With more disease- and symptom-specific measures available and research pointing to increased usefulness, patient-reported outcome measures (PROMs) can be routinely used in clinical care. PROMs increase efficiency in healthcare, improve the clinician–patient relationship, and increase patient satisfaction with their care. PROMs can be administered before, during, and after clinic visits using paper-and-pencil, mobile phones, tablets, and computers. Herein, we combine available literature with expert views to discuss overcoming barriers and helping dermatologists incorporate PROMs into routine patient-centered care. We believe dermatology patients will benefit from broader PROM implementation and routine clinical use. However, a few major barriers exist: (1) cost to implement the technology, (2) selecting the right PROMs for each disease, and (3) helping both patients and clinicians understand how PROMs add to and complement their current clinical experience. We provide recommendations to assist dermatologists when considering whether to implement PROMs in their practices.

IMPORTANCE Actinic keratosis is prevalent and has the potential to progress to keratinocyte carcinoma. Changes in the use and costs of actinic keratosis treatment are not well understood in the aging population. OBJECTIVE To evaluate trends in the use and costs of actinic keratosis destruction in Medicare patients. DESIGN, SETTING, AND PARTICIPANTS A billing claims analysis was performed of the Medicare Part B Physician/Supplier Procedure Summary Master Files and National Summary Data of premalignant skin lesion destructions performed from 2007 to 2015 among Medicare Part B fee-for-service beneficiaries. MAIN OUTCOMES AND MEASURES Mean number of actinic keratosis lesions destroyed and associated treatment payments in 2015 US dollars estimated per 1000 Medicare Part B fee-for-service beneficiaries. Data analysis was performed from November 2017 to July 2018. RESULTS More than 35.6 million actinic keratosis lesions were treated in 2015, increasing from 29.7 million in 2007. Treated actinic keratosis lesions per 1000 beneficiaries increased from 917 in 2007 to 1051 in 2015, while mean inflation-adjusted payments per 1000 patients decreased from $11 749 to $10 942 owing to reimbursement cuts. The proportion of actinic keratosis lesions treated by independently billing nurse practitioners and physician assistants increased from 4.0% in 2007 to 13.5% in 2015. CONCLUSIONS AND RELEVANCE This study's findings suggest that actinic keratosis imposes continuously increasing levels of treatment burden in the Medicare fee-for-service population. Reimbursement decreases have been used to control rising costs of actinic keratosis treatment. Critical research may be warranted to optimize access to actinic keratosis treatment and value for prevention of keratinocyte carcinoma.

Background: Ultrasound was first introduced in clinical dermatology in 1979. Since that time, ultrasound technology has continued to develop along with its popularity and utility. Main text summary: Today, high-frequency ultrasound (HFUS), or ultrasound using a frequency of at least 10 megahertz (MHz), allows for high-resolution imaging of the skin from the stratum corneum to the deep fascia. This non-invasive and easy-to-interpret tool allows physicians to assess skin findings in real-time, enabling enhanced diagnostic, management, and surgical capabilities. In this review, we discuss how HFUS fits into the landscape of skin imaging. We provide a brief history of its introduction to dermatology, explain key principles of ultrasonography, and review its use in characterizing normal skin, common neoplasms of the skin, dermatologic diseases and cosmetic dermatology. Conclusion: As frequency advancements in ultrasonography continue, the broad applications of this imaging modality will continue to grow. HFUS is a fast, safe and readily available tool that can aid in diagnosing, monitoring and treating dermatologic conditions by providing more objective assessment measures.

Multifocal ill-defined and confluently distributed squamous cell carcinomas (SCCs) on actinically damaged legs can be therapeutically challenging. Additionally, patients may have treatment fatigue or be poor candidates for extensive surgery or radiation. Women, in particular, with multiple SCCs of the legs have this striking clinical phenotype.1 Acitretin, intralesional 5-fluorouracil (5-FU), and 5-FU chemowraps have each alone shown efficacy in preventing or treating SCCs; however, their combined effectiveness has never been reported. We present 2 cases using combined triple therapy to treat widespread SCCs on the legs, illustrating a promising option for patients unwilling or unable to undergo surgery.

Background/Objectives: Despite rising skin cancer rates in children, multiple studies reveal inadequate youth sun-protective behavior (eg, sunscreen use). Using Healthy Passages data for fifth-graders, we set out to determine sunscreen adherence in these children and investigated factors related to sunscreen performance. Methods: Survey data were collected from 5119 fifth-graders and their primary caregivers. Logistic regression was used to assess associations between sunscreen adherence and performance of other preventive health behaviors (eg, flossing, helmet use) and examine predictors of sunscreen adherence. Analyses were repeated in non-Hispanic black, Hispanic, and non-Hispanic white subgroups. Results: Five thousand one hundred nineteen (23.4%) children almost always used sunscreen, 5.9% of non-Hispanic blacks (n = 1748), 23.7% of Hispanics (n = 1802), and 44.8% of non-Hispanic whites (n = 1249). Performing other preventive health behaviors was associated with higher odds of sunscreen adherence (all P <.001), with the greatest association with flossing teeth (odds ratio = 2.41, 95% confidence interval = 1.86-3.13, P <.001). Factors for lower odds of sunscreen adherence included being male and non-Hispanic black or Hispanic and having lower socioeconomic status. School-based sun-safety education and involvement in team sports were not significant factors. Conclusion: Our data confirm low use of sun protection among fifth-graders. Future research should explore how public health success in increasing prevalence of other preventive health behaviors may be applied to enhance sun protection messages. Identifying risk factors for poor adherence enables providers to target patients who need more education. Improving educational policies and content in schools may be an effective way to address sun safety.

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Psoriasis is a chronic, immune-mediated disease associated with increased risk of cardiovascular disease [1]. Subclinical atherosclerosis, carotid intima–media thickening, arterial stiffness and endothelial dysfunction have been reported in psoriasis [2]. Tumor necrosis factor-alpha (TNF-α) is central to the pathogenesis of psoriasis and contributes to endothelial dysfunction [3]. Circulating progenitor cells (PCs) represent an index of regenerative potential and are stimulated by injury. Low PC counts are predictors of adverse cardiovascular outcomes [4]. PCs are identified by expression of CD34 on mononuclear cells and concomitant expression of vascular endothelial growth factor receptor-2 (VEGFR2) identifies a sub-population enriched for endothelial PCs [5]. Early studies have suggested that psoriasis is associated with decreased PCs [6,7]. Etanercept, a competitive inhibitor of TNF-α, improves arterial stiffness and endothelial dysfunction in rheumatoid arthritis and may decrease cardiovascular disease risk [8]. Herein, we characterized endogenous regenerative capacity as the number of circulating PCs, endothelial function measured as flow-mediated vasodilation, and arterial stiffness in subjects with psoriasis, before and after TNF-α inhibition with etanercept. We hypothesized that subjects with psoriasis will have lower flow-mediated dilation, increased arterial stiffness, and lower PC levels compared to a matched healthy cohort, and that etanercept will improve these indices.

Chronic pruritus is common with substantial quality-of-life (QOL) impact. Existing surveys capture multiple itch characteristics, but limited data provide empirical evidence on how aspects of itch characteristics inform itch-related QOL. To address this gap, we aimed to identify latent factors (hidden combinations of itch characteristics) from subjective itch descriptors that predict impact on QOL. In a secondary analysis of a cross-sectional survey of 405 US veterans reporting chronic pruritus lasting >6 weeks1, we identified latent factors within 45 subjective itch descriptors as measured by the Questionnaire for the Assessment of Pruritus (QAP)2. Latent factors were empirically derived from observed itch descriptors using exploratory factor analysis with varimax rotation. Latent factors were correlated with itch-specific QOL impact as measured by ItchyQoL3 total score and domain scores using multivariable linear regression, adjusting for significant sociodemographic differences. P<0.05 in 2-sided tests was considered significant.

Introduction: Improving remote triage is crucial given expansions in tele-dermatology and with limited in-person care during COVID-19. In addition to clinical pictures, dermoscopic images may provide utility for triage. Objectives: To determine if dermoscopic images enhance confidence, triage accuracy, and triage prioritization for tele-dermatology. Methods: In this preliminary parallel convergent mixed-methods study, a cohort of dermatologists and residents assessed skin lesions using clinical and dermoscopic images. For each case, participants viewed a clinical image and determined diagnostic category, management, urgency, and decisionmaking confidence. They subsequently viewed the associated dermoscopy and answered the same questions. A moderated focus group discussion followed to explore perceptions on the role of dermoscopy in tele-dermatology. Results: Dermoscopy improved recognition of malignancies by 23% and significantly reduced triage urgency measures for non-malignant lesions. Participants endorsed specific utilities of tele-dermoscopy, such as for evaluating pigmented lesions, with limitations including poor image quality. Conclusions: Dermoscopic images may be useful when remotely triaging skin lesions. Standardized imaging protocols are needed.