters is a dermatologist. Biographic sketches that describe some of the features of the authors who write these novels are provided. The authors include nine non-medical writers: Sue Civil-Brown, Tom Jordon, Janice Kaplan, Lynn Schnurnberger, Carolyn See, Terry Southern, Camy Tang, Bruce Wagner, and Sheila Gewirtzman. They also include a non-dermatologist physician (Sara Cohen who is a physiatrist and writes under the pseudonym Freida McFadden), and dermatologists Terry Cronin and Garry Gewirtzman (who writes with his wife Sheila, who is an accountant). A total of 10 dermatologists are included in the 18 books in which a dermatologist is a main character; one author wrote three books that had the same dermatologist as a protagonist, and a husband and wife team of writers wrote a series of seven novels in which a dermatologist was featured. The fictional dermatologists were either the protagonist (seven dermatologists in 15 novels), the antagonist (two dermatologists), or the deuteragonist (one dermatologist). The 18 novels were written by 12 authors. Nine of the authors had not attended medical school; however, three of the authors were physicians. Seven books were written by a husband and wife team (a dermatologist and his accountant wife). One book was written by two women who were not physicians. The dermatologist is a man as in six of the dermatologists or a women as in four of the dermatologists. All four of the women dermatologists were characters in novels written by women (five authors). The six men were included in books by either a man (four authors) or a woman (one author) or coauthors (including both a man and a woman). Some writers publish their novels under a pseudonym, with the authors having various personal reasons for using a pen name. Six of the 12 (50%) of the authors who wrote a novel with a dermatologist as the main character either used a pseudonym in that novel, or a different book, or both. Many of the non-physician authors (five of nine, 56%) used a pen name; these included four women and two men. Only the woman physician author used a pseudonym. One of the men used a shortened version of his first name and did not include the suffix after his last name; both of the men did not include their middle name or the first letter of their middle name. The dermatologist-as either a protagonist, an antagonist, or a deuteroantagonist-provides the reader with an intriguing character in a novel.
This review provides an overview of current evidence on the presence, distribution, and physiological role of glucagon-like peptide-1 (GLP-1) receptors in skin tissue. Although GLP-1 receptor agonists are primarily used to treat type 2 diabetes mellitus and obesity, increasing evidence suggests that they may also have direct effects on the skin. This review examines the available research on GLP-1 receptor expression in major skin cell types, including keratinocytes, dermal fibroblasts, and the cutaneous microvascular endothelium. The strength of the evidence is evaluated according to the species studied, the experimental model used, and the method of receptor detection, including gene expression, protein identification, and functional activity. Differences in findings across animal models, cultured cells, and human tissue are also considered. In addition, this review distinguishes between skin effects that are likely mediated by direct activation of GLP-1 receptors within cutaneous tissue and those that occur indirectly through systemic metabolic improvement or modulation of immune and inflammatory pathways.
Sexual health is central to quality of life; yet, its relationship to dermatologic disease remains insufficiently studied. Skin conditions can directly contribute to sexual dysfunction through pruritus, scarring, pain, and body image distress, and genital involvement is common but often overlooked. We present two cases to examine the ethical implications for dermatologic practice. In the first, a patient with vulvar lichen sclerosus reports avoiding intimacy, but the dermatologist does not explore the concern further. In the second, a patient with well-controlled plaque psoriasis never discusses the effects of genital involvement, because the dermatologist does not initiate the conversation. These cases show how silence may perpetuate unrecognized suffering and restrict meaningful patient autonomy. Ethical dermatologic care for sexual manifestations of skin disease requires sensitivity; permission-based, trauma-informed inquiry that prioritizes the patient's control, safety, and agency by asking consent before discussing sensitive topics; equitable screening; treatment of modifiable cutaneous contributors; and appropriate referral when concerns extend beyond dermatologic management.
