To the Editor: As medicine shifts from the traditional doctor-patient relationship toward 1 that empowers patients, shared decision making becomes an effective communication framework for clinicians and patients to make health-related decisions. Patient decision aids (PDAs) foster informed treatment decisions through increasing patient awareness of risks versus benefits, creating realistic outcome expectations and encouraging the implementation of personal values in decision making.1 PDAs differ from typical health education materials, which consist of general information, by focusing more on options and outcomes.

Quality photographic documentation of lesions prior to biopsy can decrease the risk of wrong site surgery, improve patient care, and save lives.

Division of Dermatology, Department of Medicine, Washington University, St. Louis, Missouri The author has indicated no significant interest with commercial supporters.

*Both authors are affiliated with the Department of Dermatology, Dermatologic Surgery and Melanoma Program, University Hospitals Cleveland Medical Center-Case Western Reserve University, Cleveland, Ohio Address correspondence and reprint requests to: Jeremy S. Bordeaux, MD, MPH, Department of Dermatology, Dermatologic Surgery and Melanoma Program, University Hospitals Cleveland Medical Center-Case Western Reserve University, Cleveland, OH 44106, or e-mail: [email protected] The authors have indicated no significant interest with commercial supporters.

To the Editor: A 60-year-old woman presented for evaluation of a 1-year history of left hallux nail plate dystrophy and proximal nail fold inflammation. Her medical history included Cushing disease with associated uncontrolled diabetes mellitus (DM) and a remote history of cutaneous lichen planus (LP) that resolved 15 years prior to presentation. She noted improvement during intravenous courses of antibiotics for other infections. Examination of the left hallux revealed onycholysis, loss of the nail plate, and a yellow fibrinous base alongside erosion, erythema, and edema of the proximal toenail fold (Figure 1). The left second toe pad was markedly tender to palpation with scant exudate expressed from underneath the nail bed. Two biopsies of the hallux were performed. The proximal nail fold specimen revealed mild epidermal hyperplasia, and the nail bed demonstrated a nonspecific ulcer that was negative for acid-fast bacilli and fungi. Treatment over 2 months with cephalexin yielded improvement in both erythema and edema. Initial and repeat nail plate cultures grew ampicillinand penicillin-sensitive Enterococcus faecalis. Magnetic resonance imaging was performed to evaluate for osteomyelitis because of lack of resolution. Results demonstrated osteomyelitis of the distal tuft of the left hallux and the distal phalanx of the second toe (Figure 2). Vascular surgery evaluation revealed no evidence of large vessel arterial insufficiency. She was started on amoxicillin for superficial Enterococcus and Radiographic Changes of Osteomyelitis in a Patient With Periungual Lichen Planus

The relationship between patient experience and health care quality has generated significant interest in the patient experience measure. However, it is challenging to find information on how to improve one's patient experience score because scientific data on this topic are weak or lacking, and suggestions provided by scoring vendors are often overgeneralized and not specialty- specific. This review will focus on the current state of evidence supporting factors influencing patient experience (both positive and negative) in outpatient specialist encounters that are applicable to general and surgical dermatology. The literature review includes research from multiple medical specialties. Identified studies were based on title and abstract and sourced from Medline, PubMed, and Scopus databases. Medical subject headings terms in PubMed and Ovid Medline included "dermatology/standards,'' "patient satisfaction,'' "surgery/standards,'' "physician- patient relations,'' "surgery,'' "practice management,'' "practice management, medical,'' "office management,'' "patient experience,'' "practice guidelines,'' "best practice,'' and "outpatient surgery.'' During this review, three main themes affecting the patient experience emerged: communication, time, and access. Of the three, communication appears to be the dominant theme affecting the patient experience measure. (J Am Acad Dermatol 2018; 78: 653- 9.)

Assessing the patient experience has been a component of national health care policy for years in various forms, and it is now incorporated into many areas affecting physician practice. This review will focus on the origin and importance of this measure and address its critiques. The evolution of the measure as it progressed from patient satisfaction to patient experience and the rationale behind this shift will be detailed, the thought process behind the measure as an indicator of a culture of patient-centeredness and quality rather than as strictly a score will be reviewed, and the various motivators for physicians to improve patient experience will be divided into extrinsic and intrinsic and discussed.

BACKGROUND There is a paucity of data on Mohs surgery workforce patterns. OBJECTIVE To identify if gender differences exist in practice patterns of Mohs surgeons, factors that influence these differences, and factors influencing job satisfaction among Mohs surgeons. MATERIALS AND METHODS An electronic survey was distributed to dermatology organizations targeting members of the American College of Mohs Surgery (ACMS), from October 2015 to April 2016. RESULTS Two hundred twenty-seven ACMS members responded; 37% were women. Twenty-five percent of women and 19% of men work part time. Thirty-seven percent of women practice in academia versus 22% of men. Forty-three percent of women and 23% of men identified children as a factor affecting their ability to work full time. Gender comparisons for current job satisfaction show 57% of women and 35% of women being very satisfied. Supervision/feedback/recognition adds to satisfaction at a higher rate for women (53%) than for men (29%). For both genders combined, work content, patient base, and autonomy had the highest average job satisfaction ratings. CONCLUSION Gender differences exist in practice patterns and job satisfaction of Mohs surgeons. This study demonstrates factors that could influence job satisfaction among female Mohs surgeons-knowledge that is important to individuals who lead, mentor, or supervise female Mohs surgeons.

It is common for dermatology surgery patients to present on the day of surgery with more than one skin cancer needing Mohs micrographic surgery. When these carcinomas are located near one another, it may be more practical to treat both at the same time as the reconstruction for one defect may involve or otherwise affect the treatment or reconstruction for the other carcinoma. Treating both cancers on the same day creates an opportunity for efficient repairs where a creative single reconstruction may minimize the amount of tissue wasted during reconstruction,and minimize morbidity for the patient. Further,combining multiple defects into one closure may reduce cost as it has been shown that reconstructive choice affects the cost-effectiveness of Mohs surgery relative to a traditional excision and Mohs surgeons more commonly select less costly options for wound management. We present a case series of two-in-one closures - repairing two defects with one closure.

BACKGROUND:Irritant dermatitis, caused by genetic barrier dysfunction in atopic dermatitis or wet work in hand dermatitis, induces innate immune response that might predispose to allergic contact sensitization to less potent sensitizers.OBJECTIVES:We sought to determine if positive patch test results to less potent allergens are more prevalent in patients with a history of childhood flexural dermatitis or current wet work.METHODS:We examined our database of patients presenting to a contact dermatitis clinic tested to potential contact allergens as indicated by their history. Allergens from our most recent standard were studied if they could be classified as weak, moderate, or strong sensitizers based on published data from the local lymph node assay. Patients were stratified by a history of childhood-onset flexural dermatitis as a proxy for atopic dermatitis and by occupation.RESULTS:History of childhood-onset dermatitis predisposed to contact allergy to weak sensitizers and wet work to medium-potency sensitizers. Neither predisposed to contact allergy from strong sensitizers.LIMITATIONS:Association cannot prove causation.CONCLUSIONS:We conclude that strong sensitizers do not require wet work or atopy to cause sensitization. Barrier defects associated with childhood eczema and wet work may promote sensitization to weak antigens.

Department of Dermatology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio The authors have indicated no significant interest with commercial supporters.

Kohli, Nita MD, MPH1; Honda, Kord S. MD1; Bordeaux, Jeremy S. MD, MPH1 Author Information