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Changing paradigms in dermatology: proteomics: a new approach to skin disease.

Completion of the human genome sequence in 2001 heralded a new age in the understanding of cellular function. By eliminating the need for meticulous nucleotide identification of suspect proteins, a short segment can be identified and, within seconds the remaining sequences culled. Now, investigations can be more specifically targeted at the proteins themselves. Unlike the one gene, one protein approach of years past, proteomics is the field of unraveling the vast network of protein interactions within living cells. Recently, certain dermatologic conditions, such as psoriasis and eczema, have been shown to be the result of immune deregulation. By better understanding the proteins responsible for immune system function, targeted disruptions can alter tissue responses. It is in this vein that proteomics attempts to understand cellular regulation for the eventual therapeutic modification of biologic behavior.

Biomedical Research↗

Herbal and complementary medicine in dermatology.

This article is a description of how I have integrated Complementary Medicine into the practice of dermatology over the past 2 decades. It emphasizes observing the principles of the system being used, such as the herbal concept of the synergy of the entire plant extract. Examples discussed include the use of flavonoids to protect the liver and capillaries. Herbs and techniques for reducing the inflammatory response, as well as for enhancing immunity, are given. The concept of homeopathy and a few remedies to use in office practice are discussed. Finally, a few methods to complement the treatment of melanoma are presented.

Complementary Therapies↗

Evaluating clinical rating scales for evidence-based dermatology: some basic concepts.

Evidence-based dermatology has necessitated the development of rating scales that measure multidimensional and abstract constructs, such as quality of life. This article discusses some basic psychometric concepts, such as reliability, validity, standardization, and measurement precision, which need to be considered when choosing a clinical rating instrument. Also discussed is the impact of these parameters on increasing the statistical power of a clinical trial.

Dermatology↗

Obsessive-compulsive disorders and dermatologic disease.

Obsessive-compulsive disorder and obsessive-compulsive spectrum disorders are often associated with dermatologic manifestations. The phenomenology is discussed and possible animal models explored. Treatment involves both pharmacotherapy and cognitive behavior therapy. Many of these patients experience considerable shame over their behavior and may be reluctant to acknowledge the existence of a psychiatric disorder. The dermatologist's approach to this patient is discussed.

Adult↗

Psychologic trauma, posttraumatic stress disorder, and dermatology.

Psychologic trauma refers to events (such as sexual assault, major earthquake, or plane crashes) that overwhelm an individual's capacity to cope. Psychologic trauma can result in chronic and recurring dermatologic symptoms that persist after the trauma subsides. Examples are cutaneous sensory flashbacks (which may be fragments of the sensory component of the traumatic experience), autonomic hyperarousal (with symptoms such as profuse sweating or flare-up of an underlying stress-reactive dermatosis), conversion symptoms (such as numbness, pain, or other medically unexplained cutaneous symptoms), and cutaneous self-injury (manifesting in many forms, including trichotillomania, dermatitis artefacta, and neurotic excoriations--tension-reducing behaviors in patients who have posttraumatic stress disorder).

Adult↗

Pregnancy and dermatologic surgery.

The physiologic changes of pregnancy and risks to the fetus require attention during dermatologic surgery. Elective surgery should be performed in the second trimester or the postpartum period. Cosmetic work should occur after delivery to avoid hypertrophic or hyperpigmented scars. Skin preparatory agents and anesthetics may have fetal implications and should be chosen with care. Antibiotic selection for any infections must take into account possible maternal and fetal risks. Attention to detail and awareness of the changes in pregnancy should lead to safe surgery in the pregnant patient.

Analgesics↗

The first images of atopic dermatitis: an attempt at retrospective diagnosis in dermatology.

BACKGROUND: Atopic dermatitis was defined in 1933. Earlier descriptions have yet not been thoroughly studied. OBJECTIVE: Our purpose was to identify the first images of atopic dermatitis among historical illustrations of skin diseases. METHODS: We posted 20 selected images on an Internet site and asked experts in pediatric dermatology to decide whether or not they represented atopic dermatitis. RESULTS: By means of the Delphi technique, a consensus could be reached for 19 of the 20 images. The experts' accuracy was good. LIMITATIONS: Thirty-one experts participated. No validated criteria were used for the selection of the images. CONCLUSION: The first representations of atopic dermatitis are engravings of skin diseases described under the names of strophulus confertus (Willan, 1796), lichen agrius (Willan, 1796), porrigo larvalis (Bateman, 1816), and eczema rubrum (Rayer, 1835). Teledermatology techniques can be reliably applied to retrospective diagnosis.

Anatomy, Artistic↗

Clinical e-mail in an academic dermatology setting.

BACKGROUND: Use of e-mail among patients and physicians is limited by reservations over issues such as medicolegal aspects, reimbursement, and time-management. OBJECTIVE: Our purpose was to identify the content of patient-related e-mails in an academic dermatology practice and determine whether clinical questions could be answered by e-mail. METHODS: The first 100 e-mails received each year that related to patients from January 1, 2000 to June 1, 2005 (plus any messages received in e-mail threads started in the original 100) were studied (N = 614). E-mails were sent by patients, potential patients, or physicians in reference to a patient. E-mails were divided into 8 categories on the basis of content. E-mails were subdivided as relating to new (patients who had never been seen in-person) or established patients. All clinical questions were categorized as to whether they were answered by e-mail. The average number of e-mails received per e-mail thread was tallied. RESULTS: E-mails were distributed as follows: clinical question from a physician (20%), clinical question from a patient (17%), appointment request (18%), request for referral to another physician (7%), prescription refill (3%), research inquiry (2%), thank-you correspondence (31%), other (17%). Percentages do not equal 100 because some e-mails contained more than one subject. Clinical questions were more likely to be answered when posed by physicians (100%) than patients (70%; P = .001), and when from established (79%) versus new patients (60%; P = .02). There were fewer e-mails per thread for queries from physicians (1.6 messages received) versus patients (2.2; P < .001) and for established (1.6) versus new patients (2.2; P < .001). LIMITATIONS: This study was limited to the experience of one dermatologist in an academic setting. CONCLUSION: E-mail broadens communication between patients and their dermatologist. E-mail may facilitate consultation with other physicians and management of patients with chronic disease. "Thank-you" responses engage a substantial amount of e-mail resources.

Dermatology↗

Educational conferences in dermatology residency programs.

To characterize conferences in dermatology residency programs, we surveyed directors and chief residents. Most respondents thought their amount of conference time was just right (7-8 hours/wk); they also identified grand rounds, dermatopathology, and clinical images as best implemented, whereas journal club and basic science needed most improvement. By contrast, respondents diverged regarding conferences they wanted to establish; directors identified research and basic science, whereas chief residents listed pediatrics and surgery.

Congresses as Topic↗

A rapid HPLC method for simultaneous determination of tretinoin and isotretinoin in dermatological formulations.

A rapid method using an isocratic high-pressure liquid chromatography and UV detection for determination of both all-trans retinoic acid (tretinoin) and 13-cis retinoic acid (isotretinoin) in dermatological preparations is presented. Tretinoin and isotretinoin samples were extracted with acetonitrile by a procedure that can be completed in less than 10 min. Subsequent separation and quantification of amounts as low as 10 pmol was accomplished in less than 15 min using reversed-phase HPLC with isocratic elution with 0.01% trifluoroacetic acid (TFA)/acetonitrile (15:85, v/v). Validation experiments confirmed the precision and accuracy of the method. When applied to commercial tretinoin samples, recoveries of 104.9% for cream formulations and 107.7% for gel formulations were obtained. Application of the method for analysis of a tretinoin cream exposed to solar simulated light (SSL) demonstrated detection of the major photoisomerization product isotretinoin as well as 9-cis retinoic acid, demonstrating the utility of the method for studies of tretinoin photostability. The method should also facilitate studies of the formulation compatibility and photocompatibility of tretinoin with agents that may improve its clinical tolerability.

Acetonitriles↗

Cosmetic dermatology and physicians' ethical obligations: more than just hope in a jar.

Cosmetic dermatology provides new esthetic options for patients and expanded practice opportunities for physicians. Perhaps because of its recent inception, discussions of the ethical quandaries in the field are relatively new. Certainly, these dilemmas remain unresolved. This article aims to identify ethical obligations that practicing cosmetic dermatologists and the professional societies that regulate them should assume. Heightened attention to familiar duties and new attention to proposed responsibilities will enhance patient safety and choice. It will also ensure that dermatologists practice their craft in an ethically sound manner.

Cosmetics↗

CPT coding and reimbursement issues in dermatology.

In the past 6 years, significant changes have been made in Current Procedural Terminology codes, descriptors, and guidelines affecting dermatologists. These changes involved excision, repair, measuring excised diameter, measuring flap defects, skin biopsy and Mohs surgery guidelines, KOH examination, and fungus cultures. New codes were introduced for photodynamic therapy, laser treatment, and whole-body photography. Reimbursement issues affecting dermatologists are also discussed, including inappropriate bundling of separate services, failure to recognize modifiers, and unfair multiple procedure reduction. The successes of the American Academy of Dermatology Association advocacy efforts with insurance carriers are summarized, with an update on the current status of these issues. Physician responsibilities, documentation requirements, and expectations are also outlined.

Current Procedural Terminology↗

[Study of the significance of female dermatologists in the Spanish Academy of Dermatology and Venereology].

BACKGROUND: Most Spanish dermatologists are members of the Spanish Academy of Dermatology and Venereology (AEDV). Their development and history can be considered to parallel each other. The aim of our study is to determine the role women have played in the AEDV throughout its history, both in number and as officers or directors. MATERIAL AND METHODS: To obtain our data, we consulted AEDV's files from the time it was founded until the year 2002. We also asked other medical associations, obtaining a response from three of them. RESULTS: No women joined the AEDV until 1964. After that date, the percentage rose slowly (1975, 5.5 %), until the last decade when it increased more sharply, reaching 41.34 % in 2001. There are only 11 women on the boards of directors, all in non-presidential roles. The percentages of women in Pediatrics, Ophthalmology and Pathology are similar. CONCLUSIONS: The number of female dermatologists in the AEDV has increased gradually, although not steadily, reaching a maximum in the last decade. Women are rarely officers or directors, and there are no female presidents. The data shows that women have gradually become more prevalent in the medical profession, the same as in the rest of society as a whole.

Academies and Institutes↗

Pediatric dermatology.

Physicians who treat children will encounter dermatologic conditions in their daily practice. A general approach to the diagnosis and management of pediatric skin disease is discussed in this article, and specific common entities are summarized, with emphasis on diagnosis and treatment.

Biopsy↗

Primary care management of common dermatologic disorders in women. Pharmacologic considerations.

This article describes the clinical management of dermatologic disorders most commonly encountered in the primary care setting. The common presenting clinical signs and symptoms are reviewed, and the initial laboratory tests that may establish the diagnosis are recommended. Pharmacologic and nonpharmacologic treatments are reviewed. Diagnosis and management of disorders of the sebaceous and apocrine glands, disorders of the hair and pigmentation, fungal, viral, and bacterial infections, dermatitis, and infestations are discussed. A review of the care of skin burns and wounds is included as well as the diagnosis and management of urticaria.

Antiparasitic Agents↗

Evaluation of a history questionnaire in dermatologic practice.

A history questionnaire completed by 1,236 new dermatology patients yielded at least one item relevant to the presenting complaint in two thirds of the patients. The questionnaire saved physician time, frequently elicited clinically useful information, and provided insights as to the patients' general medical state and attitudes toward their illness. Dermatologists are urges to evaluate a history questionnaire in their practices.

Dermatology↗

Socioeconomic issues in dermatology.

The organization and delivery of health services in the United States is currently being re-evaluated in light of emerging trends in the supply and distribution of physicians. The recent GMENAC report identified an impending physician surplus in many specialties and a near-balance situation for dermatology by 1990. In this paper we examine the supply, distribution, and economics of medical practice for dermatologists relative to other specialties. To address the prospect of increasing physician supply, we evaluate emerging national health manpower policies. In addition, we discuss potential effects of market forces in the health care sector.

Dermatology↗

Quality care, costs, market share, and income purposes of the American Academy of Dermatology Blue Ribbon Committee.

Definitions are offered for quality of health care, reasonable costs or fees, an appropriate share of the dermatologic market, and reasonable income or profit for dermatologists. Physician control of these items was almost complete in the recent past, but control is now passing rapidly to government in the form of regulations and to large health care corporations in the form of unbridled competition in the marketplace. Physicians, including dermatologists, must mobilize and unite to retain reasonable controls, especially over quality care and personal income. The Academy (as an organization of all of us) can help in this process, but individual dermatologists at local, regional, and national levels must play major roles in retention of controls.

Academies and Institutes↗