BACKGROUND Patients with darker skin phototypes self-report less facial aging than their lighter-skinned counterparts. However, the association of skin phototype with the type of cosmetic procedures received, is yet to be established in a Canadian context. OBJECTIVE To compare the pattern of nonsurgical cosmetic procedures performed on people with different Fitzpatrick SPTs. MATERIALS AND METHODSCross-sectional study of patient encounters from October 2020-April 2022. Charts and photographs were reviewed and analyzed for age, sex, SPT, and procedure type. Participants were stratified by SPT into 2 cohorts: SPT I-III and SPT IV-VI. SPTs were collapsed into groups based on definitions of "skin of color" (SPT IV-VI) in previous literature. RESULTS We analyzed 350 patients with mean age 43.4, of whom 320 (91%) were female and 30 (9%) were male. The SPT I-III cohort was older (mean age 45 vs 38.5 years, p < .0001) and more frequently underwent neuromodulator injection. The SPT IV-VI cohort more frequently underwent microneedling, platelet-rich plasma, or electrodessication. CONCLUSION There are distinct patterns of cosmetic procedures performed. The SPT I-III cohort more commonly received procedures to manage facial aging. The SPT IV-VI cohort was younger and more commonly underwent procedures to manage hyperpigmentation.

PurposeThe free bilamellar autograft (FBA) procedure involves harvesting a free, full-thickness section of eyelid tissue from one of the patient's healthy eyelids to reconstruct a large defect of the involved eyelid. No vascular augmentation is employed. The purpose of this study was to determine the structural and cosmetic results of this procedure. MethodsA case series was performed, looking at patients who underwent the FBA procedure for large, full-thickness eyelid defects (>50% eyelid length) between 2009 and 2020 at a single oculoplastic surgical centre. Basal cell carcinomas most frequently met criteria for the procedure. OHSN-REB waived ethics approval. All surgeries were performed by one surgeon. A single operation, with surgical steps reported in detail, was completed with follow-up documentation at ideally 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year. The mean follow-up period was 28 months. ResultsThirty-one patients (17 males, 14 females, mean age 78-years-old) were included in the case series. Comorbidities included diabetes and smoking. Most patients had known basal cell carcinomas removed from the upper or lower eyelid. The mean widths of the recipient and donor sites were 18.8 and 11.5 mm, respectively. All 31 FBA surgeries resulted in structurally functional, cosmetically pleasing, and viable eyelids. Six patients developed minor graft dehiscence, 3 developed an ectropion, and 1 developed mild superficial graft necrosis secondary to frostbite, which fully recovered. Three healing phases were identified. ConclusionThis case series adds to the currently sparse data on the free bilamellar autograft procedure. The surgical technique is clearly articulated and illustrated. The FBA procedure is a simple and efficient alternative to current surgical techniques in the reconstruction of full-thickness upper and lower eyelid defects. The FBA provides functional and cosmetic success, despite the absence of an intact blood supply, with decreased operative time and faster recovery.

Photoprotection is a critical health prevention strategy to reduce the deleterious effects of ultraviolet radiation (UVR) and visible light (VL). Methods of photoprotection are reviewed in this paper, with an emphasis on sunscreen. The most appropriate sunscreen formulation for personal use depends on several factors. Active sunscreen ingredients vary in their protective effect over the UVR and VL spectrum. There are dermatologic diseases that cause photosensitivity or that are aggravated by a particular action spectrum. In these situations, sunscreen suggestions can address the specific concern. Sunscreen does not represent a single entity. Appropriate personalized sunscreen selection is critical to improve compliance and clinical outcomes. Health care providers can facilitate informed product selection with awareness of evolving sunscreen formulations and counseling patients on appropriate use. This review aims to summarize different forms of photoprotection, discuss absorption of sunscreen ingredients, possible adverse effects, and disease-specific preferences for chemical, physical or oral agents that may decrease UVR and VL harmful effects.

Over 1 million isotretinoin prescriptions are authorized in the United States per year. An insight into the frequency, dose dependency, timing, and reversibility of hair loss associated with isotretinoin treatment for acne vulgaris could help guide dosing regimens and patient counseling. The objective of this systematic review was to assess the frequency of hair loss in patients with acne vulgaris on < 0.5 mg/kg/d daily doses of isotretinoin versus the frequency of hair loss in patients with acne vulgaris on >= 0.5 mg/kg/d daily doses of isotretinoin. An Embase and MEDLINE search was conducted on July 15, 2020, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta -Analyses guidelines. The review focused on acne vulgaris patients. The treatment of acne vulgaris is the most common use of isotretinoin, and the population is typically younger and with fewer comorbidities. Twenty-two studies reported hair loss with oral isotretinoin treatment. A frequency analysis suggested that patients with acne vulgaris on < 0.5 mg/kg/d of isotretinoin experienced hair loss at a frequency of 3.2% (n = 18/565) compared with those on >= 0.5 mg/kg/d, who experienced hair loss at a frequency of 5.7% (n = 192/3375). Inferential statistics were not possible. Physicians should consider counseling patients about the risk of telogen effluvium prior to drug initiation, as is commonly done for other side effects. The potential trend of increased hair loss frequency at a higher daily dosing warrants further investigation using higher -quality research.

IMPORTANCE:Understanding postoperative opioid consumption is key to reducing opioid misuse. OBJECTIVE:The aim of the study was to quantify the amount of outpatient opioids consumed after urogynecologic surgery. STUDY DESIGN:This is a prospective multicenter cohort study sponsored by the American Urogynecologic Society Fellow's Pelvic Research Network. Women undergoing pelvic organ prolapse or urinary incontinence surgery between May 2019 and January 2021 were included. Patients used text messaging to report daily opioid consumption, pain levels, and nonopioid analgesic consumption 2 weeks postoperatively. Demographic and perioperative factors associated with high opioid use (>75th percentile) were identified. RESULTS:Two hundred sixty-one patients were included from 9 academic centers. The median (interquartile range) morphine milligram equivalents (MME) consumed were 28 (0-65) and prescribed were 75 (50-113). The median ibuprofen and acetaminophen tablets consumed were 19 (10-34) and 12 (4-26). The median pain level was 2.7 of 10 (1.7-4.4). Factors associated with high MME use (>65 MME) included body mass index greater than 30 ( P < 0.01), chronic pain ( P < 0.01), elevated baseline pain score ( P < 0.01), elevated blood loss ( P < 0.01), longer operating time ( P < 0.01), and southern region ( P < 0.01). High MME consumers more frequently underwent perineorrhaphy ( P = 0.03), although this was not significant on multivariate analysis. CONCLUSIONS:Urogynecology patients consume a median of 28 MME (3-4 oxycodone 5-mg tablets) after surgery, and surgeons prescribe 3 times this amount (75 MME, 10 oxycodone tablets). In addition, there are several factors that can be used to identify patients who will require greater numbers of opioids. These data may be used to enhance existing prescribing guidelines.

To the Editor: Kong et al1Kong H.E. Pollack B.P. Blalock T.W. Cannabinoids in dermatologic surgery.J Am Acad Dermatol. 2021; 85: 1565-1570Abstract Full Text Full Text PDF Scopus (3) Google Scholar comprehensively reviewed the impact of cannabinoids on inflammation, proliferation, fibrosis, pain management, and wound healing, with a focus on implications for dermatologic surgery. We would like to extend this thorough discussion to include the effect of cannabinoids on tissue perfusion and chronic wound healing as well as the potential concerns with the modes of administration of cannabinoids.Studies examining the impact of cannabinoids on tissue perfusion have reported mixed results. In a study of 18 patients, the administration of HU210, a synthetic cannabinoid receptor agonist, was shown to decrease blood flow, as measured using laser Doppler.2Dvorak M. Watkinson A. McGlone F. Rukwied R. Histamine-induced responses are attenuated by a cannabinoid receptor agonist in human skin.Inflamm Res. 2003; 52: 238-245Crossref PubMed Scopus (126) Google Scholar However, a recent systematic review outlined the literature on the vasodilatory and vasoconstrictive effects of cannabinoids.3Richter J.S. Quenardelle V. Rouyer O. et al.A systematic review of the complex effects of cannabinoids on cerebral and peripheral circulation in animal models.Front Physiol. 2018; 9: 622Crossref PubMed Scopus (23) Google Scholar In this review, it was suggested that the vascular effects of endocannabinoids depend on the dose, time since administration, use of anesthesia, and baseline arterial pressure. Although currently, there is limited and poor-quality evidence to definitively conclude how cannabinoids affect postoperative tissue perfusion and chronic wound healing, it is an important area of future study.The anti-inflammatory and analgesic effects of cannabinoids may positively impact chronic wound healing. Although the exact mechanisms are unclear, it has been postulated that cannabinoids decrease the levels of tumor necrosis factor α, reactive oxygen species, and lipoxygenases, resulting in beneficial effects on periwound tissues and improved wound healing.4Maida V. Shi R.B. Fazzari F.G. Zomparelli L. Topical cannabis-based medicines - A novel paradigm and treatment for non-uremic calciphylaxis leg ulcers: an open label trial.Int Wound J. 2020; 17: 1508-1516Crossref PubMed Scopus (21) Google Scholar Although the current data suggesting that cannabinoid use is beneficial for wound healing are limited to a few case reports, several higher-quality studies are underway. An ongoing open-label clinical trial of 35 patients is examining the effect of topical cannabis-based medicine, which includes a mixture of cannabinoids, terpenes, and flavonoids, on chronic wound healing and wound-related pain (ISRCTN16488940). The preliminary results of 2 elderly female patients with recalcitrant nonuremic calciphylaxis leg ulcers demonstrated complete wound closure after a mean of 76 days, with no adverse effects.4Maida V. Shi R.B. Fazzari F.G. Zomparelli L. Topical cannabis-based medicines - A novel paradigm and treatment for non-uremic calciphylaxis leg ulcers: an open label trial.Int Wound J. 2020; 17: 1508-1516Crossref PubMed Scopus (21) Google Scholar The results of the ongoing and future larger clinical trials will help establish whether topical cannabinoids may be an effective and safe treatment for chronic wounds.Finally, the method of cannabis administration and the type of vehicle are important considerations for the efficacy of wound healing, given the numerous systemic formulations available (smoking, vaping, edibles, patches, as well as topical formulations with oils, creams, and sprays). Patients who smoke cannabis are more likely to smoke tobacco than patients who do not and may not disclose that tobacco is rolled in with the marijuana. Mechanistically, heated tobacco, nicotine, and gaseous byproducts cause tissue hypoxia via vasoconstriction and increased blood viscosity. This ultimately leads to poor wound healing5McDaniel J.C. Browning K.K. Smoking, chronic wound healing, and implications for evidence-based practice.J Wound Ostomy Continence Nurs. 2014; 41: 415-423Crossref PubMed Scopus (82) Google Scholar and is an important confounder to consider clinically. Given this potential risk, a restriction on smoking both cannabis and tobacco preoperatively may be warranted.In summary, considering the factors affecting tissue perfusion, their role in wound healing, and the method of administration is substantial for the evaluation of the safety and efficacy of cannabinoids in relation to medical and surgical dermatology. High-quality clinical trials are warranted to help establish future recommendations and guidelines. To the Editor: Kong et al1Kong H.E. Pollack B.P. Blalock T.W. Cannabinoids in dermatologic surgery.J Am Acad Dermatol. 2021; 85: 1565-1570Abstract Full Text Full Text PDF Scopus (3) Google Scholar comprehensively reviewed the impact of cannabinoids on inflammation, proliferation, fibrosis, pain management, and wound healing, with a focus on implications for dermatologic surgery. We would like to extend this thorough discussion to include the effect of cannabinoids on tissue perfusion and chronic wound healing as well as the potential concerns with the modes of administration of cannabinoids. Studies examining the impact of cannabinoids on tissue perfusion have reported mixed results. In a study of 18 patients, the administration of HU210, a synthetic cannabinoid receptor agonist, was shown to decrease blood flow, as measured using laser Doppler.2Dvorak M. Watkinson A. McGlone F. Rukwied R. Histamine-induced responses are attenuated by a cannabinoid receptor agonist in human skin.Inflamm Res. 2003; 52: 238-245Crossref PubMed Scopus (126) Google Scholar However, a recent systematic review outlined the literature on the vasodilatory and vasoconstrictive effects of cannabinoids.3Richter J.S. Quenardelle V. Rouyer O. et al.A systematic review of the complex effects of cannabinoids on cerebral and peripheral circulation in animal models.Front Physiol. 2018; 9: 622Crossref PubMed Scopus (23) Google Scholar In this review, it was suggested that the vascular effects of endocannabinoids depend on the dose, time since administration, use of anesthesia, and baseline arterial pressure. Although currently, there is limited and poor-quality evidence to definitively conclude how cannabinoids affect postoperative tissue perfusion and chronic wound healing, it is an important area of future study. The anti-inflammatory and analgesic effects of cannabinoids may positively impact chronic wound healing. Although the exact mechanisms are unclear, it has been postulated that cannabinoids decrease the levels of tumor necrosis factor α, reactive oxygen species, and lipoxygenases, resulting in beneficial effects on periwound tissues and improved wound healing.4Maida V. Shi R.B. Fazzari F.G. Zomparelli L. Topical cannabis-based medicines - A novel paradigm and treatment for non-uremic calciphylaxis leg ulcers: an open label trial.Int Wound J. 2020; 17: 1508-1516Crossref PubMed Scopus (21) Google Scholar Although the current data suggesting that cannabinoid use is beneficial for wound healing are limited to a few case reports, several higher-quality studies are underway. An ongoing open-label clinical trial of 35 patients is examining the effect of topical cannabis-based medicine, which includes a mixture of cannabinoids, terpenes, and flavonoids, on chronic wound healing and wound-related pain (ISRCTN16488940). The preliminary results of 2 elderly female patients with recalcitrant nonuremic calciphylaxis leg ulcers demonstrated complete wound closure after a mean of 76 days, with no adverse effects.4Maida V. Shi R.B. Fazzari F.G. Zomparelli L. Topical cannabis-based medicines - A novel paradigm and treatment for non-uremic calciphylaxis leg ulcers: an open label trial.Int Wound J. 2020; 17: 1508-1516Crossref PubMed Scopus (21) Google Scholar The results of the ongoing and future larger clinical trials will help establish whether topical cannabinoids may be an effective and safe treatment for chronic wounds. Finally, the method of cannabis administration and the type of vehicle are important considerations for the efficacy of wound healing, given the numerous systemic formulations available (smoking, vaping, edibles, patches, as well as topical formulations with oils, creams, and sprays). Patients who smoke cannabis are more likely to smoke tobacco than patients who do not and may not disclose that tobacco is rolled in with the marijuana. Mechanistically, heated tobacco, nicotine, and gaseous byproducts cause tissue hypoxia via vasoconstriction and increased blood viscosity. This ultimately leads to poor wound healing5McDaniel J.C. Browning K.K. Smoking, chronic wound healing, and implications for evidence-based practice.J Wound Ostomy Continence Nurs. 2014; 41: 415-423Crossref PubMed Scopus (82) Google Scholar and is an important confounder to consider clinically. Given this potential risk, a restriction on smoking both cannabis and tobacco preoperatively may be warranted. In summary, considering the factors affecting tissue perfusion, their role in wound healing, and the method of administration is substantial for the evaluation of the safety and efficacy of cannabinoids in relation to medical and surgical dermatology. High-quality clinical trials are warranted to help establish future recommendations and guidelines. None disclosed. Cannabinoids in dermatologic surgeryJournal of the American Academy of DermatologyVol. 85Issue 6PreviewThough known as a medicinal herb for centuries, the recent legalization of cannabinoids across many states has ushered in a new era where cannabinoids have become a popular treatment option among clinicians and patients alike. Cannabinoids have demonstrated efficacy in wound healing, reducing inflammation, ameliorating pain, and have shown potential as an antitumor agent. As a result, cannabinoids have been rapidly woven into the fabric of modern medicine. However, the utility of cannabinoids in dermatologic surgery has not been explored to date. Full-Text PDF

To the Editor: Alopecia remains a therapeutic challenge to dermatologists. Topical 5% minoxidil is a Food and Drug Administration (FDA)–approved treatment for androgenetic alopecia (AGA), with a variable response rate. Studies suggest that low dose oral minoxidil (LDOM) requires decreased follicular enzymatic activity compared with its topical form.1 Although reports document its successful use in dermatology, adaptation in North America has been low. It is unclear whether this is due to concern about patient safety or lack of established oral minoxidil dosing for hair loss.

BACKGROUND:Prurigo pigmentosa (PP) is a rare inflammatory dermatosis characterized by pruritic erythematous papules that coalesce to form a reticulate pattern. PP is often misdiagnosed, and patients are treated with ineffective therapies. Although the majority of reports about PP are from East Asia, patients of all backgrounds can be affected.OBJECTIVES:To perform a systematic review of reported PP cases with the purpose of summarizing the clinical presentation and treatment of PP.METHODS:MEDLINE and Embase were searched for original articles describing PP. We identified 115 studies from 24 countries representing 369 patients to include in the analysis.RESULTS:Of the 369 patients included in the analysis, the mean age was 25.6 years (range: 13-72 years) with 72.1% (266 of 369) female. Risk factors or aggravating factors were described in 52.3% (193 of 369) of patients and included dietary changes (25.5%, 94 of 369), friction (8.4%, 31 of 369), sweat (7.6%, 28 of 369), and ketonuria (5.1%, 19 of 369). Of those patients who experienced PP following dietary changes, 40.4% (38 of 94) started a ketogenic diet. Minocycline monotherapy was the most frequently prescribed treatment for PP (20.9%, 77 of 369), achieving complete resolution in 48.1% (37 of 77) of patients.CONCLUSIONS:PP is sometimes associated with ketogenic diets and can be effectively managed with oral tetracyclines.

To the Editor: Ocular melanoma makes up <5% of all melanomas and can be subdivided into uveal (choroid, ciliary body, iris), conjunctival, eyelid, and orbital melanoma.1Kaliki S. Shields C.L. Uveal melanoma: relatively rare but deadly cancer.Eye. 2017; 31: 241-257Crossref PubMed Scopus (249) Google Scholar,2Helgadottir H. Höiom V. The genetics of uveal melanoma: current insights.App Clin Genet. 2016; 9: 147-155Crossref PubMed Scopus (71) Google Scholar Uveal melanoma is the most common type (83%) of ocular melanoma and is associated with high mortality rates.1Kaliki S. Shields C.L. Uveal melanoma: relatively rare but deadly cancer.Eye. 2017; 31: 241-257Crossref PubMed Scopus (249) Google Scholar Although ophthalmologists are primarily responsible for diagnosing and managing ocular melanoma, dermatologists can play a role in early recognition and referral for this vision- and life-threatening diagnosis. Dermatologists are in a unique position to arrange screening due to shared risk factors between ocular and cutaneous melanoma as well as the increased risk of ocular melanoma associated with several dermatologic conditions. Each subtype of ocular melanoma has potential cutaneous manifestations (Supplemental Table I, available via Mendeley at https://doi.org/10.17632/26sjznk48d.1ed). We review the risk factors and cutaneous signs for ocular melanoma that might prompt an early referral to ophthalmology. Risk factors for ocular melanoma include light eye color (blue/grey; relative risk, 1.75), fair skin (relative risk, 1.80), and inability to tan (relative risk, 1.64), but not blonde hair.1Kaliki S. Shields C.L. Uveal melanoma: relatively rare but deadly cancer.Eye. 2017; 31: 241-257Crossref PubMed Scopus (249) Google Scholar Whether a history of ultraviolet light exposure is a risk factor remains unclear.1Kaliki S. Shields C.L. Uveal melanoma: relatively rare but deadly cancer.Eye. 2017; 31: 241-257Crossref PubMed Scopus (249) Google Scholar Patients with a family history of ocular melanoma, familial atypical mole and melanoma syndrome, xeroderma pigmentosum, and dysplastic nevi also have increased risk of ocular melanoma.3Nayman T. Bostan C. Logan P. Burnier M.N. Uveal melanoma risk factors: a systematic review of meta-analyses.Curr Eye Res. 2017; 42: 1085-1093Crossref PubMed Scopus (34) Google Scholar Oculodermal melanocytosis (nevus of Ota) increases the risk for both uveal melanoma and orbital melanoma.1Kaliki S. Shields C.L. Uveal melanoma: relatively rare but deadly cancer.Eye. 2017; 31: 241-257Crossref PubMed Scopus (249) Google Scholar Occupational exposures (ie, welding) may be associated with uveal melanoma.3Nayman T. Bostan C. Logan P. Burnier M.N. Uveal melanoma risk factors: a systematic review of meta-analyses.Curr Eye Res. 2017; 42: 1085-1093Crossref PubMed Scopus (34) Google Scholar Finally, patients with primary acquired melanosis of the conjunctiva should be monitored and referred for biopsy, because 13% progress to melanoma when severe atypia is present.4Shields J.A. Shields C.L. Mashayekhi A. et al.Primary acquired melanosis of the conjunctiva: risks for progression to melanoma in 311 eyes.Ophthalmology. 2008; 115: 511-519Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Most cases of uveal melanoma are sporadic, but a small percentage are inherited.2Helgadottir H. Höiom V. The genetics of uveal melanoma: current insights.App Clin Genet. 2016; 9: 147-155Crossref PubMed Scopus (71) Google Scholar Uveal melanomas express GNAQ, GNAQ11, BRCA1-associated protein 1 (BAP1), EIF1AX, and SF3B1 mutations.2Helgadottir H. Höiom V. The genetics of uveal melanoma: current insights.App Clin Genet. 2016; 9: 147-155Crossref PubMed Scopus (71) Google Scholar A germline mutation of BAP1 can cause BAP1 predisposition syndrome, with higher risk of cutaneous melanoma, uveal melanoma, basal cell carcinoma, malignant mesothelioma, and renal cell carcinoma.1Kaliki S. Shields C.L. Uveal melanoma: relatively rare but deadly cancer.Eye. 2017; 31: 241-257Crossref PubMed Scopus (249) Google Scholar Somatic BAP1 mutations are strongly correlated with metastatic disease in uveal melanoma.2Helgadottir H. Höiom V. The genetics of uveal melanoma: current insights.App Clin Genet. 2016; 9: 147-155Crossref PubMed Scopus (71) Google Scholar Dermatologists should examine for cutaneous signs of ocular melanoma (Supplemental Table I) and refer to ophthalmology when a patient has metastatic melanoma with an unknown primary. One-tenth of metastatic uveal melanomas involve the skin and subcutaneous tissue (12%) and lymph nodes (11%).1Kaliki S. Shields C.L. Uveal melanoma: relatively rare but deadly cancer.Eye. 2017; 31: 241-257Crossref PubMed Scopus (249) Google Scholar Dermatologists should also consider screening patients with shared risk factors for cutaneous melanoma. Because eyelid melanoma presents similarly to cutaneous melanoma, the periocular region should be examined as part of a complete skin examination, with careful attention to the medial canthus region and eyelid creases. Conjunctival melanoma can be visible on the ocular surface (bulbar conjunctiva) (Fig 1) or the palpebral conjunctiva, which can extend to the eyelid margin (Fig 2) and periocular skin. Acquired poliosis of the eyelashes is a subtle cutaneous finding that can suggest a larger conjunctival or orbital melanoma.5Alsuhaibani A.H. Alhumayed M. Primary orbital melanoma with poliosis and a palpable mass.Arch Ophthalmol. 2011; 129: 1382-1383Crossref PubMed Scopus (13) Google ScholarFig 2Melanoma extending full thickness on the lower eyelid margin. Photograph taken by Dr Hector McDonald.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In summary, there is a significant overlap in patient populations with ocular melanoma and cutaneous melanoma. By becoming familiar with the cutaneous signs and risk factors associated with ocular melanoma, dermatologists can help improve clinical outcomes for these patients through timely diagnosis and referral to ophthalmology. The authors thank Hector McDonald, MD, FRCSC (Oculoplastic Surgery, Ottawa, ON, Canada), for providing the photograph of the full-thickness melanoma on the lower eyelid margin.

To the Editor: We appreciate the analysis of minoxidil-related information of adverse events by Ortega-Quijano and colleagues, particularly the information highlighting 8 patients prescribed oral minoxidil (Loniten; Pfizer).

Skin-centered body dysmorphic disorder (BDD) and excoriation disorder (ED) are categorized under Obsessive Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and are characterized by excessive or inappropriate skin picking. Patients with skin-centered BDD and ED often first present to dermatology. These conditions are important to recognize and appropriately diagnose, as perpetuation of the disorder is inevitable without appropriate psychiatric treatment. These conditions are associated with increased morbidity and BDD is associated with increased suicide risk. This review aims to present a combined dermatologic and psychiatric approach to diagnosing, differentiating, and managing skin-centered BDD and ED. Patient presentation, DSM-5 criteria, and management approaches are reviewed.

Skin-centered body dysmorphic disorder (BDD) and excoriation disorder (ED) are categorized under Obsessive Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and are characterized by excessive or inappropriate skin picking. Patients with skin-centered BDD and ED often first present to dermatology. These conditions are important to recognize and appropriately diagnose, as perpetuation of the disorder is inevitable without appropriate psychiatric treatment. These conditions are associated with increased morbidity and BDD is associated with increased suicide risk. This review aims to present a combined dermatologic and psychiatric approach to diagnosing, differentiating, and managing skin-centered BDD and ED. Patient presentation, DSM-5 criteria, and management approaches are reviewed.

Factitious disorder can present in multiple health care settings, with patients intentionally producing symptoms to assume the sick role. This assumption of the sick role can result in multiple hospitalizations with unnecessary diagnostic workup, as well as invasive diagnostic procedures that can lead to worrisome side effects. Differential diagnoses that should be ruled out include malingering, somatic symptom disorder, and anxiety disorders. For many providers, patients with factitious disorder can be a challenge to treat because the etiology of the disorder remains unclear. There are multiple psychological theories that attempt to explain the motivation and thought process behind the voluntary production of symptoms. Some of these theories have addressed disruptive attachments during childhood, possible intergenerational transfer of the disorder, personal identity conflicts, somatic illness as a form of masochistic activity toward oneself, and intrapsychic conflicts. Confrontation and psychotherapy with a multidisciplinary team has been proposed as a form of treatment. An understanding of the psychological factors associated with factitious disorder can help providers understand the rationale behind the patient's presentation and aid in the formulation of a treatment plan.

For decades it has been widely accepted that elective procedures should be delayed for at least 6-months following completion of isotretinoin therapy. However, numerous 2017 publications demonstrate the need for change in best practice. The evidence has yet to be succinctly summarized in a single article or in a stand-alone quick reference algorithm for physicians. This article's review of all 2017 publications confirms that the 6-month delay is not necessary for all procedures and provides a simple algorithmic approach to summarize the updated recommendations for procedural delay of cosmetic procedures following systemic isotretinoin therapy. This is a useful tool for clinicians and allows patients to receive the most appropriate and timely cosmetic therapy to minimize the psychosocial impact of the skin condition.

This Viewpoint examines the role of the Patient Health Questionnaire-2 in dermatology concerning secondary psychiatric disorders that involve emotional disturbances and manifest in response to the psychologic stress caused by dermatologic conditions.

BACKGROUND:An eczema action plan (EAP) is an individualized tool to help caregivers and patients self-manage eczema. While novel illustrated EAPs have been developed and validated, there is limited literature examining the value of EAPs from patient and caregiver perspectives.OBJECTIVES:The objective of this study was to test the usability, satisfaction, and usefulness of our validated EAP from the perspective of patients and caregivers.METHODS:Consecutive patients from the pediatric dermatology clinic of a tertiary children's hospital from July 2016 to July 2017 were offered enrolment in a prospective survey study; informed consent was obtained from participants. The illustrated EAP was explained to the participant by a trained research assistant. Participants were sent electronic postvisit surveys using Likert scale questions via REDCap on EAP usability and satisfaction (9 items) as well as on usefulness (3 items).RESULTS:Of 233 consecutive clinic patients, 192 participants (82%) were enrolled, and 112 (58%; 85 caregivers and 22 patients) completed the postvisit surveys. Characteristics were similar between responders and nonresponders. Overall, participants rated the usability (96%), satisfaction (85%), and usefulness (78%) of the EAP positively. Education level, experience with eczema, previous dermatology consultation, and participant type (caregiver vs patient) did not significantly affect the usability or usefulness ratings. However, caregivers' overall EAP ratings were significantly higher ( P = .02) than the patients'.CONCLUSION:The caregivers and participants demonstrate that the EAP is a useful and highly usable tool. Future research should examine the effectiveness of EAP use on objective atopic dermatitis outcomes using a pragmatic clinical trial design.

In Reply We thank Dr Nwabudike for replying to our publication on the Patient Health Questionnaire-2 (PHQ-2) in Dermatology. 1 We address his inquiries in chronological order:1.The confusion between emotional distress and depression is one of the key reasons we introduced the PHQ-2 into dermatology.The questionnaire is a brief version of psychiatry's Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria for depression, translating the 2 most heavily weighted criteria into a questionnaire format. 2 The complete DSM-5 depression criteria are not necessary for dermatologists to remember.Our goal is for dermatologists to recognize and screen for possible depression, detect suicidal ideation, and act on this by following our algorithm.We do not suggest that dermatologists formally diagnose or independently manage psychiatric conditions.Screening questionnaires are inadequate to make a diagnosis, and specialists should try to avoid making diagnoses outside the scope of their practice.2. We proposed the PHQ-2 as a screening tool because it is the most succinct questionnaire for use in busy clinics.There are more extensive questionnaires, but we believe that these would be challenging to integrate in a time-pressed system.Therefore, we recommend keeping the approach simple by using the PHQ-2 to standardize screening.3. Indeed, psychophysiologic disorders are considered a tertiary group within psychodermatologic conditions, 3 and we thank Dr Nwabudike for raising this point.In dermatology, these disorders occur when skin conditions are influenced by a person's state of the mind; classically, these patients will experience a flare of their skin condition when they are under emotional stress. 3 Although we believe that these patients are not the primary target of our algorithm, a subset of these patients may experience depression and suicidal ideation, and they could benefit from identification and appropriate action, as outlined in our algorithm.4. We hope that dermatologists do not feel uncomfortable asking patients questions about mental health.Dermatologists completed comprehensive medical training before entering the specialty.We believe that this foundational training appropriately equips any physician to screen for depression and suicidal ideation.Dermatologists have additional practice from screening patients undergoing treatment with systemic isotretinoin.Some dermatologists have already adopted the PHQ-2 for this specific purpose. 4 We are simply formalizing, standardizing, and expanding the concept so that it is applied in more patient situations.The goal of the PHQ-2 is to avoid in-depth dis-cussion and perform very targeted screening.We do not mean to imply that the dermatologist is responsible for management if the screen result is positive.Instead, the patient's family physician should be involved, as outlined in the algorithm. 1There is no indication for the dermatologist to personally refer the patient to a psychiatrist, so direct refusal of care is unlikely.We hope that with therapeutic rapport and a delicate approach, dermatologists will be successful in applying the algorithm.