BACKGROUND:Dermatofibromas are benign fibrohistiocytic neoplasms with numerous histologic variants including the hypocellular variant. Anecdotal observations suggest that dermatofibromas may become increasingly sclerotic and hypocellular with advancing patient age. OBJECTIVE:This study aimed to evaluate the association between patient age and the frequency of hypocellular dermatofibromas. METHODS:A total of 392 dermatofibroma specimens were independently classified by two dermatopathologists into discrete histologic variants: conventional, hypocellular, hemosiderotic/aneurysmal, cellular, lipidized, indeterminate, or other. Only cases with concordant classification between the two dermatopathologists were included in the analysis. Linear regression analysis to be used to evaluate the association between patient age and the prevalence of hypocellular dermatofibromas. RESULTS:Out of the original 392 cases, 307 (78%) specimens received concordant histologic variant classification and were included in the analysis. The frequency of the hypocellular variant was consistently low (0%-18%) in patients in the youngest age groups (10-49 years), increased to 25% in the 50-59 age group, and ranged from 25% to 40% in patients aged 60-89 years old. Linear regression analysis demonstrated a strong positive correlation between patient age and the prevalence of hypocellular dermatofibromas (R-squared = 0.82, p 0.002). LIMITATIONS:The high proportion of shave biopsy specimens (63%) limited assessment of deep dermal histologic features. Another limitation is the inherent subjectivity of categorizing based on cellularity. CONCLUSION:Hypocellular dermatofibromas are increasingly prevalent with advancing age. One possible explanation is that dermatofibromas undergo gradual involution over time, with a corresponding reduction in cellular density as lesions mature.

BACKGROUND:There is a lack of substantial evidence supporting the safety and effectiveness of endovascular thrombectomy in treating distal medium vessel occlusions (DMVOs). OBJECTIVE:To summarize the current evidence regarding endovascular thrombectomy for DMVOs. METHODS:We conducted a narrative review of key articles related to the diagnosis and management of DMVOs. We manually searched PubMed and Google Scholar from January 2010 to July 2023, and only included articles published in the English language. RESULTS:While diagnosing and treating DMVOs is tricky due to access limitations and potential limited benefit from mechanical clot removal, recent improvements in catheter and retrieval technology suggest that endovascular thrombectomy might be a potential treatment option. However, more high-quality research is needed to confirm its effectiveness for DMVOs. CONCLUSION:Experts disagree on how to classify DMVOs and what the best mode of endovascular treatment is.

Dermatology outpatient care is limited for patients of lower income, uninsured status, or minority background. Previous studies have shown that the uninsured often present with more advanced disease and experience worse clinical outcomes than the insured. Saint Louis University's Health Resource Center clinic serves the city's underinsured patients, and dermatology specialty care became available as a once-monthly clinic in August 2021. Our research objectives were to investigate the outcomes of care and to address barriers to care. Study participants completed three surveys: baseline, two-week follow-up, and eight-week follow-up. After two-week follow-up, an intervention was attempted for each patient who reported barriers to medication access. Among 49 eligible patients who were seen for 23 different diagnoses, 42 completed the baseline survey. Twenty-nine patients completed the two-week follow-up survey, and 29 patients completed the eight-week follow-up survey. Eighty-seven percent reported that their skin condition had been present for >1 year, but only 33% had ever seen a dermatologist before. Ninety-seven percent of respondents reported that they benefited from the clinic. At two-week follow-up, 48% of patients had obtained all their medications. After patient-specific interventions, 72% had obtained all their medications by eight-week follow-up. There was a trend, though not significant, towards improvement in a self-reported 5-point severity score (mean pre-score 2.1 vs mean post-score 1.7) as well as the negative impact of the skin condition on their lives. This research demonstrates that a new free dermatology clinic was able to improve access to dermatologic care and to identify barriers to medication acquisition.

Bibee, MD PhD, Johns Hopkins University School of Medicine; Jeffrey Scott, MD, Johns Hopkins University School of Medicine; Jaroslaw Jedrych, MD, Johns Hopkins University School of Medicine; Elise Ng, MD, Johns Hopkins University School of Medicine

Introduction: Morphologic features of the mandible are influenced by the genes of each individual. Mandible size is important to orthodontists because the mandible is the mechanism by which the lower face influences facial esthetics and dental function. To date, no biological marker has been identified that indicates eventual mandible size. This study aimed to correlate the expression of DLX5, DLX6, EDN1, HAND2, PRRX1, and MSX1 to mandible size. Methods: Fifty-nine orthodontic patients aged >6 years who had available cephalo-metric radiographs were studied. Patients were classified on the basis of condylion-to-gnathion measurements. Messenger RNA was isolated from saliva and subjected to real-time quantitative polymerase chain reaction. Results: Threshold cycle values for subjects with small mandibles (>1 standard deviation [SD] from the mean) had the least expression of DLX6 and MSX1. Threshold cycle values for subjects with large mandibles (>1 SD) had less expression of DLX6 and MSX1 than subjects within 1 SD but more than those with small mandibles. Conclusions: DLX6 and MSX1 are related to mandible development and size. This finding could be used to improve treatment planning for medical and dental professionals seeking to understand the impact of genetics on bone growth.

Background: It is estimated that skin of color (SOC) individuals will comprise 50% of the US population by 2042.1 The use of SOC didactics among non-dermatology residents is particularly limited.2 Prior studies have confirmed a greater need for SOC education among primary care providers.2,3 Objective: To assess if an educational dermatology curriculum designed by dermatologists increases primary care residents' knowledge and comfort level when treating SOC patients.

BACKGROUND:Full-thickness skin grafts (FTSGs) are useful repairs for reconstructing nasal alar defects. Traditional donor sites include the preauricular, postauricular, and supraclavicular skin.OBJECTIVE:To evaluate esthetic outcomes and complications of nasal alar defects repaired with FTSGs from the medial cheek.MATERIALS AND METHODS:A retrospective chart review of Mohs surgery patients who had FTSG repair of the nasal ala between January 2015 and August 2020 was performed. Demographic, surgery, and follow-up visit data were reviewed. Cosmesis was rated by a facial plastic surgeon, a Mohs surgeon, and a plastic surgeon using baseline, defect, and follow-up visit photographs.RESULTS:Sixty-nine patients with FTSG repairs of nasal alar defects were identified. 51 of 69 patients (73.9%) had the cheek donor site, and 18 of 69 patients (26.1%) had a noncheek donor site. The mean (SD) rater visual analog score for both cohorts was good with no significant difference (cheek: 65.9 [13.8]; noncheek: 66.1 [15.3]; p = .96). A notable difference in the complication rate by donor site was observed (cheek: 6.9%, noncheek: 16.7%; p = .13), although it did not reach significance.CONCLUSION:The cheek is a reliable FTSG donor site for nasal alar defects after Mohs micrographic surgery, with a trend toward fewer complications.

Studies show that minorities are underrepresented in high-paying subspecialties. Additional study is needed to further examine the extent to which early life socioeconomic background influences US physicians' academic performance and medical specialty choice. We distributed a Qualtrics survey to all house-staff at Saint Louis University (approximately 600 physicians) and to other dermatology programs through a national Dermatology Program Directors Listserv. Survey respondents were asked about their demographics, family socioeconomic status, medical specialty, United States Medical Licensing Exam (USMLE) Step 1 scores, and amount of debt from loans. The medical specialties were grouped into 3 categories based on level of competitiveness according to 2020 NMRP applicant match data: least competitive with average Step 1 scores of 220-229, medium competitive with scores of 230-239, and highly competitive with scores of >240. Respondents were also stratified into low, medium, and high-risk groups based on having certain risk factors, including being female, nonwhite, non-Asian, foreign-born, and having a childhood household income <$50,000. Univariate analysis was performed. Average Step 1 scores were higher in respondents in the low-risk group (238) compared with respondents in high-risk groups (210), P = .016. More respondents in the low-risk group matched into competitive versus noncompetitive specialties (42% versus 35%), and more respondents in the medium risk group matched into noncompetitive versus competitive specialties (65% versus 55%). This study demonstrates that early life socioeconomic factors influence academic performance and specialty choice. The study is limited because it does not capture the personal preferences that factor into specialty choice.

To the Editor: It has been estimated that 5.4 million new cases of nonmelanoma skin cancer are diagnosed each year,1 with up to 10% of basal cell carcinomas and 20% of squamous cell carcinomas occurring on the lower extremities.2 The treatment for nonmelanoma skin cancer is often destructive or surgical, with Mohs micrographic surgery frequently used for skin cancers below the knee. This increase in the incidence of skin cancer on the lower extremities results in an increase in the number of postoperative lower extremity wounds.

To the Editor: Health care policy changes implemented during the COVID-19 pandemic significantly increased access to telehealth starting March 2020.1,2 Given the expanded acceptance of synchronous teledermatology, we collected data to inform the planning of dermatology access during and after the pandemic.

Background Appropriate use criteria (AUC) provide patient-centered physician guidance in test selection. An initial set of AUC was reported by the American Society of Dermatopathology (ASDP) in 2018. AUC reflect evidence collected at single timepoints and may be affected by evolving evidence and experience. The objective of this study was to update and expand AUC for selected tests. Methods RAND/UCLA (RAND Corporation [Santa Monica, CA]/University of California Los Angeles) methodology used includes the following: (a) literature review; (b) review of previously rated tests and previously employed clinical scenarios; (c) selection of previously rated tests for new ratings; (d) development of new clinical scenarios; (e) selection of additional tests; (f) three rating rounds with feedback and group discussion after rounds 1 and 2. Results For 220 clinical scenarios comprising lymphoproliferative (light chain clonality), melanocytic (comparative genomic hybridization, fluorescence in situ hybridization, reverse transcription polymerase chain reaction, telomerase reverse transcriptase promoter), vascular disorders (MYC), and inflammatory dermatoses (periodic acid-Schiff, Gomori methenamine silver), consensus by panel raters was reached in 172 of 220 (78%) scenarios, with 103 of 148 (70%) rated "usually appropriate" or "rarely appropriate" and 45 of 148 (30%), "appropriateness uncertain." Limitations: The study design only measures appropriateness. Cost, availability, test comparison, and additional clinical considerations are not measured. The possibility that the findings of this study may be influenced by the inherent biases of the dermatopathologists involved in the study cannot be excluded. Conclusions AUC are reported for selected diagnostic tests in clinical scenarios that occur in dermatopathology practice. Adhering to AUC may reduce inappropriate test utilization and improve healthcare delivery.

Introduction: Insurance policy changes and stay-at-home orders during the COVID-19 pandemic led to increased use of teledermatology. This study measured patient and provider views about teledermatology, March to August 2020.

Background: Medical billing and coding remain increasingly complicated and confusing issues for young and old dermatologists alike, often causing inconsistencies in billing among providers. Over and under billing are a common source of audits in private practice, and a source of angst for many physicians. There is an increasing emphasis on billing and coding as part of residency education; however, few studies have been done to date on resident proficiency in billing and coding.

To the Editor: Rising pressure for rapid patient care and changing medicolegal landscapes have created a demand for alternate surgical skills development models.1 Although traditional models are based on animals and cadavers, these models carry the risk of infection and high costs. Tomatoes (Lycopersicon esculentum) are described as a low-cost model with many advantages: availability; a variety of shapes and contours; and the ability to measure biopsy accuracy, breadth, and depth. However, their use has never been evaluated for efficacy.

Alopecia is a challenging complaint dermatologists address. Traditionally, the evaluation consists of a thorough history, a physical exam that grossly evaluates the presence (or absence) of follicular ostia, perifollicular erythema, scaling, pustules, hair shaft abnormalities, laboratory evaluation, and if warranted a scalp biopsy. Although histopathological assessment is the gold standard in diagnosis, some refuse this diagnostic procedure due to the perceived invasive nature. Recognizing the value of dermoscopy in differentiating pigmented lesions, some dermatologists use dermoscopy to aid in distinguishing various hair disorders from one another. To date, trichoscopy education in dermatology residency programs is minimal at best. This project assessed current understanding among Saint Louis University Dermatology residents and faculty of the trichoscopic features of lichen planopilaris (LPP) and central centrifugal cicatricial alopecia (CCCA) through 1 educational intervention. At baseline, 75% of residents (n = 8) and attendings (n = 4) use trichoscopy to help diagnose various forms of alopecia. Participants had variable degrees of comfort in recognition of trichoscopic features of LPP and CCCA at baseline, but post intervention, participants as a whole were more comfortable identifying trichoscopic characteristics, which was statistically significant. More, post intervention, correctly selected peripilar scale as the most common trichoscopic sign of LPP and perifollicular white/grey dots or halos, as the most common dermoscopic feature of CCCA. In spite of convincing trichoscopic signs of LPP or CCCA, participants would not defer biopsy. In sum, the educational intervention increased comfort in detecting common trichoscopic features of LPP and CCCA, in a statistically significant manner.

INTRODUCTION:Patients with both major depressive disorder (MDD) and generalized anxiety disorder (GAD) in addition to one or multiple comorbid non-communicable chronic diseases (NCCDs) face unique challenges. However, few studies have characterized how the burden of co-occurring MDD and GAD differs from that of only MDD or only GAD among patients with NCCDs. METHODS:In this study, we used Medical Expenditures Panel Survey data from 2010-2017 to understand how the economic and humanistic burden of co-occurring MDD and GAD differs from that of MDD or GAD alone among patients with NCCDs. We used generalized linear models to investigate this relationship and controlled for patient sociodemographics and clinical characteristics. RESULTS:Co-occurring MDD and GAD was associated with increases in mean annual per patient inpatient visits, office visits, emergency department visits, annual drug costs, and total medical costs. Among patients with 3+ NCCDs, MDD or GAD only was associated with lower odds ratios (ORs) of limitations in activities of daily living (ADLs; 0.532 and 0.508, respectively) and social (0.503, 0.526) and physical limitations (0.613, 0.613) compared to co-occurring MDD and GAD. Compared to patients with co-occurring MDD and GAD, having MDD only or GAD only was associated with significantly lower odds of cognitive limitations (0.659 and 0.461, respectively) in patients with 1-2 NCCDs and patients with 3+ NCCDs (0.511, 0.416). DISCUSSION:Comorbid MDD and GAD was associated with higher economic burden, lower quality of life, and greater limitations in daily living compared to MDD or GAD alone. Health-related economic and humanistic burden increased with number of NCCDs.

Introduction: Metabolic resuscitation of organ donors and the attenuation of oxidative stress incurred by organs following brain death and transplantation have the potential to improve organ yield and allograft function. Thiamine (vitamin B1) is a vital coenzyme in both energy metabolism and the production of antioxidants that has not been studied in the donor population. Research Aim: To determine the frequency of subclinical thiamine deficiency in brain-dead organ donors and its correlation with demographics, length of hospitalization, donor management, lactic acidosis, and the requirement for vasoactive support. Design: Prospective cohort study of brain-dead donors managed at a single organ procurement organization’s organ recovery facility. Results: A total 64 donors were enrolled; 24 donors had thiamine levels drawn upon arrival and 40 donors had levels drawn at the time of organ procurement. Whole blood thiamine levels were inversely correlated with the time from death (P = .007) and 20% (8/40) of donors had levels below the normal range at the time of organ procurement. Demographic features of the donor were not associated with thiamine levels although longer hospital stays prior to death were associated with lower levels ( P < .05). The presence and resolution of lactic acidosis was not associated with whole blood thiamine level. Higher thiamine levels were associated with earlier discontinuation of vasoactive support ( P = .04). Discussion: Whole blood thiamine deficiency was not uncommon at the time of organ procurement. Thiamine may be associated with the requirement for hemodynamic support.

To the Editor: Compression stocking use for stasis dermatitis is an effective treatment to control symptoms, especially during acute flares.1 The annual health care cost of stasis dermatitis is $195 to $515 million, including unnecessary hospitalizations.2 High rates of noncompliance (60%-70%) with compression stocking use have been documented, but underlying factors are not well understood.1 We sought to characterize the patient-reported concerns that influence adherence to prescribed use of compression stockings.