Social determinants of health (SDOH) have received increasing attention in all aspects of healthcare. However, the role of SDOH in dermatological care is an ongoing area of research. We demonstrate the occupational, language and literacy constraints that complicate the diagnosis and treatment of an immigrant Vietnamese nail salon technician with chronic dyshidrotic eczema. This case serves to illustrate the importance of SDOH considerations in optimizing dermatological care.

Pruritus has long been linked to hepatic dysfunction; however, there are limited data characterizing the association between liver disease and prurigo nodularis (PN), a chronic inflammatory skin disease featuring severe pruritis. We thus conducted a cross-sectional analysis of hepatic comorbidities in PN patients using TriNetX, a large global health research network. This analysis revealed that PN patients had a higher risk (p < 0.001) of developing liver cirrhosis, acute and subacute hepatic failure, inflammatory liver disease, chronic hepatitis, nonalcoholic steatohepatitis, portal hypertension, fatty liver, chronic passive congestion of the liver, and hepatocellular carcinoma compared with healthy controls. The cumulative incidence of liver disease was about three times higher in PN patients compared with healthy controls. These findings provided the basis for translational studies to investigate a genetic mechanism for this association. Cutaneous transcriptomic analysis performed on PN patients revealed the dysregulation of genes related to hepatic failure in lesional PN compared with both nonlesional PN and control skin. Similarly, gene set variation analysis (GSVA) revealed a significantly increased (p < 0.05) activation of liver metabolism, chronic hepatic failure, acute hepatic failure, cholestatic liver disease, polycystic liver disease, and hepatocellular carcinoma pathways in lesional PN compared with control skin. A subsequent genome-wide association study (GWAS) identified shared single-nucleotide polymorphisms (SNPs) in the genes AR, EDIL3, MACROD2, PCSK5, RUNX1T1, TENM4, and ZEB2 between PN and liver disease from the FinnGen cohort. Significant dysregulation of the skin–liver axis in PN patients may explain the increased incidence and severity of hepatic comorbidities and help identify future therapeutic targets for PN.

Background: Emerging evidence suggests that cutaneous immune-related adverse events (cirAEs) are associated with a survival benefit in the setting of advanced melanoma treated with immune checkpoint inhibitor (ICI) therapy. Previous studies have not examined the role of melanoma subtypes on cirAE development and downstream therapeutic outcomes.Objective: Examine the impact of melanoma subtypes on cirAE onset and survival among ICI recipients.Methods: Retrospective multi-institutional cohort study. Multivariate time-series regressions were utilized to assess relationships between melanoma subtype, cirAE development, and survival.Results: Among 747 ICI recipients, 236 (31.6%) patients developed a cirAE. Patients with acral melanoma were less likely to develop a cirAE (hazard ratio [HR] = 0.41, P = .016) compared to patients with nonacral cutaneous melanoma. Across all melanoma subtypes, cirAEs were associated with reduced mortality (HR = 0.76, P = .042). Patients with acral (HR = 2.04, P = .005), mucosal (HR = 2.30, P < .001), and uveal (HR = 4.09, P < .001) primaries exhibited the worst survival. Limitations: Retrospective cohort study.Conclusion: This is the first study to demonstrate differences in cirAE development among melanoma subtypes. The presence of cirAEs was associated with better survival. Further, the lower incidence of cirAEs may be a marker of immunotherapy response, which is reflected in the association between acral melanoma and mortality. ( J Am Acad Dermatol 2023;88:1308-16.)

We used the information component (IC), a disproportionate Bayesian analysis comparing the number of observed versus expected adverse drug reactions, to determine the potential association between anti-neoplastic agents and thrombotic microangiopathy (TMA). The IC025 indicates the lower end of 95% of IC, in which a value >0 suggests a disproportionality signal between the drug of interest and the adverse drug reaction. Carfilzomib had the highest IC025 for TMA among all studied chemotherapies followed by gemcitabine, mitomycin, bevacizumab, and bortezomib.

To the Editor: Immune checkpoint inhibitors (ICIs) have revolutionized cancer care. Cutaneous immune-related adverse events (cirAEs) are frequent ICI side effects, often with a diverse presentation. However, cirAE duration and impact on ICI treatment are poorly characterized.1-4 Here, we investigate the timeline of cirAE presentation and resolution in a real-world setting by both nondermatologist and dermatologist providers.

Background: Sarcoidosis is a multisystem granulomatous disease with a wide variety of presentations and clinical courses. Cutaneous manifestations and comorbidities associated with sarcoid prognosis remain understudied. Methods: An EPIC query was run for patients age 18+ at the Johns Hopkins Hospital with a diagnosis of sarcoidosis of the skin according to the ICD-10-CM code D86.3. Data were obtained from a population-based sample of 240 patients from 2015 to 2020. Results: A total of 240 patients were included in the cohort study. The mean (SD) age was 43.76 (11.72) years, and 30% of participants were male; 76.25% of patients identified as black, 19.58% as white, and 4.17% as other. The average age of onset in remissive patients was significantly higher than progressive (47 ± 12 vs. 40 ± 10, p = 0.0005); 49% of black patients experienced progressive sarcoid compared to 32.6% of white patients (p = 0.028). Progressive disease was associated with the presence of lupus pernio (aOR = 3.29, 95% CI, 1.60–6.77) and at least one autoimmune comorbidity (aOR 6.831, 95% CI 1.819–11.843). Conclusions: When controlling for patient demographics, lupus pernio and the presence of at least one autoimmune condition were associated with progressive cutaneous sarcoidosis.

Self-reported racial or ethnic discrimination in a healthcare setting has been linked to worse health outcomes and not having a usual source of care, but has been rarely examined among Asian ethnic subgroups. We examined the association between Asian ethnic subgroup and self-reported discrimination in a healthcare setting, and whether both factors were associated with not having a usual source of care. Using the California Health Interview Survey (CHIS) 2015–2017, we used logistic regression models to assess associations among Asian ethnic subgroup, self-reported discrimination, and not having a usual source of care. Interactions between race and self-reported discrimination, foreign-born status, poverty level, and limited English proficiency were also analyzed. Respondents represented adults age 18 + residing in California who identified as White, Black, Hispanic, American Indian/Alaska Native, Asian (including Chinese, Filipino, Japanese, Korean, Vietnamese, and Other Asian), and Other. We examined two main outcomes: self-reported discrimination in a healthcare setting and having a usual source of care. There were 62,965 respondents. After survey weighting, Asians (OR 1.78, 95% CI 1.19–2.66) as an aggregate group were more likely to report discrimination than non-Hispanic Whites. When Asians were disaggregated, Japanese (3.12, 1.36–7.13) and Koreans (2.42, 1.11–5.29) were more likely to report discrimination than non-Hispanic Whites. Self-reported discrimination was marginally associated with not having a usual source of care (1.25, 0.99–1.57). Koreans were the only group associated with not having a usual source of care (2.10, 1.23–3.60). Foreign-born Chinese (ROR 7.42, 95% CI 1.7–32.32) and foreign-born Japanese (ROR 4.15, 95% CI 0.82–20.95) were more associated with self-reported discrimination than being independently foreign-born and Chinese or Japanese. Differences in self-reported discrimination in a healthcare setting and not having a usual source of care were observed among Asian ethnic subgroups. Better understanding of these differences in their sociocultural contexts will guide interventions to ensure equitable access to healthcare.

Cutaneous immune-related adverse events (cirAEs) are the most prevalent complication to arise from immunotherapy and cause significant morbidity. We aimed to determine the spectrum, timing, clinical features, and outcomes of cirAEs by conducting an observational pharmacovigilance study using VigiBase, the World Health Organization's global database of individual case safety reports from over 130 member countries (ClinicalTrials.gov, number NCT04898751). We compared adverse event reporting in patients who received immune checkpoint inhibitors (91,323 adverse events) with those of the full reporting database (18,919,358 adverse events). There were 10,933 cases of cirAEs within 51 distinct dermatologic types, with 27 specific eruptions with disproportionate signal represented (information component [IC]025 > 0). Of these 27 eruptions, there were eight cirAEs with n > 100 reports, including vitiligo (IC025 = 4.87), bullous pemphigoid (IC025 = 4.08), lichenoid dermatitis (IC025 = 3.69), erythema multiforme (IC025 = 1.03), toxic epidermal necrolysis (IC025 = 0.95), Stevens‒Johnson syndrome (IC025 = 0.41), drug eruption (IC025 = 0.11), and eczematous dermatitis (IC025 = 0.11). There were differences in time to onset after immune checkpoint inhibitor initiation, with a median of approximately 1 month (erythema multiforme, Stevens‒Johnson syndrome, and toxic epidermal necrolysis), 2 months (drug eruption and eczematous dermatitis), 4 months (lichenoid dermatitis), and 5‒6 months (bullous pemphigoid and vitiligo). CirAEs are diverse, dependent on cancer type, and have distinct and different onset times that are linked to the cirAE subtype.

Background: Prurigo nodularis (PN) is an understudied, pruritic inflammatory skin disease. Little is known about the effect of PN on quality of life and its associated economic burden.& nbsp;Objective: To quantify the impact of PN on quality of life and its economic implications.& nbsp;Methods: A cohort study of PN patients (n = 36) was conducted using the Health Utilities Index Mark 3 questionnaire. Control data from US adults (n = 4187) were obtained from the 2002-2003 Joint Canada/ United States Survey of Health. Quality-adjusted life year loss and economic costs were estimated by comparing the Health Utilities Index Mark 3 scores of the PN patients with those of the controls.& nbsp;Results: The PN patients had lower overall health performance compared to the controls, (mean +/- SE, 0.52 +/- 0.06 vs 0.86 +/- 0.003, respectively, P < .001). In multivariable regression, PN was found to be associated with worse health performance (coefficient -0.34, 95% CI [-0.46 to -0.23]), most prominent in the pain subdomain (coefficient -0.24, 95% CI [-0.35 to -0.13]). This correlated to an average of 6.5 lifetime quality-adjusted life years lost per patient, translating to an individual lifetime economic burden of $323,292 and a societal burden of $38.8 billion.& nbsp;Conclusion: These results demonstrate that PN is associated with significant quality-of-life impairment, similar to the level of other chronic systemic conditions. PN is also associated with a substantial individual economic burden, emphasizing the necessity of research on effective treatment options.

IMPORTANCE:Despite the efficacy of immune checkpoint inhibitors (ICIs), cutaneous immune-related adverse events (cirAEs) occur in 20% to 40% of all treated patients. To our knowledge, little is known about the predictive value of these cutaneous eruptions and their subtypes regarding cancer survival. OBJECTIVE:To determine the association of developing cirAEs following treatment with anti-programmed cell death 1 (PD-1) or anti-programmed cell death ligand 1 (PD-L1) therapy with patient survival. DESIGN, SETTING, AND PARTICIPANTS:This retrospective cohort study used data from the TriNetX Diamond Network, a database of health records and claims data from more than 200 million US and European patients, to conduct a population-level cohort analysis. The study included 7008 eligible patients who developed cirAEs after treatment with anti-PD-1 or anti-PD-L1 therapy for malignant neoplasms of digestive organs, bronchus or lung, melanoma of skin, and urinary tract who were identified through the TriNetX Diamond Network along with 7008 matched controls. EXPOSURES:Development of cirAEs within 6 months following anti-PD-1 or anti-PD-L1 therapy. MAIN OUTCOMES AND MEASURES:A 6-month analysis using a Cox proportional hazards model was performed to determine the association of cirAEs with overall survival after adjusting for demographic characteristics, cancer type, and cancer stage. RESULTS:A total of 7008 patients (3036 women [43.3%]; mean [SD] age, 68.2 [11.2] years) were matched to 7008 (3044 women [43.4%]; mean [SD] age, 68.3 [11.1] years) controls. Pruritus (hazard ratio [HR], 0.695; 95% CI, 0.602-0.803; P < .001), drug eruption (HR, 0.755; 95% CI, 0.635-0.897; P = .001), xerosis (HR, 0.626; 95% CI, 0.469-0.834; P = .001), nonspecific rashes (HR, 0.704; 95% CI, 0.634-0.781; P < .001), and appearance of any cirAE (HR, 0.778; 95% CI, 0.726-0.834; P < .001) were significantly protective of mortality using a Benjamini-Hochberg correction with a significance level of .05. Additionally, psoriasis (HR, 0.703; 95% CI, 0.497-0.994; P = .045) and lichen planus/lichenoid dermatitis (HR, 0.511; 95% CI, 0.279-0.939; P = .03) were significant. Eczematous dermatitis (HR, 0.612; 95% CI, 0.314-1.195), vitiligo (HR, 0.534; 95% CI, 0.254-1.123), bullous pemphigoid (HR, 0.524; 95% CI, 0.140-1.956), and Grover disease (HR, 0.468; 95% CI, 0.115-1.898) were all associated with strong protective clinical effects. CONCLUSIONS AND RELEVANCE:The results of this cohort study suggest that the development of cirAEs is strongly associated with response to ICI therapy and patient survival.

BACKGROUND:Asian American (AsAm) representation is lacking in conversations surrounding cultural humility in healthcare. We aimed to investigate US medical student perspectives on AsAm patient inclusion in cultural humility training in medical education.METHODS:This qualitative study analyzed free-text responses to an optional, open-ended question presented at the conclusion of an online survey assessing medical student experiences with and perceptions regarding AsAm patients in their medical education. This survey was distributed to a convenience sample of nine US medical schools. Medical students who completed at least one clinical rotation were eligible to participate in the survey. Qualitative analysis of free-text responses was conducted in an iterative process to generate emergent themes.RESULTS:There was a total of 195 optional free-text responses from 688 participants (28%). Motivation to learn about AsAm population included shared identity and desire to better serve the AsAm population in their local community and future careers. Topics of interest included healthcare-related cultural preferences, healthcare delivery strategies, and health disparities for the AsAm population and other minority patients. Students reported that they drew on personal experiences and some pre-clinical or clinical exposures to learn about AsAm patients. Respondents cited the lack of exposure in the medical school curriculum and clinical experiences as the main challenge to learning about AsAm health and provided suggestions for the delivery of this education in their pre-clinical and clinical education. Respondents emphasized that AsAms are treated as a monolith in medical education and healthcare, despite their heterogeneity.CONCLUSIONS:Medical students identified a need and interest for greater inclusion of AsAm topics in medical education on cultural humility and minority health.

Introduction: Prurigo nodularis (PN) is characterized by intensely pruritic, hyperkeratotic nodules and has been linked to sleep disturbance and decreased quality of life. However, little is known about psychiatric disorders among PN patients in the inpatient setting or the financial burden of concomitant mental health (MH) disorders.

BACKGROUND:Dermatoses are common and potentially serious complications of programmed cell death receptor PD-1 immune checkpoint inhibitor (anti-PD-1 ICI) therapy. Understanding their incidence is necessary to support clinical awareness, diagnosis, and management. OBJECTIVE:To examine the incidence and odds of reported non-cancerous dermatoses in the setting of anti-PD-1 ICI therapy. METHODS:Cross-sectional study of anti-PD-1 (pembrolizumab or nivolumab) treated patients at a tertiary healthcare institution. Selected dermatologic events following immunotherapy were identified in the electronic medical record. Comparator arm were patients that developed these same dermatoses without receiving anti-PD-1 ICI therapy. RESULTS:There were 13.7% (254/1857) patients that developed one of 28 dermatoses. Compared with the general population, patients treated with anti-PD-1 had a greater risk for development of mucositis (OR 65.7, 95% CI 35.0-123.3), xerostomia (OR 11.9, 95% CI 8.4-16.8), pruritus (11.3, 95% CI 8.9-14.3), and lichen planus/lichenoid dermatitis (OR 10.7, 95% CI 5.6-20.7). CONCLUSIONS:We report the frequency of dermatoses encountered in the setting of ICI therapy, both common (pruritus, rash, vitiligo) and uncommon (scleroderma, urticaria).

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intense pruritus, but information on patient experience and impact on quality of life (QoL) remains understudied.

We examine management practices of tinea capitis at 2 US academic centers. The majority of providers treated tinea capitis with the oral antifungal agent griseofulvin and did not obtain a fungal culture. We recommend newer antifungal treatments such as terbinafine and fluconazole and obtaining a fungal culture for effective treatment.

Purpose of review Tinea capitis, a superficial infection of the scalp, is the most common pediatric dermatophyte fungal infection worldwide and is particularly common in the USA in low-income, low-resource settings. There are still gaps in knowledge and heterogeneities in practice in terms of diagnostic and management strategies. Furthermore, there are no clinical guidelines for management and treatment of tinea capitis in the USA. This review aims to summarize recent advances, recommend optimal management for the practicing pediatrician, and identify areas for future research for tinea capitis. Recent findings Trichophyton tonsurans infections are best treated with terbinafine and Microsporum canis infections are best treated with griseofulvin. Trichophyton tonsurans is the predominant cause of tinea capitis in the USA, although the main gold standard of treatment in the USA is griseofulvin. Dermatophyte antifungal resistance is an active area of investigation but seems to not be of current concern for tinea capitis in the USA. Summary We recommend all clinical providers ascertain the causative organism in fungal infection, either through fungal culture or newer methods which may become more readily available and cost-effective in the future, such as polymerase chain reaction assay. We also recommend terbinafine as first-line treatment of tinea capitis, with adjustment as necessary after species identification.

To the Editor: Prurigo nodularis (PN) is a chronic inflammatory skin condition characterized by intensely pruritic and hyperkeratotic nodules on the torso and extremities.1Kwatra S.G. Breaking the itch–scratch cycle in prurigo nodularis.N Engl J Med. 2020; 382: 757-758Crossref PubMed Scopus (23) Google Scholar Studies to date have shown that PN is associated with many systemic and psychiatric comorbidities, and racial/ethnic minorities are affected disproportionately.2Huang A.H. Williams K.A. Kwatra S.G. Prurigo nodularis: epidemiology and clinical features.J Am Acad Dermatol. 2020; 83: 1559-1565Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Although the morbidity of PN is well documented, there are no available data on the mortality associated with PN. We sought to investigate the mortality among patients with PN and stratify by race/ethnicity to identify racial disparities. We used TriNetX, a health research network of approximately 64 million patients in 45 large health care organizations. Patients with PN were identified by individuals with ≥2 International Classification of Diseases, Tenth Revision (ICD-10) codes for PN (L28.1). The primary years of analysis included 1995 through 2020; diagnoses prior to the introduction of ICD-10 were mapped by TriNetX using SNOMED-CT concepts.3Thyssen J.P. Skov L. Egeberg A. Cause-specific mortality in adults with atopic dermatitis.J Am Acad Dermatol. 2018; 78: 506-510Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Control patients included those with no diagnostic codes for PN. Patients with PN were matched to controls by age, sex, race, and ethnicity using 1:1 propensity score matching. Patients were stratified by race/ethnicity, and each subgroup was compared with a corresponding control subgroup of similar race/ethnicity to control for inherent disparities in mortality. The all-cause mortality was determined by searching for death in a 20-year observation period following the index date; the index date for each patient was the time of the first diagnosis. The baseline demographics were compared using the Student t test for continuous variables and Z test for proportions. The all-cause mortality hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using the Cox proportional hazards model. The differences in survival were assessed using the log-rank test. A total of 22,858 patients with ≥2 ICD-10 codes for PN were identified. Before matching, patients with PN were older, more likely to be women, non-Hispanic, and Black compared with control patients (Table I). After propensity score matching, there were no significant differences in age, sex, or race/ethnicity. Patients with PN, overall, had higher all-cause mortality than controls (HR, 1.70; 95% CI, 1.51-1.91; P < .001) (Fig 1). Black patients with PN had the highest mortality (HR, 2.07; 95% CI, 1.64-2.61; P < .001), followed by White (HR, 1.74; 95% CI, 1.52-2.00; P < .001) and Hispanic (HR, 1.62; 95% CI, 1.03-2.54; P = .029) patients. Increased mortality was not observed in Asian patients with PN.Table IBaseline demographics of prurigo nodularis and control patients, before and after propensity score matching, by age, sex, race, and ethnicityDemographicsBefore matchingAfter matchingPrurigo nodularis (N = 22,858)Control (N = 5,382,112)P valuePrurigo nodularis (N = 22,858)Control (N = 22,858)P valueAge, mean ± SD53.9 ± 17.534.0 ± 25.6<.000153.9 ± 17.553.9 ± 17.5.9989Sex Female, % (n)61.10% (13,967)55.72% (2,999,128)<.000161.10% (13,967)61.10% (13,967)>.9999 Male,% (n)38.88% (8886)44.25% (2,381,660)<.000138.88% (8886)38.88% (8888).9847Race White, % (n)60.85% (13,909)65.86% (3,544,857)<.000160.85% (13,909)60.84% (13,907).9847 Black, % (n)22.62% (5170)18.04% (970,787)<.000122.62% (5170)22.62% (5170)>.9999 Asian, % (n)3.21% (733)3.40% (183,199).10103.21% (733)3.21% (733)>.9999 American Indian or Alaska Native, % (n)0.38% (86)0.34% (18,537).41270.38% (86)0.39% (88).8793 Native Hawaiian or Other Pacific Islander, % (n)0.11% (26)0.13% (7176).41790.11% (26)0.11% (26)>.9999Ethnicity Hispanic or Latino, % (n)7.15% (1635)11.10% (597,333)<.00017.15% (1635)7.15% (1635)>.9999 Not Hispanic or Latino, % (n)68.53% (15,664)56.57% (3,044,656)<.000168.53% (15,664)68.53% (15,664)>.9999 Open table in a new tab We found that patients with PN, overall, had higher all-cause mortality than control patients, likely due to the high comorbidity burden seen in patients with PN. The observed HR was higher than reported HRs of other inflammatory dermatoses, such as psoriasis (HR, 1.21) and atopic dermatitis (HR, 1.27).3Thyssen J.P. Skov L. Egeberg A. Cause-specific mortality in adults with atopic dermatitis.J Am Acad Dermatol. 2018; 78: 506-510Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar,4Springate D.A. Parisi R. Kontopantelis E. Reeves D. Griffiths C.E.M. Ashcroft D.M. Incidence, prevalence and mortality of patients with psoriasis: a U.K. population-based cohort study.Br J Dermatol. 2017; 176: 650-658Crossref PubMed Scopus (112) Google Scholar Additionally, subgroup analysis revealed that Black patients with PN had the highest mortality. This observation may be because PN exacerbates the existing racial disparities in the social determinants of health. Additionally, PN was recently found to feature systemic and cutaneous Th22 polarization, so the patterns observed in this study may suggest that Black patients with PN may suffer from greater systemic inflammation, leading to higher mortality.5Belzberg M. Alphonse M.P. Brown I. et al.Prurigo nodularis is characterized by systemic and cutaneous T helper 22 immune polarization.J Invest Dermatol. 2021; 141: 2208-2218.e14Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Further research is needed, however, to explore the cause of these disparities in mortality among patients with PN. Dr Kwatra is an advisory board member/consultant for Abbvie, Celldex Therapeutics, Galderma, Incyte Corporation, Pfizer Inc, Regeneron Pharmaceuticals, and Kiniksa Pharmaceuticals and has received grant funding from Galderma , Pfizer Inc, and Kiniksa Pharmaceuticals . Authors Sutaria, Adawi, Brown, Parthasarathy, Roh, Choi, Bordeaux, Trinh, Le, and Deng and Drs Semenov and Kwatra have no conflicts of interest to disclose.

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy, but lead to significant toxicities, with cutaneous toxicities (cirAEs) most commonly reported. However, the data on racial and ethnic incidence of cirAEs is limited. Using electronic medical record data from 41 US medical centers, we examined the influence of race and ethnicity on cirAE incidence and outcomes. We identified 33,297 patients receiving ICI treatment (69.1% non-Hispanic white, 7.0% non-Hispanic black, 1.9% Asian, and 4.1% Hispanic). The overall cirAE incidence was 21.5%. Nonspecific rashes (12.2%), drug eruptions (4.6%), and pruritus (6.4%) were the most common diagnoses. Compared to white patients, black patients had a lower risk of cirAEs (RR=0.65, p <0.0001), and Asian patients had a higher risk (RR=1.41, p<0.01), after controlling for age, sex, and cancer type. Asian (RR=0.66) and Hispanic (RR=0.80) patients had a lower risk of mortality following ICI therapy initiation (both p<0.0001). However, despite their overall lower rate of cirAEs, black patients had overall similar mortality to white patients (RR=0.96, p=0.29). A sensitivity analysis exploring the risk of cutaneous diagnoses in the non-ICI cancer setting showed similar rates of dermatoses among Asian (RR=0.96, p=0.07) patients, but lower rates among black and Hispanic patients (RR=0.83 and 0.87, respectively, both p<0.0001) compared to white patients. This finding suggests that the increased incidence of cirAEs among Asian patients is related to ICIs, but that the decreased rate seen among black patients may be due to poorer identification of these conditions in skin of color, requiring investigation into addressable biases. Future studies should also explore specific contributions of genetic ancestry and germline genetic variation to the observed differences in incidence.

BACKGROUND:Asian Americans (AsAm) are a rapidly growing population in the U.S. With this growing population, U.S. healthcare providers must be equipped to provide culturally competent care for AsAm patients. This project surveyed U.S. medical students on their knowledge of and attitudes towards AsAm to assess predictors of readiness to care for AsAm patients.METHOD:This cross-sectional study surveyed medical students who had completed at least one clinical rotation. The survey was distributed online to nine medical schools throughout the U.S. The survey measured self-rated knowledge of, comfort with, cultural competency (CC) towards, and explicit biases towards AsAm patients. The first three domains were analyzed in a multivariate regression model including sociodemographic characteristics and past clinical, curricular, and social experiences with AsAm. Explicit bias questions were reported descriptively.RESULTS:There were 688 respondents. Asian race, AsAm-prevalent hometown, AsAm-related extracurricular activities, Asian language knowledge, and having taken a population health course predicted increased AsAm knowledge. Social interactions with AsAm increased comfort with AsAm patients. Increasing year in medical school, more frequent exposure to AsAm patients on rotations, and prior travel to an Asian country were predictors of increased CC toward AsAm. Importantly, having completed a CC course was a significant predictor in all domains. In terms of explicit bias, students felt that AsAm patients were more compliant than Caucasian patients. Students also believed that Caucasian patients were generally more likely to receive self-perceived "preferred" versus "acceptable" care, but that in their own clinical experiences neither group received preferred care.CONCLUSION:Experience with and exposure to AsAm prior to and during medical school and CC courses may increase medical student knowledge, comfort, and CC with AsAm patients. Standardized and longitudinal CC training, increased simulations with AsAm patients, diverse student recruitment, and support for students to engage in AsAm-related activities and interact with AsAm may improve CC of future physicians towards AsAm patients and possibly other minority populations.

e14553 Background: Cutaneous immune-related adverse events (cirAEs) from immune checkpoint inhibitor (ICI) therapy are increasing as these drugs are more widely used. Population-level studies are lacking. In this retrospective cohort study, we analyzed the primary tumor’s effect on cirAE incidence and downstream utilization of systemic immunosuppression in a national healthcare database (TriNetX). Methods: Index event was defined as day of ICI initiation; outcomes were restricted to 2 years from index. cirAEs were defined as 42 dermatoses identified in a comprehensive review of the cirAE literature (Sibaud 2018) and expert opinion. Systemic immunosuppression was classified as steroidal or non-steroidal. Primary outcomes included aggregate and cancer-specific incidence of cirAEs across the four most common cancer indications for ICI therapy (melanoma, lung, urinary, and gastrointestinal). Secondary outcomes included utilization of new steroidal or non-steroidal systemic immunosuppression. For each analysis, we excluded patients with an outcome prior to the index event. Risk ratios (RR) were calculated after 1-to-1 propensity score matching, adjusting for age at index, sex, race, ethnicity, and ICI target, with the lung cancer group as reference. Results: We identified 27,481 eligible subjects. Aggregate incidence of cirAEs across all cancer types was 23.41%, with non-specific rashes, pruritus, and drug eruptions as the most common diagnoses. Among all patients, new steroidal and non-steroidal immunosuppression use following ICI initiation was 16.1% and 4.1%, respectively. After adjusting for covariates, melanoma (RR 1.60, 95% CI 1.43-1.79, p < 0.001) was associated with a higher risk of cirAE, while urinary and gastrointestinal tract cancers were not significantly different from the reference. Melanoma (RR 0.64, 95% CI 0.55-0.74), urinary tract (RR 0.71, 95% CI 0.62-0.81) and gastrointestinal tract (RR 0.46, 95% CI 0.39-0.53) cancers were all less likely to require steroidal immunosuppression (all p < 0.001). However, patients with urinary tract cancer (RR 4.03, 95% CI 3.04-5.35) and melanoma (RR 2.44, 95% CI 1.75-3.40) were more likely to receive non-steroidal systemic immunosuppression (both p < 0.001). Conclusions: Our results reinforce that ICI recipients commonly develop skin toxicities and provide robust evidence that melanoma is independently associated with their incidence. Furthermore, we found that patients with lung cancers received steroidal systemic immunosuppression most frequently, an intervention associated with poorer overall survival (Riudavets 2020). In contrast, patients with melanoma were more likely to receive non-steroidal immunosuppression. This study is the first population-based analysis of an irAE across tumor types and is proof-of-concept for future investigations into clinical risk factors in a large dataset.