Cutis

Practice Gap

Lipoatrophy associated with HIV is characterized by loss of adipose tissue in distinctive anatomic areas, most prominently in the nasolabial folds, temples, and medial cheeks.¹ This adverse effect further stigmatizes patients with HIV, and its association with highly active antiretroviral therapy (HAART)—specifically protease inhibitors—may contribute to suboptimal adherence to treatment.^1,2 Moreover, this finding is not uncommon: The prevalence of facial lipoatrophy after receiving HAART can range from 28% in patients treated for less than 5 years to 54% in those treated for a median of 10 years.² The associated stigma, notable decrease in quality of life, and known affiliation as an adverse effect of HAART make correction of facial lipoatrophy in patients with HIV an important management option.

Poly-L-lactic acid is approved by the US Food and Drug Administration for addressing fat loss due to HAART in patients with HIV.^2,3 When used as a dermal filler for correction of facial lipoatrophy, PLLA is well tolerated and has been shown to improve quality of life.^2,3 Poly-L-lactic acid is available for clinical use as microparticles of lyophilized alpha hydroxy acid polymers. Once injected (after the carrier substance is absorbed), PLLA induces an inflammatory response that ultimately leads to the production of new collagen.³ Unfortunately, PLLA microparticles often obstruct needles and make the product difficult to use, potentially hindering effective injection; thus, it is in the best interest of the patient to mitigate needle obstruction during this procedure. In this article, we describe a simple and effective way to mitigate this problem by utilizing a water bath to warm the filler prior to injection.

Technique

The required supplies include a thermostatic water bath, reconstituted PLLA, a syringe, and a 26-gauge injection needle. Because laboratory-grade heated water baths typically cost between $300 and $3000,⁴ we recommend using a more affordable, commercially available thermostatic water bath (eg, baby bottle warmer)(Figure 1) to warm the filler prior to injection, as the optimal temperature for this technique can still be achieved while remaining cost effective. Vials of PLLA reconstituted with 7 mL of sterile water and 2 mL lidocaine hydrochloride 1% should be labeled with the date of reconstitution and manually agitated for 30 seconds. The reconstituted product should be stored for 24 hours to ensure even suspension and powder saturation.⁵ On the day of the procedure, the vial should be placed into the water bath (heated to 100 °C) for 10 minutes prior to injection (Figure 2) and agitated again immediately before withdrawal into the syringe. The clinician then should sterilize the rubber top and draw the product from the warmed vial using the same size needle that will be used for injection. Although a larger gauge needle may make drawing up the product easier in typical practice, drawing and injecting with the same gauge needle helps prevent larger particles from clogging a smaller injection needle. Using a 26-gauge injection needle for withdrawal further reduces clogging by serving as a filter to prevent larger product particles from entering the injection syringe. The vials of PLLA can be kept in the water bath throughout the procedure between uses to keep the filler at a consistent temperature.

Practice Implications

Although many clinicians reduce needle obstructions by warming PLLA before injection, a published protocol currently is not available. One consideration when utilizing this technique is the limited data on the clinical stability and efficacy of PLLA at varying temperatures. Two studies recommend bringing the reconstituted vial to room temperature prior to injection, while others have documented an endothermic melting point in the range of 120 °C to 180 °C for PLLA, which lies well above the physiologic temperature readily achievable by baby bottle warmers.^6,7 Easily accessible bottle warmers can maintain the suspension at approximately 100 °C, keeping it in its crystalline polymer form and preventing melting. With this technique, the authors observed an improvement in efficacy due to fewer clogged needles, resulting in the delivery of more filler to the patient. In addition to comparable clinical results to not warming the product, our experience has shown that warming the PLLA prior to injection is not associated with increased patient discomfort and is well tolerated. Furthermore, patients experience less bruising and bleeding, as fewer needle sticks are necessary. This combination of a consistently heated filler with the added benefit of needle filtration yields dramatically fewer needle obstructions, fewer needle sticks, and increased patient satisfaction, improving the experience of patients with HIV-associated lipoatrophy seeking correction.

Practice Gap

Lipoatrophy associated with HIV is characterized by loss of adipose tissue in distinctive anatomic areas, most prominently in the nasolabial folds, temples, and medial cheeks.¹ This adverse effect further stigmatizes patients with HIV, and its association with highly active antiretroviral therapy (HAART)—specifically protease inhibitors—may contribute to suboptimal adherence to treatment.^1,2 Moreover, this finding is not uncommon: The prevalence of facial lipoatrophy after receiving HAART can range from 28% in patients treated for less than 5 years to 54% in those treated for a median of 10 years.² The associated stigma, notable decrease in quality of life, and known affiliation as an adverse effect of HAART make correction of facial lipoatrophy in patients with HIV an important management option.

Poly-L-lactic acid is approved by the US Food and Drug Administration for addressing fat loss due to HAART in patients with HIV.^2,3 When used as a dermal filler for correction of facial lipoatrophy, PLLA is well tolerated and has been shown to improve quality of life.^2,3 Poly-L-lactic acid is available for clinical use as microparticles of lyophilized alpha hydroxy acid polymers. Once injected (after the carrier substance is absorbed), PLLA induces an inflammatory response that ultimately leads to the production of new collagen.³ Unfortunately, PLLA microparticles often obstruct needles and make the product difficult to use, potentially hindering effective injection; thus, it is in the best interest of the patient to mitigate needle obstruction during this procedure. In this article, we describe a simple and effective way to mitigate this problem by utilizing a water bath to warm the filler prior to injection.

Technique

The required supplies include a thermostatic water bath, reconstituted PLLA, a syringe, and a 26-gauge injection needle. Because laboratory-grade heated water baths typically cost between $300 and $3000,⁴ we recommend using a more affordable, commercially available thermostatic water bath (eg, baby bottle warmer)(Figure 1) to warm the filler prior to injection, as the optimal temperature for this technique can still be achieved while remaining cost effective. Vials of PLLA reconstituted with 7 mL of sterile water and 2 mL lidocaine hydrochloride 1% should be labeled with the date of reconstitution and manually agitated for 30 seconds. The reconstituted product should be stored for 24 hours to ensure even suspension and powder saturation.⁵ On the day of the procedure, the vial should be placed into the water bath (heated to 100 °C) for 10 minutes prior to injection (Figure 2) and agitated again immediately before withdrawal into the syringe. The clinician then should sterilize the rubber top and draw the product from the warmed vial using the same size needle that will be used for injection. Although a larger gauge needle may make drawing up the product easier in typical practice, drawing and injecting with the same gauge needle helps prevent larger particles from clogging a smaller injection needle. Using a 26-gauge injection needle for withdrawal further reduces clogging by serving as a filter to prevent larger product particles from entering the injection syringe. The vials of PLLA can be kept in the water bath throughout the procedure between uses to keep the filler at a consistent temperature.

Practice Implications

Although many clinicians reduce needle obstructions by warming PLLA before injection, a published protocol currently is not available. One consideration when utilizing this technique is the limited data on the clinical stability and efficacy of PLLA at varying temperatures. Two studies recommend bringing the reconstituted vial to room temperature prior to injection, while others have documented an endothermic melting point in the range of 120 °C to 180 °C for PLLA, which lies well above the physiologic temperature readily achievable by baby bottle warmers.^6,7 Easily accessible bottle warmers can maintain the suspension at approximately 100 °C, keeping it in its crystalline polymer form and preventing melting. With this technique, the authors observed an improvement in efficacy due to fewer clogged needles, resulting in the delivery of more filler to the patient. In addition to comparable clinical results to not warming the product, our experience has shown that warming the PLLA prior to injection is not associated with increased patient discomfort and is well tolerated. Furthermore, patients experience less bruising and bleeding, as fewer needle sticks are necessary. This combination of a consistently heated filler with the added benefit of needle filtration yields dramatically fewer needle obstructions, fewer needle sticks, and increased patient satisfaction, improving the experience of patients with HIV-associated lipoatrophy seeking correction.

Practice Gap

Lipoatrophy associated with HIV is characterized by loss of adipose tissue in distinctive anatomic areas, most prominently in the nasolabial folds, temples, and medial cheeks.¹ This adverse effect further stigmatizes patients with HIV, and its association with highly active antiretroviral therapy (HAART)—specifically protease inhibitors—may contribute to suboptimal adherence to treatment.^1,2 Moreover, this finding is not uncommon: The prevalence of facial lipoatrophy after receiving HAART can range from 28% in patients treated for less than 5 years to 54% in those treated for a median of 10 years.² The associated stigma, notable decrease in quality of life, and known affiliation as an adverse effect of HAART make correction of facial lipoatrophy in patients with HIV an important management option.

Poly-L-lactic acid is approved by the US Food and Drug Administration for addressing fat loss due to HAART in patients with HIV.^2,3 When used as a dermal filler for correction of facial lipoatrophy, PLLA is well tolerated and has been shown to improve quality of life.^2,3 Poly-L-lactic acid is available for clinical use as microparticles of lyophilized alpha hydroxy acid polymers. Once injected (after the carrier substance is absorbed), PLLA induces an inflammatory response that ultimately leads to the production of new collagen.³ Unfortunately, PLLA microparticles often obstruct needles and make the product difficult to use, potentially hindering effective injection; thus, it is in the best interest of the patient to mitigate needle obstruction during this procedure. In this article, we describe a simple and effective way to mitigate this problem by utilizing a water bath to warm the filler prior to injection.

Technique

The required supplies include a thermostatic water bath, reconstituted PLLA, a syringe, and a 26-gauge injection needle. Because laboratory-grade heated water baths typically cost between $300 and $3000,⁴ we recommend using a more affordable, commercially available thermostatic water bath (eg, baby bottle warmer)(Figure 1) to warm the filler prior to injection, as the optimal temperature for this technique can still be achieved while remaining cost effective. Vials of PLLA reconstituted with 7 mL of sterile water and 2 mL lidocaine hydrochloride 1% should be labeled with the date of reconstitution and manually agitated for 30 seconds. The reconstituted product should be stored for 24 hours to ensure even suspension and powder saturation.⁵ On the day of the procedure, the vial should be placed into the water bath (heated to 100 °C) for 10 minutes prior to injection (Figure 2) and agitated again immediately before withdrawal into the syringe. The clinician then should sterilize the rubber top and draw the product from the warmed vial using the same size needle that will be used for injection. Although a larger gauge needle may make drawing up the product easier in typical practice, drawing and injecting with the same gauge needle helps prevent larger particles from clogging a smaller injection needle. Using a 26-gauge injection needle for withdrawal further reduces clogging by serving as a filter to prevent larger product particles from entering the injection syringe. The vials of PLLA can be kept in the water bath throughout the procedure between uses to keep the filler at a consistent temperature.

Practice Implications

Although many clinicians reduce needle obstructions by warming PLLA before injection, a published protocol currently is not available. One consideration when utilizing this technique is the limited data on the clinical stability and efficacy of PLLA at varying temperatures. Two studies recommend bringing the reconstituted vial to room temperature prior to injection, while others have documented an endothermic melting point in the range of 120 °C to 180 °C for PLLA, which lies well above the physiologic temperature readily achievable by baby bottle warmers.^6,7 Easily accessible bottle warmers can maintain the suspension at approximately 100 °C, keeping it in its crystalline polymer form and preventing melting. With this technique, the authors observed an improvement in efficacy due to fewer clogged needles, resulting in the delivery of more filler to the patient. In addition to comparable clinical results to not warming the product, our experience has shown that warming the PLLA prior to injection is not associated with increased patient discomfort and is well tolerated. Furthermore, patients experience less bruising and bleeding, as fewer needle sticks are necessary. This combination of a consistently heated filler with the added benefit of needle filtration yields dramatically fewer needle obstructions, fewer needle sticks, and increased patient satisfaction, improving the experience of patients with HIV-associated lipoatrophy seeking correction.

Infantile hemangioma (IH) is the most common vascular tumor of infancy, appearing within the first few weeks of life and typically reaching peak size by age 3 to 5 months.¹ It classically manifests as a raised or flat bright-red lesion in the upper dermis of the skin and/or subcutaneous tissue and can vary in number, size, shape, and location.² It is characterized by a rapid proliferative phase, especially between 5 and 8 weeks of age, followed by gradual spontaneous regression over 1 to 10 years.^1-3

Infantile hemangiomas are categorized based on depth (superficial, deep, or mixed) and distribution pattern (focal, multifocal, segmental, or indeterminate).⁴ In most cases, complete regression occurs by age 4 years, but there can be residual telangiectasia, fibrofatty tissue, and/or scarring.^1,4 About 10% to 15% of IHs result in complications that require medical intervention (eg, visual, airway, or auditory compromise; ulceration; disfigurement); ideally, these patients should be referred to a specialist by 5 weeks of age.⁴ Prompt assessment of IH severity is essential to prevent or mitigate potential complications and ultimately improve outcomes.³ Social drivers of health contribute to delayed diagnosis and management of hemangiomas, leading to increased complications in some patient populations.^5-7

Epidemiology

Infantile hemangiomas are estimated to manifest in 4.5% of infants in the United States.¹ The most common type is superficial IH, typically found on the head or neck.⁵ Risk factors in infants include female sex, White race, premature birth, and low birth weight (<1000 g).^1,3 Maternal risk factors include advanced gestational age (ie, >35 years), multiple gestations, family history of IH, tobacco use, use of progesterone therapy during pregnancy, and pre-eclampsia.^1,3

Focal IH typically manifests as a single localized lesion that can occur anywhere on the body.^2,3 In contrast, segmental IH manifests in a linear pattern and/or is distributed on a large anatomic area, most commonly on the face and less frequently the extremities and trunk.^2,3 Segmental IHs are more common in Hispanic patients and carry a higher risk for morbidity, often complicated by ulceration that can lead to functional and cosmetic challenges.⁸

Key Clinical Features

Superficial IH in patients with darker skin tones may appear as a dark-red or violaceous papule or plaque compared to bright red in lighter skin tones.⁵ Deep IH may appear as a soft, round, flesh-colored or blue-hued subcutaneous mass, the color of which may be harder to appreciate in those with darker skin tones.⁵

Worth Noting

Complications from IH may require imaging, close follow-up, systemic therapy, multidisciplinary care, and advanced health literacy and patient/family navigation. Multifocal IHs (≥5 lesions) are more likely to be associated with infantile hepatic hemangiomas.^2,3 Large (>5 cm) segmental IHs on the face and lumbosacral area require further evaluation for PHACES (posterior fossa malformation, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal raphe/cleft defects) and LUMBAR (lower-body segmental IH; urogenital anomalies and ulceration; ­myelopathy; bony deformities; anorectal malformations and arterial anomalies; and renal anomalies) syndromes, which are more common in patients of Hispanic ethnicity.^2,3

The Infantile Hemangioma Referral Score is a recently validated tool that can assist primary care physicians in timely referral of IHs requiring early specialist intervention.^4,9 It takes into account the location, number, and size of the lesions and the age of the patient; these factors help to determine which IHs may be managed conservatively vs those that may require treatment to prevent ­life-threatening complications.^1-3 

Systemic corticosteroids historically have been the primary treatment for IH; however, in the past decade, propranolol oral solution (4.28 mg/mL) has become the first-line therapy for most infants requiring systemic management.¹⁰ It is the only medication approved by the US Food and Drug Administration for proliferating IH, with treatment initiation as young as 5 weeks corrected age.¹¹ As a nonselective beta-blocker, propranolol is believed to reduce IHs through vasoconstriction or by inhibition of angiogenesis.^1,4,10 

For small superficial IHs, treatment options include timolol maleate ophthalmic solution 0.5% (one drop applied twice daily to the IH) or pulsed dye laser therapy.^4,10 Surgical excision typically is avoided during infancy due to concerns about anesthetic risks and potential blood loss.^4,10 Surgery is reserved for cases involving residual fibrofatty tissue, postinvolution scarring, obstruction of vital structures, or lesions in aesthetically sensitive areas as well as when propranolol is contraindicated.^4,10

Health Disparity Highlight

Infants with skin of color and those of lower socioeconomic status (SES) face a heightened risk for delayed diagnosis and more advanced disease at the initial evaluation for IH.^5,7 Access barriers such as geographic limitations to specialty services, lack of insurance, underinsurance, and language differences impact timely diagnosis and treatment.^5,6 Implementation of telemedicine services in areas with limited access to specialists can facilitate early evaluation and risk stratification for IH.¹²

A retrospective cohort study of 804 children seen at a large academic hospital found that those of lower SES were more likely to seek care after 3 months of age than their higher-SES counterparts.⁶ Those who presented after 6 months of age also had higher IH severity scores compared to their counterparts with higher SES.⁶ Delayed access to care may cause children to miss the critical treatment window during the rapid proliferative growth phase.^6,12 However, children insured through Medicaid or the Children’s Health Insurance Program who participated in institutional care management programs (which assist in scheduling specialty care appointments within the institution) sought treatment earlier regardless of their SES, suggesting that such programs may help reduce disparities in timely access for children of lower SES.⁶ 

An epidemiologic study analyzing the demographics of children hospitalized across the United States demonstrated that Black infants with IH were more likely to belong to the lowest income quartile compared with White infants or those of other races. They also were 2 times older on average at initial presentation (1.8 vs 1.0 years), experienced longer hospitalizations (16.4 vs 13.8 days), and underwent more IH-related procedures than White infants and infants of other races (2.4, 1.9, and 2.1, respectively).⁷

These and other factors may contribute to missed windows of opportunity for timely treatment of high-risk IHs in patients with darker skin tones and/or those facing challenges stemming from social drivers of health.

Infantile hemangioma (IH) is the most common vascular tumor of infancy, appearing within the first few weeks of life and typically reaching peak size by age 3 to 5 months.¹ It classically manifests as a raised or flat bright-red lesion in the upper dermis of the skin and/or subcutaneous tissue and can vary in number, size, shape, and location.² It is characterized by a rapid proliferative phase, especially between 5 and 8 weeks of age, followed by gradual spontaneous regression over 1 to 10 years.^1-3

Infantile hemangiomas are categorized based on depth (superficial, deep, or mixed) and distribution pattern (focal, multifocal, segmental, or indeterminate).⁴ In most cases, complete regression occurs by age 4 years, but there can be residual telangiectasia, fibrofatty tissue, and/or scarring.^1,4 About 10% to 15% of IHs result in complications that require medical intervention (eg, visual, airway, or auditory compromise; ulceration; disfigurement); ideally, these patients should be referred to a specialist by 5 weeks of age.⁴ Prompt assessment of IH severity is essential to prevent or mitigate potential complications and ultimately improve outcomes.³ Social drivers of health contribute to delayed diagnosis and management of hemangiomas, leading to increased complications in some patient populations.^5-7

Epidemiology

Infantile hemangiomas are estimated to manifest in 4.5% of infants in the United States.¹ The most common type is superficial IH, typically found on the head or neck.⁵ Risk factors in infants include female sex, White race, premature birth, and low birth weight (<1000 g).^1,3 Maternal risk factors include advanced gestational age (ie, >35 years), multiple gestations, family history of IH, tobacco use, use of progesterone therapy during pregnancy, and pre-eclampsia.^1,3

Focal IH typically manifests as a single localized lesion that can occur anywhere on the body.^2,3 In contrast, segmental IH manifests in a linear pattern and/or is distributed on a large anatomic area, most commonly on the face and less frequently the extremities and trunk.^2,3 Segmental IHs are more common in Hispanic patients and carry a higher risk for morbidity, often complicated by ulceration that can lead to functional and cosmetic challenges.⁸

Key Clinical Features

Superficial IH in patients with darker skin tones may appear as a dark-red or violaceous papule or plaque compared to bright red in lighter skin tones.⁵ Deep IH may appear as a soft, round, flesh-colored or blue-hued subcutaneous mass, the color of which may be harder to appreciate in those with darker skin tones.⁵

Worth Noting

Complications from IH may require imaging, close follow-up, systemic therapy, multidisciplinary care, and advanced health literacy and patient/family navigation. Multifocal IHs (≥5 lesions) are more likely to be associated with infantile hepatic hemangiomas.^2,3 Large (>5 cm) segmental IHs on the face and lumbosacral area require further evaluation for PHACES (posterior fossa malformation, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal raphe/cleft defects) and LUMBAR (lower-body segmental IH; urogenital anomalies and ulceration; ­myelopathy; bony deformities; anorectal malformations and arterial anomalies; and renal anomalies) syndromes, which are more common in patients of Hispanic ethnicity.^2,3

The Infantile Hemangioma Referral Score is a recently validated tool that can assist primary care physicians in timely referral of IHs requiring early specialist intervention.^4,9 It takes into account the location, number, and size of the lesions and the age of the patient; these factors help to determine which IHs may be managed conservatively vs those that may require treatment to prevent ­life-threatening complications.^1-3 

Systemic corticosteroids historically have been the primary treatment for IH; however, in the past decade, propranolol oral solution (4.28 mg/mL) has become the first-line therapy for most infants requiring systemic management.¹⁰ It is the only medication approved by the US Food and Drug Administration for proliferating IH, with treatment initiation as young as 5 weeks corrected age.¹¹ As a nonselective beta-blocker, propranolol is believed to reduce IHs through vasoconstriction or by inhibition of angiogenesis.^1,4,10 

For small superficial IHs, treatment options include timolol maleate ophthalmic solution 0.5% (one drop applied twice daily to the IH) or pulsed dye laser therapy.^4,10 Surgical excision typically is avoided during infancy due to concerns about anesthetic risks and potential blood loss.^4,10 Surgery is reserved for cases involving residual fibrofatty tissue, postinvolution scarring, obstruction of vital structures, or lesions in aesthetically sensitive areas as well as when propranolol is contraindicated.^4,10

Health Disparity Highlight

Infants with skin of color and those of lower socioeconomic status (SES) face a heightened risk for delayed diagnosis and more advanced disease at the initial evaluation for IH.^5,7 Access barriers such as geographic limitations to specialty services, lack of insurance, underinsurance, and language differences impact timely diagnosis and treatment.^5,6 Implementation of telemedicine services in areas with limited access to specialists can facilitate early evaluation and risk stratification for IH.¹²

A retrospective cohort study of 804 children seen at a large academic hospital found that those of lower SES were more likely to seek care after 3 months of age than their higher-SES counterparts.⁶ Those who presented after 6 months of age also had higher IH severity scores compared to their counterparts with higher SES.⁶ Delayed access to care may cause children to miss the critical treatment window during the rapid proliferative growth phase.^6,12 However, children insured through Medicaid or the Children’s Health Insurance Program who participated in institutional care management programs (which assist in scheduling specialty care appointments within the institution) sought treatment earlier regardless of their SES, suggesting that such programs may help reduce disparities in timely access for children of lower SES.⁶ 

An epidemiologic study analyzing the demographics of children hospitalized across the United States demonstrated that Black infants with IH were more likely to belong to the lowest income quartile compared with White infants or those of other races. They also were 2 times older on average at initial presentation (1.8 vs 1.0 years), experienced longer hospitalizations (16.4 vs 13.8 days), and underwent more IH-related procedures than White infants and infants of other races (2.4, 1.9, and 2.1, respectively).⁷

These and other factors may contribute to missed windows of opportunity for timely treatment of high-risk IHs in patients with darker skin tones and/or those facing challenges stemming from social drivers of health.

Infantile hemangioma (IH) is the most common vascular tumor of infancy, appearing within the first few weeks of life and typically reaching peak size by age 3 to 5 months.¹ It classically manifests as a raised or flat bright-red lesion in the upper dermis of the skin and/or subcutaneous tissue and can vary in number, size, shape, and location.² It is characterized by a rapid proliferative phase, especially between 5 and 8 weeks of age, followed by gradual spontaneous regression over 1 to 10 years.^1-3

Infantile hemangiomas are categorized based on depth (superficial, deep, or mixed) and distribution pattern (focal, multifocal, segmental, or indeterminate).⁴ In most cases, complete regression occurs by age 4 years, but there can be residual telangiectasia, fibrofatty tissue, and/or scarring.^1,4 About 10% to 15% of IHs result in complications that require medical intervention (eg, visual, airway, or auditory compromise; ulceration; disfigurement); ideally, these patients should be referred to a specialist by 5 weeks of age.⁴ Prompt assessment of IH severity is essential to prevent or mitigate potential complications and ultimately improve outcomes.³ Social drivers of health contribute to delayed diagnosis and management of hemangiomas, leading to increased complications in some patient populations.^5-7

Epidemiology

Infantile hemangiomas are estimated to manifest in 4.5% of infants in the United States.¹ The most common type is superficial IH, typically found on the head or neck.⁵ Risk factors in infants include female sex, White race, premature birth, and low birth weight (<1000 g).^1,3 Maternal risk factors include advanced gestational age (ie, >35 years), multiple gestations, family history of IH, tobacco use, use of progesterone therapy during pregnancy, and pre-eclampsia.^1,3

Focal IH typically manifests as a single localized lesion that can occur anywhere on the body.^2,3 In contrast, segmental IH manifests in a linear pattern and/or is distributed on a large anatomic area, most commonly on the face and less frequently the extremities and trunk.^2,3 Segmental IHs are more common in Hispanic patients and carry a higher risk for morbidity, often complicated by ulceration that can lead to functional and cosmetic challenges.⁸

Key Clinical Features

Superficial IH in patients with darker skin tones may appear as a dark-red or violaceous papule or plaque compared to bright red in lighter skin tones.⁵ Deep IH may appear as a soft, round, flesh-colored or blue-hued subcutaneous mass, the color of which may be harder to appreciate in those with darker skin tones.⁵

Worth Noting

Complications from IH may require imaging, close follow-up, systemic therapy, multidisciplinary care, and advanced health literacy and patient/family navigation. Multifocal IHs (≥5 lesions) are more likely to be associated with infantile hepatic hemangiomas.^2,3 Large (>5 cm) segmental IHs on the face and lumbosacral area require further evaluation for PHACES (posterior fossa malformation, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal raphe/cleft defects) and LUMBAR (lower-body segmental IH; urogenital anomalies and ulceration; ­myelopathy; bony deformities; anorectal malformations and arterial anomalies; and renal anomalies) syndromes, which are more common in patients of Hispanic ethnicity.^2,3

The Infantile Hemangioma Referral Score is a recently validated tool that can assist primary care physicians in timely referral of IHs requiring early specialist intervention.^4,9 It takes into account the location, number, and size of the lesions and the age of the patient; these factors help to determine which IHs may be managed conservatively vs those that may require treatment to prevent ­life-threatening complications.^1-3 

Systemic corticosteroids historically have been the primary treatment for IH; however, in the past decade, propranolol oral solution (4.28 mg/mL) has become the first-line therapy for most infants requiring systemic management.¹⁰ It is the only medication approved by the US Food and Drug Administration for proliferating IH, with treatment initiation as young as 5 weeks corrected age.¹¹ As a nonselective beta-blocker, propranolol is believed to reduce IHs through vasoconstriction or by inhibition of angiogenesis.^1,4,10 

For small superficial IHs, treatment options include timolol maleate ophthalmic solution 0.5% (one drop applied twice daily to the IH) or pulsed dye laser therapy.^4,10 Surgical excision typically is avoided during infancy due to concerns about anesthetic risks and potential blood loss.^4,10 Surgery is reserved for cases involving residual fibrofatty tissue, postinvolution scarring, obstruction of vital structures, or lesions in aesthetically sensitive areas as well as when propranolol is contraindicated.^4,10

Health Disparity Highlight

Infants with skin of color and those of lower socioeconomic status (SES) face a heightened risk for delayed diagnosis and more advanced disease at the initial evaluation for IH.^5,7 Access barriers such as geographic limitations to specialty services, lack of insurance, underinsurance, and language differences impact timely diagnosis and treatment.^5,6 Implementation of telemedicine services in areas with limited access to specialists can facilitate early evaluation and risk stratification for IH.¹²

A retrospective cohort study of 804 children seen at a large academic hospital found that those of lower SES were more likely to seek care after 3 months of age than their higher-SES counterparts.⁶ Those who presented after 6 months of age also had higher IH severity scores compared to their counterparts with higher SES.⁶ Delayed access to care may cause children to miss the critical treatment window during the rapid proliferative growth phase.^6,12 However, children insured through Medicaid or the Children’s Health Insurance Program who participated in institutional care management programs (which assist in scheduling specialty care appointments within the institution) sought treatment earlier regardless of their SES, suggesting that such programs may help reduce disparities in timely access for children of lower SES.⁶ 

An epidemiologic study analyzing the demographics of children hospitalized across the United States demonstrated that Black infants with IH were more likely to belong to the lowest income quartile compared with White infants or those of other races. They also were 2 times older on average at initial presentation (1.8 vs 1.0 years), experienced longer hospitalizations (16.4 vs 13.8 days), and underwent more IH-related procedures than White infants and infants of other races (2.4, 1.9, and 2.1, respectively).⁷

These and other factors may contribute to missed windows of opportunity for timely treatment of high-risk IHs in patients with darker skin tones and/or those facing challenges stemming from social drivers of health.

To the Editor:

Residency applicants, especially in competitive specialties such as dermatology, face major financial barriers due to the high costs of applications, interviews, and away rotations.¹ While several studies have examined application costs of other specialties, few have analyzed expenses associated with dermatology applications.^1,2 There are no data examining costs following the start of the COVID-19 pandemic in 2020; thus, our study evaluated dermatology application cost trends from 2021 to 2024 and compared them to other specialties to identify strategies to reduce the financial burden on applicants.

Self-reported total application costs, application fees, interview expenses, and away rotation costs from 2021 to 2024 were collected from the Texas Seeking Transparency in Application to Residency (STAR) database powered by the UT Southwestern Medical Center (Dallas, Texas).³ The mean total application expenses per year were compared among specialties, and an analysis of variance was used to determine if the differences were statistically significant.

The number of applicants who recorded information in the Texas STAR database was 110 in 2021, 163 in 2022, 136 in 2023, and 129 in 2024.³ The total dermatology application expenses increased from $2805 in 2021 to $6231 in 2024; interview costs increased from $404 in 2021 to $911 in 2024; and away rotation costs increased from $850 in 2021 to $3812 in 2024 (all P<.05)(Table). There was no significant change in application fees during the study period ($2176 in 2021 to $2125 in 2024 [P=.58]). Dermatology had the fourth highest average total cost over the study period compared to all other specialties, increasing from $2250 in 2021 to $5250 in 2024, following orthopedic surgery ($2250 in 2021 to $6750 in 2024), plastic surgery ($2250 in 2021 to $9750 in 2024), and neurosurgery ($1750 in 2021 to $11,250 in 2024).

Our study found that dermatology residency application costs have increased significantly from 2021 to 2024, primarily driven by rising interview and away rotation expenses (both P<.05). This trend places dermatology among the most expensive fields to apply to for residency. A cross-sectional survey of dermatology residency program directors identified away rotations as one of the top 5 selection criteria, underscoring their importance in the matching process.⁴ In addition, a cross-sectional analysis of 345 dermatology residents found that 26.2% matched at institutions where they had mentors, including those they connected with through away rotations.^5,6 Overall, the high cost of away rotations partially may reflect the competitive nature of the specialty, as building connections at programs may enhance the chances of matching. These costs also can vary based on geography, as rotating in high-cost urban centers can be more expensive than in rural areas; however, rural rotations may be less common due to limited program availability and applicant preferences. For example, nearly 50% of 2024 Electronic Residency Application Service applicants indicated a preference for urban settings, while fewer than 5% selected rural settings.⁷ Additionally, the high costs associated with applying to residency programs and completing away rotations can disproportionately impact students from rural backgrounds and underrepresented minorities, who may have fewer financial resources.

In our study, the lower application-related expenses in 2021 (during the pandemic) compared to those of 2024 (postpandemic) likely stem from the Association of American Medical Colleges’ recommendation to conduct virtual interviews during the pandemic.⁸ In 2024, some dermatology programs returned to in-person interviews, with some applicants consequently incurring higher costs related to travel, lodging, and other associated expenses.⁸ A cost-analysis study of 4153 dermatology applicants from 2016 to 2021 found that the average application costs were $1759 per applicant during the pandemic, when virtual interviews replaced in-person ones, whereas costs were $8476 per applicant during periods with in-person interviews and no COVID-19 restrictions.² However, we did not observe a significant change in application fees over our study period, likely because the pandemic did not affect application numbers. A cross-sectional analysis of dermatology applicants during the pandemic similarly reported reductions in application-related expenses during the period when interviews were conducted virtually,⁹ supporting the trend observed in our study. Overall, our findings taken together with other studies highlight the pandemic’s role in reducing expenses and underscore the potential for exploring additional cost-saving measures.

Implementing strategies to reduce these financial burdens—including virtual interviews, increasing student funding for away rotations, and limiting the number of applications individual students can submit—could help alleviate socioeconomic disparities. The new signaling system for residency programs aims to reduce the number of applications submitted, as applicants typically receive interviews only from the limited number of programs they signal, reducing overall application costs. However, our data from the Texas STAR database suggest that application numbers remained relatively stable from 2021 to 2024, indicating that, despite signaling, many applicants still may apply broadly in hopes of improving their chances in an increasingly competitive field. Although a definitive solution to reducing the financial burden on dermatology applicants remains elusive, these strategies can raise awareness and encourage important dialogues.

Limitations of our study include the voluntary nature of the Texas STAR survey, leading to potential voluntary response bias, as well as the small sample size. Students who choose to submit cost data may differ systematically from those who do not; for example, students who match may be more likely to report their outcomes, while those who do not match may be less likely to participate, potentially introducing selection bias. In addition, general awareness of the Texas STAR survey may vary across institutions and among students, further limiting the number of students who participate. Additionally, 2021 was the only presignaling year included, making it difficult to assess longer-term trends. Despite these limitations, the Texas STAR database remains a valuable resource for analyzing general residency application expenses and trends, as it offers comprehensive data from more than 100 medical schools and includes many variables.³

In conclusion, our study found that total dermatology residency application costs have increased significantly from 2021 to 2024 (all P<.05), making dermatology among the most expensive specialties for applying. This study sets the foundation for future survey-based research for applicants and program directors on strategies to alleviate financial burdens.

To the Editor:

Residency applicants, especially in competitive specialties such as dermatology, face major financial barriers due to the high costs of applications, interviews, and away rotations.¹ While several studies have examined application costs of other specialties, few have analyzed expenses associated with dermatology applications.^1,2 There are no data examining costs following the start of the COVID-19 pandemic in 2020; thus, our study evaluated dermatology application cost trends from 2021 to 2024 and compared them to other specialties to identify strategies to reduce the financial burden on applicants.

Self-reported total application costs, application fees, interview expenses, and away rotation costs from 2021 to 2024 were collected from the Texas Seeking Transparency in Application to Residency (STAR) database powered by the UT Southwestern Medical Center (Dallas, Texas).³ The mean total application expenses per year were compared among specialties, and an analysis of variance was used to determine if the differences were statistically significant.

The number of applicants who recorded information in the Texas STAR database was 110 in 2021, 163 in 2022, 136 in 2023, and 129 in 2024.³ The total dermatology application expenses increased from $2805 in 2021 to $6231 in 2024; interview costs increased from $404 in 2021 to $911 in 2024; and away rotation costs increased from $850 in 2021 to $3812 in 2024 (all P<.05)(Table). There was no significant change in application fees during the study period ($2176 in 2021 to $2125 in 2024 [P=.58]). Dermatology had the fourth highest average total cost over the study period compared to all other specialties, increasing from $2250 in 2021 to $5250 in 2024, following orthopedic surgery ($2250 in 2021 to $6750 in 2024), plastic surgery ($2250 in 2021 to $9750 in 2024), and neurosurgery ($1750 in 2021 to $11,250 in 2024).

Our study found that dermatology residency application costs have increased significantly from 2021 to 2024, primarily driven by rising interview and away rotation expenses (both P<.05). This trend places dermatology among the most expensive fields to apply to for residency. A cross-sectional survey of dermatology residency program directors identified away rotations as one of the top 5 selection criteria, underscoring their importance in the matching process.⁴ In addition, a cross-sectional analysis of 345 dermatology residents found that 26.2% matched at institutions where they had mentors, including those they connected with through away rotations.^5,6 Overall, the high cost of away rotations partially may reflect the competitive nature of the specialty, as building connections at programs may enhance the chances of matching. These costs also can vary based on geography, as rotating in high-cost urban centers can be more expensive than in rural areas; however, rural rotations may be less common due to limited program availability and applicant preferences. For example, nearly 50% of 2024 Electronic Residency Application Service applicants indicated a preference for urban settings, while fewer than 5% selected rural settings.⁷ Additionally, the high costs associated with applying to residency programs and completing away rotations can disproportionately impact students from rural backgrounds and underrepresented minorities, who may have fewer financial resources.

In our study, the lower application-related expenses in 2021 (during the pandemic) compared to those of 2024 (postpandemic) likely stem from the Association of American Medical Colleges’ recommendation to conduct virtual interviews during the pandemic.⁸ In 2024, some dermatology programs returned to in-person interviews, with some applicants consequently incurring higher costs related to travel, lodging, and other associated expenses.⁸ A cost-analysis study of 4153 dermatology applicants from 2016 to 2021 found that the average application costs were $1759 per applicant during the pandemic, when virtual interviews replaced in-person ones, whereas costs were $8476 per applicant during periods with in-person interviews and no COVID-19 restrictions.² However, we did not observe a significant change in application fees over our study period, likely because the pandemic did not affect application numbers. A cross-sectional analysis of dermatology applicants during the pandemic similarly reported reductions in application-related expenses during the period when interviews were conducted virtually,⁹ supporting the trend observed in our study. Overall, our findings taken together with other studies highlight the pandemic’s role in reducing expenses and underscore the potential for exploring additional cost-saving measures.

Implementing strategies to reduce these financial burdens—including virtual interviews, increasing student funding for away rotations, and limiting the number of applications individual students can submit—could help alleviate socioeconomic disparities. The new signaling system for residency programs aims to reduce the number of applications submitted, as applicants typically receive interviews only from the limited number of programs they signal, reducing overall application costs. However, our data from the Texas STAR database suggest that application numbers remained relatively stable from 2021 to 2024, indicating that, despite signaling, many applicants still may apply broadly in hopes of improving their chances in an increasingly competitive field. Although a definitive solution to reducing the financial burden on dermatology applicants remains elusive, these strategies can raise awareness and encourage important dialogues.

Limitations of our study include the voluntary nature of the Texas STAR survey, leading to potential voluntary response bias, as well as the small sample size. Students who choose to submit cost data may differ systematically from those who do not; for example, students who match may be more likely to report their outcomes, while those who do not match may be less likely to participate, potentially introducing selection bias. In addition, general awareness of the Texas STAR survey may vary across institutions and among students, further limiting the number of students who participate. Additionally, 2021 was the only presignaling year included, making it difficult to assess longer-term trends. Despite these limitations, the Texas STAR database remains a valuable resource for analyzing general residency application expenses and trends, as it offers comprehensive data from more than 100 medical schools and includes many variables.³

In conclusion, our study found that total dermatology residency application costs have increased significantly from 2021 to 2024 (all P<.05), making dermatology among the most expensive specialties for applying. This study sets the foundation for future survey-based research for applicants and program directors on strategies to alleviate financial burdens.

To the Editor:

Residency applicants, especially in competitive specialties such as dermatology, face major financial barriers due to the high costs of applications, interviews, and away rotations.¹ While several studies have examined application costs of other specialties, few have analyzed expenses associated with dermatology applications.^1,2 There are no data examining costs following the start of the COVID-19 pandemic in 2020; thus, our study evaluated dermatology application cost trends from 2021 to 2024 and compared them to other specialties to identify strategies to reduce the financial burden on applicants.

Self-reported total application costs, application fees, interview expenses, and away rotation costs from 2021 to 2024 were collected from the Texas Seeking Transparency in Application to Residency (STAR) database powered by the UT Southwestern Medical Center (Dallas, Texas).³ The mean total application expenses per year were compared among specialties, and an analysis of variance was used to determine if the differences were statistically significant.

The number of applicants who recorded information in the Texas STAR database was 110 in 2021, 163 in 2022, 136 in 2023, and 129 in 2024.³ The total dermatology application expenses increased from $2805 in 2021 to $6231 in 2024; interview costs increased from $404 in 2021 to $911 in 2024; and away rotation costs increased from $850 in 2021 to $3812 in 2024 (all P<.05)(Table). There was no significant change in application fees during the study period ($2176 in 2021 to $2125 in 2024 [P=.58]). Dermatology had the fourth highest average total cost over the study period compared to all other specialties, increasing from $2250 in 2021 to $5250 in 2024, following orthopedic surgery ($2250 in 2021 to $6750 in 2024), plastic surgery ($2250 in 2021 to $9750 in 2024), and neurosurgery ($1750 in 2021 to $11,250 in 2024).

Our study found that dermatology residency application costs have increased significantly from 2021 to 2024, primarily driven by rising interview and away rotation expenses (both P<.05). This trend places dermatology among the most expensive fields to apply to for residency. A cross-sectional survey of dermatology residency program directors identified away rotations as one of the top 5 selection criteria, underscoring their importance in the matching process.⁴ In addition, a cross-sectional analysis of 345 dermatology residents found that 26.2% matched at institutions where they had mentors, including those they connected with through away rotations.^5,6 Overall, the high cost of away rotations partially may reflect the competitive nature of the specialty, as building connections at programs may enhance the chances of matching. These costs also can vary based on geography, as rotating in high-cost urban centers can be more expensive than in rural areas; however, rural rotations may be less common due to limited program availability and applicant preferences. For example, nearly 50% of 2024 Electronic Residency Application Service applicants indicated a preference for urban settings, while fewer than 5% selected rural settings.⁷ Additionally, the high costs associated with applying to residency programs and completing away rotations can disproportionately impact students from rural backgrounds and underrepresented minorities, who may have fewer financial resources.

In our study, the lower application-related expenses in 2021 (during the pandemic) compared to those of 2024 (postpandemic) likely stem from the Association of American Medical Colleges’ recommendation to conduct virtual interviews during the pandemic.⁸ In 2024, some dermatology programs returned to in-person interviews, with some applicants consequently incurring higher costs related to travel, lodging, and other associated expenses.⁸ A cost-analysis study of 4153 dermatology applicants from 2016 to 2021 found that the average application costs were $1759 per applicant during the pandemic, when virtual interviews replaced in-person ones, whereas costs were $8476 per applicant during periods with in-person interviews and no COVID-19 restrictions.² However, we did not observe a significant change in application fees over our study period, likely because the pandemic did not affect application numbers. A cross-sectional analysis of dermatology applicants during the pandemic similarly reported reductions in application-related expenses during the period when interviews were conducted virtually,⁹ supporting the trend observed in our study. Overall, our findings taken together with other studies highlight the pandemic’s role in reducing expenses and underscore the potential for exploring additional cost-saving measures.

Implementing strategies to reduce these financial burdens—including virtual interviews, increasing student funding for away rotations, and limiting the number of applications individual students can submit—could help alleviate socioeconomic disparities. The new signaling system for residency programs aims to reduce the number of applications submitted, as applicants typically receive interviews only from the limited number of programs they signal, reducing overall application costs. However, our data from the Texas STAR database suggest that application numbers remained relatively stable from 2021 to 2024, indicating that, despite signaling, many applicants still may apply broadly in hopes of improving their chances in an increasingly competitive field. Although a definitive solution to reducing the financial burden on dermatology applicants remains elusive, these strategies can raise awareness and encourage important dialogues.

Limitations of our study include the voluntary nature of the Texas STAR survey, leading to potential voluntary response bias, as well as the small sample size. Students who choose to submit cost data may differ systematically from those who do not; for example, students who match may be more likely to report their outcomes, while those who do not match may be less likely to participate, potentially introducing selection bias. In addition, general awareness of the Texas STAR survey may vary across institutions and among students, further limiting the number of students who participate. Additionally, 2021 was the only presignaling year included, making it difficult to assess longer-term trends. Despite these limitations, the Texas STAR database remains a valuable resource for analyzing general residency application expenses and trends, as it offers comprehensive data from more than 100 medical schools and includes many variables.³

In conclusion, our study found that total dermatology residency application costs have increased significantly from 2021 to 2024 (all P<.05), making dermatology among the most expensive specialties for applying. This study sets the foundation for future survey-based research for applicants and program directors on strategies to alleviate financial burdens.

Pediatric alopecia areata (AA) is a chronic autoimmune disease of the hair follicles characterized by nonscarring hair loss. Its incidence in children in the United States ranges from 13.6 to 33.5 per 100,000 person-years, with a prevalence of 0.04% to 0.11%.¹ Alopecia areata has important effects on quality of life, particularly in children. Hair loss at an early age can decrease participation in school, sports, and extracurricular activities² and is associated with increased rates of comorbid anxiety and depression.³ Families also experience psychosocial stress, often comparable to other chronic pediatric illnesses.⁴ Thus, management requires not only medical therapy but also psychosocial support and school-based accommodations.

Systemic therapies for treatment of AA in adolescents and adults are increasingly available, including US Food and Drug Administration (FDA)–approved Janus kinase (JAK) inhibitors such as baricitinib, deuruxolitinib (for adults), and ritlecitinib (for adolescents and adults); however, no systemic therapies have been approved by the FDA for children younger than 12 years. The therapeutic gap is most acute for those aged 6 to 11 years, for whom the psychosocial burden is high but treatment options are limited.³

This article highlights options and strategies for managing AA in children aged 6 to 11 years, emphasizing supportive and psychosocial care (including camouflage techniques), topical therapies, and off-label systemic approaches.

Supportive and Psychosocial Care

Treatment of AA in children extends beyond the affected child to include parents, caregivers, and even school staff (eg, teachers, principals, nurses).⁴ Disease-specific organizations such as the National Alopecia Areata Foundation ­(naaf.org) and the Children’s Alopecia Project (childrensalopeciaproject.org) provide ­education, support groups, and advocacy resources. These organizations assist families in navigating school accommodations, including Section 504 plans that may allow children with AA to wear hats in school to mitigate stigma. Additional resources include handouts for teachers and school nurses developed by the Society for Pediatric Dermatology.⁵

Psychological support for these patients is critical. Many children benefit from seeing a psychologist, particularly if anxiety, depression, and/or bullying is present.³ In clinics without embedded psychology services, dermatologists should maintain referral lists or encourage families to seek guidance from their pediatrician.

Camouflage techniques can help children cope with visible hair loss. Wigs and hairpieces are available free of charge through charitable organizations for patients younger than 17; however, young children often find adhesives uncomfortable, and they will not wear nonadherent wigs for long periods of time. Alternatives include soft hats, bonnets, scarves, and beanies. For partial hair loss, root concealers, scalp powders, or hair mascara can be useful. Temporary eyebrow tattoos are a good cosmetic approach, whereas microblading generally is not advised in children younger than 12 due to procedural risks including pain.

Topical Therapies

Topical agents remain the mainstay of treatment for AA in children aged 6 to 11 years. Potent class 1 or class 2 topical corticosteroids commonly are used, sometimes in combination with calcineurin inhibitors or topical minoxidil. Off-label compounded topical JAK inhibitors also have been tried in this population and may be helpful for eyebrow hair loss,⁶ though data on their efficacy for scalp AA are mixed.⁷ Intralesional corticosteroid injections, effective in adolescents and adults, generally are poorly tolerated by younger children and may cause considerable distress. Contact immunotherapy with squaric acid dibutyl ester or anthralin can be considered, but these agents are designed to elicit irritation, which may be intolerable for young children.⁸ Shared decision-making with families is essential to balance efficacy, tolerability, and treatment burden.

Systemic Therapies

Systemic therapy generally is reserved for children with extensive or refractory AA. Low-dose oral minoxidil is emerging as an off-label option. One systematic review reported that low-dose oral minoxidil was well tolerated in pediatric patients with minimal adverse effects.⁹ Doses of 0.01 to 0.02 mg/kg/d are reasonable starting points, achieved by cutting tablets or compounding oral solutions.¹⁰

In children with AA and concurrent atopic dermatitis, dupilumab may offer dual benefit. A real-world observational study demonstrated hair regrowth in pediatric patients with AA treated with dupilumab.¹¹ Immunosuppressive options such as low-dose methotrexate or pulse corticosteroids (dexamethasone or prednisolone) also may be considered, although use of these agents requires careful monitoring due to increased risk for infection, clinically significant blood count and liver enzyme changes, and metabolic adverse effects related to long-term use of corticosteroids.

Clinical trials of JAK inhibitors in children aged 6 to 11 years are anticipated to begin in late 2025. Until then, off-label use of ritlecitinib, baricitinib, tofacitinib, or other JAK inhibitors may be considered in select cases with considerable disease burden and quality-of-life impairment following thorough discussion with the patient and their caregivers. Currently available pediatric data show few serious adverse events in children—the most common included upper respiratory infections (nasopharyngitis), acne, and headaches—but long-term risks remain unknown. Dosing challenges also exist for children who cannot swallow pills; currently ritlecitinib is available only as a capsule that cannot be opened while other JAK inhibitors are available in more accessible forms (baricitinib can be crushed and dissolved, and tofacitinib is available in liquid formulation for other pediatric indications). Insurance coverage is a major barrier, as these therapies are not FDA approved for AA in this age group.

Final Thoughts

Alopecia areata in children aged 6 to 11 years presents unique therapeutic challenges. While highly effective systemic therapies exist for older patients, younger children have limited options. For the 6-to-11 age group, management strategies should prioritize psychosocial support, topical therapy, and low-burden systemic alternatives such as low-dose oral minoxidil. Family education, school-based accommodations, and access to camouflage techniques are integral to holistic care. The commencement of pediatric clinical trials for JAK inhibitors offers hope for more robust treatment strategies in the near future. In the meantime, clinicians must engage in shared decision-making, tailoring therapy to the child’s disease severity, emotional well-being, and family priorities.

Pediatric alopecia areata (AA) is a chronic autoimmune disease of the hair follicles characterized by nonscarring hair loss. Its incidence in children in the United States ranges from 13.6 to 33.5 per 100,000 person-years, with a prevalence of 0.04% to 0.11%.¹ Alopecia areata has important effects on quality of life, particularly in children. Hair loss at an early age can decrease participation in school, sports, and extracurricular activities² and is associated with increased rates of comorbid anxiety and depression.³ Families also experience psychosocial stress, often comparable to other chronic pediatric illnesses.⁴ Thus, management requires not only medical therapy but also psychosocial support and school-based accommodations.

Systemic therapies for treatment of AA in adolescents and adults are increasingly available, including US Food and Drug Administration (FDA)–approved Janus kinase (JAK) inhibitors such as baricitinib, deuruxolitinib (for adults), and ritlecitinib (for adolescents and adults); however, no systemic therapies have been approved by the FDA for children younger than 12 years. The therapeutic gap is most acute for those aged 6 to 11 years, for whom the psychosocial burden is high but treatment options are limited.³

This article highlights options and strategies for managing AA in children aged 6 to 11 years, emphasizing supportive and psychosocial care (including camouflage techniques), topical therapies, and off-label systemic approaches.

Supportive and Psychosocial Care

Treatment of AA in children extends beyond the affected child to include parents, caregivers, and even school staff (eg, teachers, principals, nurses).⁴ Disease-specific organizations such as the National Alopecia Areata Foundation ­(naaf.org) and the Children’s Alopecia Project (childrensalopeciaproject.org) provide ­education, support groups, and advocacy resources. These organizations assist families in navigating school accommodations, including Section 504 plans that may allow children with AA to wear hats in school to mitigate stigma. Additional resources include handouts for teachers and school nurses developed by the Society for Pediatric Dermatology.⁵

Psychological support for these patients is critical. Many children benefit from seeing a psychologist, particularly if anxiety, depression, and/or bullying is present.³ In clinics without embedded psychology services, dermatologists should maintain referral lists or encourage families to seek guidance from their pediatrician.

Camouflage techniques can help children cope with visible hair loss. Wigs and hairpieces are available free of charge through charitable organizations for patients younger than 17; however, young children often find adhesives uncomfortable, and they will not wear nonadherent wigs for long periods of time. Alternatives include soft hats, bonnets, scarves, and beanies. For partial hair loss, root concealers, scalp powders, or hair mascara can be useful. Temporary eyebrow tattoos are a good cosmetic approach, whereas microblading generally is not advised in children younger than 12 due to procedural risks including pain.

Topical Therapies

Topical agents remain the mainstay of treatment for AA in children aged 6 to 11 years. Potent class 1 or class 2 topical corticosteroids commonly are used, sometimes in combination with calcineurin inhibitors or topical minoxidil. Off-label compounded topical JAK inhibitors also have been tried in this population and may be helpful for eyebrow hair loss,⁶ though data on their efficacy for scalp AA are mixed.⁷ Intralesional corticosteroid injections, effective in adolescents and adults, generally are poorly tolerated by younger children and may cause considerable distress. Contact immunotherapy with squaric acid dibutyl ester or anthralin can be considered, but these agents are designed to elicit irritation, which may be intolerable for young children.⁸ Shared decision-making with families is essential to balance efficacy, tolerability, and treatment burden.

Systemic Therapies

Systemic therapy generally is reserved for children with extensive or refractory AA. Low-dose oral minoxidil is emerging as an off-label option. One systematic review reported that low-dose oral minoxidil was well tolerated in pediatric patients with minimal adverse effects.⁹ Doses of 0.01 to 0.02 mg/kg/d are reasonable starting points, achieved by cutting tablets or compounding oral solutions.¹⁰

In children with AA and concurrent atopic dermatitis, dupilumab may offer dual benefit. A real-world observational study demonstrated hair regrowth in pediatric patients with AA treated with dupilumab.¹¹ Immunosuppressive options such as low-dose methotrexate or pulse corticosteroids (dexamethasone or prednisolone) also may be considered, although use of these agents requires careful monitoring due to increased risk for infection, clinically significant blood count and liver enzyme changes, and metabolic adverse effects related to long-term use of corticosteroids.

Clinical trials of JAK inhibitors in children aged 6 to 11 years are anticipated to begin in late 2025. Until then, off-label use of ritlecitinib, baricitinib, tofacitinib, or other JAK inhibitors may be considered in select cases with considerable disease burden and quality-of-life impairment following thorough discussion with the patient and their caregivers. Currently available pediatric data show few serious adverse events in children—the most common included upper respiratory infections (nasopharyngitis), acne, and headaches—but long-term risks remain unknown. Dosing challenges also exist for children who cannot swallow pills; currently ritlecitinib is available only as a capsule that cannot be opened while other JAK inhibitors are available in more accessible forms (baricitinib can be crushed and dissolved, and tofacitinib is available in liquid formulation for other pediatric indications). Insurance coverage is a major barrier, as these therapies are not FDA approved for AA in this age group.

Final Thoughts

Alopecia areata in children aged 6 to 11 years presents unique therapeutic challenges. While highly effective systemic therapies exist for older patients, younger children have limited options. For the 6-to-11 age group, management strategies should prioritize psychosocial support, topical therapy, and low-burden systemic alternatives such as low-dose oral minoxidil. Family education, school-based accommodations, and access to camouflage techniques are integral to holistic care. The commencement of pediatric clinical trials for JAK inhibitors offers hope for more robust treatment strategies in the near future. In the meantime, clinicians must engage in shared decision-making, tailoring therapy to the child’s disease severity, emotional well-being, and family priorities.

Pediatric alopecia areata (AA) is a chronic autoimmune disease of the hair follicles characterized by nonscarring hair loss. Its incidence in children in the United States ranges from 13.6 to 33.5 per 100,000 person-years, with a prevalence of 0.04% to 0.11%.¹ Alopecia areata has important effects on quality of life, particularly in children. Hair loss at an early age can decrease participation in school, sports, and extracurricular activities² and is associated with increased rates of comorbid anxiety and depression.³ Families also experience psychosocial stress, often comparable to other chronic pediatric illnesses.⁴ Thus, management requires not only medical therapy but also psychosocial support and school-based accommodations.

Systemic therapies for treatment of AA in adolescents and adults are increasingly available, including US Food and Drug Administration (FDA)–approved Janus kinase (JAK) inhibitors such as baricitinib, deuruxolitinib (for adults), and ritlecitinib (for adolescents and adults); however, no systemic therapies have been approved by the FDA for children younger than 12 years. The therapeutic gap is most acute for those aged 6 to 11 years, for whom the psychosocial burden is high but treatment options are limited.³

This article highlights options and strategies for managing AA in children aged 6 to 11 years, emphasizing supportive and psychosocial care (including camouflage techniques), topical therapies, and off-label systemic approaches.

Supportive and Psychosocial Care

Treatment of AA in children extends beyond the affected child to include parents, caregivers, and even school staff (eg, teachers, principals, nurses).⁴ Disease-specific organizations such as the National Alopecia Areata Foundation ­(naaf.org) and the Children’s Alopecia Project (childrensalopeciaproject.org) provide ­education, support groups, and advocacy resources. These organizations assist families in navigating school accommodations, including Section 504 plans that may allow children with AA to wear hats in school to mitigate stigma. Additional resources include handouts for teachers and school nurses developed by the Society for Pediatric Dermatology.⁵

Psychological support for these patients is critical. Many children benefit from seeing a psychologist, particularly if anxiety, depression, and/or bullying is present.³ In clinics without embedded psychology services, dermatologists should maintain referral lists or encourage families to seek guidance from their pediatrician.

Camouflage techniques can help children cope with visible hair loss. Wigs and hairpieces are available free of charge through charitable organizations for patients younger than 17; however, young children often find adhesives uncomfortable, and they will not wear nonadherent wigs for long periods of time. Alternatives include soft hats, bonnets, scarves, and beanies. For partial hair loss, root concealers, scalp powders, or hair mascara can be useful. Temporary eyebrow tattoos are a good cosmetic approach, whereas microblading generally is not advised in children younger than 12 due to procedural risks including pain.

Topical Therapies

Topical agents remain the mainstay of treatment for AA in children aged 6 to 11 years. Potent class 1 or class 2 topical corticosteroids commonly are used, sometimes in combination with calcineurin inhibitors or topical minoxidil. Off-label compounded topical JAK inhibitors also have been tried in this population and may be helpful for eyebrow hair loss,⁶ though data on their efficacy for scalp AA are mixed.⁷ Intralesional corticosteroid injections, effective in adolescents and adults, generally are poorly tolerated by younger children and may cause considerable distress. Contact immunotherapy with squaric acid dibutyl ester or anthralin can be considered, but these agents are designed to elicit irritation, which may be intolerable for young children.⁸ Shared decision-making with families is essential to balance efficacy, tolerability, and treatment burden.

Systemic Therapies

Systemic therapy generally is reserved for children with extensive or refractory AA. Low-dose oral minoxidil is emerging as an off-label option. One systematic review reported that low-dose oral minoxidil was well tolerated in pediatric patients with minimal adverse effects.⁹ Doses of 0.01 to 0.02 mg/kg/d are reasonable starting points, achieved by cutting tablets or compounding oral solutions.¹⁰

In children with AA and concurrent atopic dermatitis, dupilumab may offer dual benefit. A real-world observational study demonstrated hair regrowth in pediatric patients with AA treated with dupilumab.¹¹ Immunosuppressive options such as low-dose methotrexate or pulse corticosteroids (dexamethasone or prednisolone) also may be considered, although use of these agents requires careful monitoring due to increased risk for infection, clinically significant blood count and liver enzyme changes, and metabolic adverse effects related to long-term use of corticosteroids.

Clinical trials of JAK inhibitors in children aged 6 to 11 years are anticipated to begin in late 2025. Until then, off-label use of ritlecitinib, baricitinib, tofacitinib, or other JAK inhibitors may be considered in select cases with considerable disease burden and quality-of-life impairment following thorough discussion with the patient and their caregivers. Currently available pediatric data show few serious adverse events in children—the most common included upper respiratory infections (nasopharyngitis), acne, and headaches—but long-term risks remain unknown. Dosing challenges also exist for children who cannot swallow pills; currently ritlecitinib is available only as a capsule that cannot be opened while other JAK inhibitors are available in more accessible forms (baricitinib can be crushed and dissolved, and tofacitinib is available in liquid formulation for other pediatric indications). Insurance coverage is a major barrier, as these therapies are not FDA approved for AA in this age group.

Final Thoughts

Alopecia areata in children aged 6 to 11 years presents unique therapeutic challenges. While highly effective systemic therapies exist for older patients, younger children have limited options. For the 6-to-11 age group, management strategies should prioritize psychosocial support, topical therapy, and low-burden systemic alternatives such as low-dose oral minoxidil. Family education, school-based accommodations, and access to camouflage techniques are integral to holistic care. The commencement of pediatric clinical trials for JAK inhibitors offers hope for more robust treatment strategies in the near future. In the meantime, clinicians must engage in shared decision-making, tailoring therapy to the child’s disease severity, emotional well-being, and family priorities.

The Diagnosis: Juvenile Xanthogranuloma

Given the patient’s age, clinical features of the lesion, and characteristic setting-sun pattern on dermoscopy, a diagnosis of juvenile xanthogranuloma (JXG) was made. The patient showed no other signs of neurofibromatosis type 1 (NF1) or systemic disease and was managed conservatively with observation and routine follow-up. Minimal growth of the lesion was noted at 1-year follow-up, and he was meeting all age-appropriate developmental milestones and showed no other symptoms consistent with NF1. 

Juvenile xanthogranuloma is the most common childhood non–Langerhans cell histiocytosis. While it typically manifests as an isolated condition, JXG also can be associated with NF1 as well as juvenile myelomonocytic leukemia.^1-3 Neurofibromatosis type 1 is a multisystem disorder with variable clinical manifestations that commonly is associated with skin findings such as café au lait macules, intertriginous freckling, and neurofibromas, in addition to JXG.^2,3 Diagnosis of JXG should prompt noninvasive evaluation for further signs and symptoms of NF1, including thorough patient and family history and physical examination to identify other characteristic cutaneous findings, and can include consideration of slit lamp eye examination and radiography for identification of osseous findings. 

The pathogenesis of JXG is not fully known, though there is evidence that it may be associated with a mutation in the mitogen-activated protein kinase pathway.¹ The majority of cases appear in the first year of life.⁴ Clinically, JXG can manifest with extracutaneous lesions, including on the eyes and lungs.^5-7 Juvenile xanthogranuloma can be noninvasively diagnosed with dermoscopy. As seen in our patient, dermoscopic findings include a red-yellow or yellow-orange background with an erythematous border, typically described as a setting-sun pattern.^4,8 Biopsy can confirm the diagnosis; however, given the usually benign course, this often is unnecessary. Most pediatric patients with cutaneous manifestations have a self-limited course with regression over several months to years. Generally, no treatment is required for cutaneous manifestations alone; however, lesions can be removed for aesthetic concerns. For those with systemic involvement, a range of other treatments have been used, including chemotherapy, radiotherapy, systemic corticosteroids, and cyclosporine.^6,7 

The differential diagnosis for JXG includes Brooke-Spiegler syndrome, Fabry disease, solitary cutaneous mastocytoma, and tuberous sclerosis complex. Brooke-Spiegler syndrome is an autosomal-dominant condition characterized by the growth of adnexal neoplasms, including trichoepitheliomas, cylindromas, and spiradenomas. These lesions usually manifest on the face but can include other areas such as the trunk.⁹ Fabry disease is an X-linked recessive lysosomal storage disorder with cutaneous manifestations such as angiokeratoma corporis diffusum and hypohidrosis. Patients also may present with systemic symptoms including hypertension and renal and cardiovascular disease.¹⁰ Mastocytosis encompasses several clinical disorders defined by mast cell hyperplasia and accumulation in various organ systems, and solitary cutaneous mastocytoma is the most common manifestation in children.^11,12 Cutaneous mastocytoma can manifest as a single red-brown or yellow papule, usually located on the arms or legs.¹³ Solitary cutaneous mastocytomas in pediatric patients typically are diagnosed based on clinical appearance and the formation of a wheal upon firm palpation (Darier sign).^11-13 Our patient did not demonstrate the Darier sign, and the lesion was asymptomatic. Tuberous sclerosis complex is an autosomal-dominant neurocutaneous disorder with neurologic and skin findings that occur early in the disease course and include facial angiofibromas, hypomelanotic macules, shagreen patches, and café-au-lait macules.¹⁴

The Diagnosis: Juvenile Xanthogranuloma

Given the patient’s age, clinical features of the lesion, and characteristic setting-sun pattern on dermoscopy, a diagnosis of juvenile xanthogranuloma (JXG) was made. The patient showed no other signs of neurofibromatosis type 1 (NF1) or systemic disease and was managed conservatively with observation and routine follow-up. Minimal growth of the lesion was noted at 1-year follow-up, and he was meeting all age-appropriate developmental milestones and showed no other symptoms consistent with NF1. 

Juvenile xanthogranuloma is the most common childhood non–Langerhans cell histiocytosis. While it typically manifests as an isolated condition, JXG also can be associated with NF1 as well as juvenile myelomonocytic leukemia.^1-3 Neurofibromatosis type 1 is a multisystem disorder with variable clinical manifestations that commonly is associated with skin findings such as café au lait macules, intertriginous freckling, and neurofibromas, in addition to JXG.^2,3 Diagnosis of JXG should prompt noninvasive evaluation for further signs and symptoms of NF1, including thorough patient and family history and physical examination to identify other characteristic cutaneous findings, and can include consideration of slit lamp eye examination and radiography for identification of osseous findings. 

The pathogenesis of JXG is not fully known, though there is evidence that it may be associated with a mutation in the mitogen-activated protein kinase pathway.¹ The majority of cases appear in the first year of life.⁴ Clinically, JXG can manifest with extracutaneous lesions, including on the eyes and lungs.^5-7 Juvenile xanthogranuloma can be noninvasively diagnosed with dermoscopy. As seen in our patient, dermoscopic findings include a red-yellow or yellow-orange background with an erythematous border, typically described as a setting-sun pattern.^4,8 Biopsy can confirm the diagnosis; however, given the usually benign course, this often is unnecessary. Most pediatric patients with cutaneous manifestations have a self-limited course with regression over several months to years. Generally, no treatment is required for cutaneous manifestations alone; however, lesions can be removed for aesthetic concerns. For those with systemic involvement, a range of other treatments have been used, including chemotherapy, radiotherapy, systemic corticosteroids, and cyclosporine.^6,7 

The differential diagnosis for JXG includes Brooke-Spiegler syndrome, Fabry disease, solitary cutaneous mastocytoma, and tuberous sclerosis complex. Brooke-Spiegler syndrome is an autosomal-dominant condition characterized by the growth of adnexal neoplasms, including trichoepitheliomas, cylindromas, and spiradenomas. These lesions usually manifest on the face but can include other areas such as the trunk.⁹ Fabry disease is an X-linked recessive lysosomal storage disorder with cutaneous manifestations such as angiokeratoma corporis diffusum and hypohidrosis. Patients also may present with systemic symptoms including hypertension and renal and cardiovascular disease.¹⁰ Mastocytosis encompasses several clinical disorders defined by mast cell hyperplasia and accumulation in various organ systems, and solitary cutaneous mastocytoma is the most common manifestation in children.^11,12 Cutaneous mastocytoma can manifest as a single red-brown or yellow papule, usually located on the arms or legs.¹³ Solitary cutaneous mastocytomas in pediatric patients typically are diagnosed based on clinical appearance and the formation of a wheal upon firm palpation (Darier sign).^11-13 Our patient did not demonstrate the Darier sign, and the lesion was asymptomatic. Tuberous sclerosis complex is an autosomal-dominant neurocutaneous disorder with neurologic and skin findings that occur early in the disease course and include facial angiofibromas, hypomelanotic macules, shagreen patches, and café-au-lait macules.¹⁴

The Diagnosis: Juvenile Xanthogranuloma

Given the patient’s age, clinical features of the lesion, and characteristic setting-sun pattern on dermoscopy, a diagnosis of juvenile xanthogranuloma (JXG) was made. The patient showed no other signs of neurofibromatosis type 1 (NF1) or systemic disease and was managed conservatively with observation and routine follow-up. Minimal growth of the lesion was noted at 1-year follow-up, and he was meeting all age-appropriate developmental milestones and showed no other symptoms consistent with NF1. 

Juvenile xanthogranuloma is the most common childhood non–Langerhans cell histiocytosis. While it typically manifests as an isolated condition, JXG also can be associated with NF1 as well as juvenile myelomonocytic leukemia.^1-3 Neurofibromatosis type 1 is a multisystem disorder with variable clinical manifestations that commonly is associated with skin findings such as café au lait macules, intertriginous freckling, and neurofibromas, in addition to JXG.^2,3 Diagnosis of JXG should prompt noninvasive evaluation for further signs and symptoms of NF1, including thorough patient and family history and physical examination to identify other characteristic cutaneous findings, and can include consideration of slit lamp eye examination and radiography for identification of osseous findings. 

The pathogenesis of JXG is not fully known, though there is evidence that it may be associated with a mutation in the mitogen-activated protein kinase pathway.¹ The majority of cases appear in the first year of life.⁴ Clinically, JXG can manifest with extracutaneous lesions, including on the eyes and lungs.^5-7 Juvenile xanthogranuloma can be noninvasively diagnosed with dermoscopy. As seen in our patient, dermoscopic findings include a red-yellow or yellow-orange background with an erythematous border, typically described as a setting-sun pattern.^4,8 Biopsy can confirm the diagnosis; however, given the usually benign course, this often is unnecessary. Most pediatric patients with cutaneous manifestations have a self-limited course with regression over several months to years. Generally, no treatment is required for cutaneous manifestations alone; however, lesions can be removed for aesthetic concerns. For those with systemic involvement, a range of other treatments have been used, including chemotherapy, radiotherapy, systemic corticosteroids, and cyclosporine.^6,7 

The differential diagnosis for JXG includes Brooke-Spiegler syndrome, Fabry disease, solitary cutaneous mastocytoma, and tuberous sclerosis complex. Brooke-Spiegler syndrome is an autosomal-dominant condition characterized by the growth of adnexal neoplasms, including trichoepitheliomas, cylindromas, and spiradenomas. These lesions usually manifest on the face but can include other areas such as the trunk.⁹ Fabry disease is an X-linked recessive lysosomal storage disorder with cutaneous manifestations such as angiokeratoma corporis diffusum and hypohidrosis. Patients also may present with systemic symptoms including hypertension and renal and cardiovascular disease.¹⁰ Mastocytosis encompasses several clinical disorders defined by mast cell hyperplasia and accumulation in various organ systems, and solitary cutaneous mastocytoma is the most common manifestation in children.^11,12 Cutaneous mastocytoma can manifest as a single red-brown or yellow papule, usually located on the arms or legs.¹³ Solitary cutaneous mastocytomas in pediatric patients typically are diagnosed based on clinical appearance and the formation of a wheal upon firm palpation (Darier sign).^11-13 Our patient did not demonstrate the Darier sign, and the lesion was asymptomatic. Tuberous sclerosis complex is an autosomal-dominant neurocutaneous disorder with neurologic and skin findings that occur early in the disease course and include facial angiofibromas, hypomelanotic macules, shagreen patches, and café-au-lait macules.¹⁴

The patient was diagnosed with erythema ab igne based on characteristic skin findings on physical examination along with a convincing history of chronic localized heat exposure. Erythema ab igne manifests as a persistent reticulated, erythematous, or hyperpigmented rash at sites of chronic heat exposure.¹ Commonplace items that emit heat such as electric heaters, car heaters, heating pads, hot water bottles, and, in our case, laptops also emit infrared radiation, which can lead to changes in the skin with long-term exposure.² Because exposure to these sources often is limited to one area of the body, erythema ab igne usually manifests locally, as exemplified in this case. Chronic heat exposure and infrared radiation from these sources are thought to induce hyperthermia below the threshold for a thermal burn, and the cutaneous findings correspond with the dermal venous plexus.³

Diagnosis of erythema ab igne primarily is made clinically based on characteristic skin findings and exposure history. Relevant history may include occupations with prolonged heat exposure, such as baking, silversmithing, or foundry work. Heat exposure also may result from cultural practices such as cupping with moxibustion.⁴ Additionally, repeated use of heating pads or hot water bottles for pain relief by patients diagnosed with chronic pain or an underlying illness may contribute to development of erythema ab igne.^1,4

Biopsy was not needed for diagnosis of this patient, but if the presentation is equivocal and history of potential exposures is unclear, a biopsy may be taken. A hematoxylin and eosin stain would reveal dilation of small vascular channels in the superficial dermis, contributing to the classic reticulated appearance. Biopsy findings also would reveal either an interface dermatitis or pigment incontinence containing melanin-laden macrophages correlating to either the erythema or hyperpigmentation, respectively.⁴

The prognosis for erythema ab igne is excellent, especially if diagnosed early. Treatment involves removal of the inciting heat source.¹ The discoloration may resolve within a few months to years or may persist. If the hyperpigmentation is persistent, patients may consider laser treatments or lightening agents such as topical hydroquinone or topical tretinoin.⁴ However, if undiagnosed, patients may be at risk for development of a cutaneous malignancy, such as squamous cell carcinoma, Merkel cell carcinoma, poorly differentiated carcinoma, or cutaneous marginal zone lymphoma.^2,4 Malignant transformation has been reported to occur decades after the initial skin eruption, although the risk is rare⁵; however, due to this risk, patients with erythema ab igne should be followed regularly and screened for new lesions in the affected areas.

The patient was diagnosed with erythema ab igne based on characteristic skin findings on physical examination along with a convincing history of chronic localized heat exposure. Erythema ab igne manifests as a persistent reticulated, erythematous, or hyperpigmented rash at sites of chronic heat exposure.¹ Commonplace items that emit heat such as electric heaters, car heaters, heating pads, hot water bottles, and, in our case, laptops also emit infrared radiation, which can lead to changes in the skin with long-term exposure.² Because exposure to these sources often is limited to one area of the body, erythema ab igne usually manifests locally, as exemplified in this case. Chronic heat exposure and infrared radiation from these sources are thought to induce hyperthermia below the threshold for a thermal burn, and the cutaneous findings correspond with the dermal venous plexus.³

Diagnosis of erythema ab igne primarily is made clinically based on characteristic skin findings and exposure history. Relevant history may include occupations with prolonged heat exposure, such as baking, silversmithing, or foundry work. Heat exposure also may result from cultural practices such as cupping with moxibustion.⁴ Additionally, repeated use of heating pads or hot water bottles for pain relief by patients diagnosed with chronic pain or an underlying illness may contribute to development of erythema ab igne.^1,4

Biopsy was not needed for diagnosis of this patient, but if the presentation is equivocal and history of potential exposures is unclear, a biopsy may be taken. A hematoxylin and eosin stain would reveal dilation of small vascular channels in the superficial dermis, contributing to the classic reticulated appearance. Biopsy findings also would reveal either an interface dermatitis or pigment incontinence containing melanin-laden macrophages correlating to either the erythema or hyperpigmentation, respectively.⁴

The prognosis for erythema ab igne is excellent, especially if diagnosed early. Treatment involves removal of the inciting heat source.¹ The discoloration may resolve within a few months to years or may persist. If the hyperpigmentation is persistent, patients may consider laser treatments or lightening agents such as topical hydroquinone or topical tretinoin.⁴ However, if undiagnosed, patients may be at risk for development of a cutaneous malignancy, such as squamous cell carcinoma, Merkel cell carcinoma, poorly differentiated carcinoma, or cutaneous marginal zone lymphoma.^2,4 Malignant transformation has been reported to occur decades after the initial skin eruption, although the risk is rare⁵; however, due to this risk, patients with erythema ab igne should be followed regularly and screened for new lesions in the affected areas.

The patient was diagnosed with erythema ab igne based on characteristic skin findings on physical examination along with a convincing history of chronic localized heat exposure. Erythema ab igne manifests as a persistent reticulated, erythematous, or hyperpigmented rash at sites of chronic heat exposure.¹ Commonplace items that emit heat such as electric heaters, car heaters, heating pads, hot water bottles, and, in our case, laptops also emit infrared radiation, which can lead to changes in the skin with long-term exposure.² Because exposure to these sources often is limited to one area of the body, erythema ab igne usually manifests locally, as exemplified in this case. Chronic heat exposure and infrared radiation from these sources are thought to induce hyperthermia below the threshold for a thermal burn, and the cutaneous findings correspond with the dermal venous plexus.³

Diagnosis of erythema ab igne primarily is made clinically based on characteristic skin findings and exposure history. Relevant history may include occupations with prolonged heat exposure, such as baking, silversmithing, or foundry work. Heat exposure also may result from cultural practices such as cupping with moxibustion.⁴ Additionally, repeated use of heating pads or hot water bottles for pain relief by patients diagnosed with chronic pain or an underlying illness may contribute to development of erythema ab igne.^1,4

Biopsy was not needed for diagnosis of this patient, but if the presentation is equivocal and history of potential exposures is unclear, a biopsy may be taken. A hematoxylin and eosin stain would reveal dilation of small vascular channels in the superficial dermis, contributing to the classic reticulated appearance. Biopsy findings also would reveal either an interface dermatitis or pigment incontinence containing melanin-laden macrophages correlating to either the erythema or hyperpigmentation, respectively.⁴

The prognosis for erythema ab igne is excellent, especially if diagnosed early. Treatment involves removal of the inciting heat source.¹ The discoloration may resolve within a few months to years or may persist. If the hyperpigmentation is persistent, patients may consider laser treatments or lightening agents such as topical hydroquinone or topical tretinoin.⁴ However, if undiagnosed, patients may be at risk for development of a cutaneous malignancy, such as squamous cell carcinoma, Merkel cell carcinoma, poorly differentiated carcinoma, or cutaneous marginal zone lymphoma.^2,4 Malignant transformation has been reported to occur decades after the initial skin eruption, although the risk is rare⁵; however, due to this risk, patients with erythema ab igne should be followed regularly and screened for new lesions in the affected areas.

Are you seeing any increase or trends in cutaneous adverse effects related to the use of GLP-1 agonists in your practice?

DR. SHIELDS: The use of GLP-1 agonists is increasing substantially across numerous populations. Patients are using these medications not only for weight management and diabetes control but also for blood pressure modulation and cardiovascular risk reduction. The market size is expected to grow at a rate of about 6% until 2027. While severe cutaneous adverse effects still are considered relatively rare with GLP-1 agonist use, mild adverse effects are quite common. Dermatologists should be familiar with these effects and how to manage them. Rare but serious cutaneous reactions include morbilliform drug eruptions, dermal hypersensitivity reactions, panniculitis, and bullous pemphigoid. It is thought that some GLP-1 agonists may cause more skin reactions than others; for example, exenatide extended-release has been associated with cutaneous adverse events more frequently than other GLP-1 agonists in a recent comprehensive literature review.

Do you see a role for dermatologists in monitoring or managing the downstream dermatologic effects of GLP-1 agonists over the next few years?

DR. SHIELDS: Absolutely. When patients develop a drug eruption, bullous pemphigoid, or eosinophilic panniculitis, dermatologists are going to be the ones to diagnose and manage therapy. Awareness of these adverse effects is crucial to timely and thoughtful discussions surrounding medication discontinuation vs a “treat through” approach.

Do you recommend coordinating with endocrinologists or obesity medicine specialists when managing shared patients on GLP-1s (particularly if skin concerns arise)?

DR. SHIELDS: Yes. This is crucial to patient success. Co-management can provide clarity around the indication for therapy and allow for a thoughtful risk-benefit discussion with the patient, primary care physician, endocrinologist, cardiologist, etc. In my practice, I have found that many patients do not want to stop therapy even when they develop cutaneous adverse effects. There are options to transition therapy or treat through in some cases, but having a comprehensive monitoring and therapy plan is critical.

Have you encountered cases in which rapid weight loss from GLP-1s worsened conditions such as loose skin, cellulite, or facial lipoatrophy, leading to new aesthetic concerns? How would you recommend counseling and/or treating affected patients?

DR. SHIELDS: Accelerated facial aging is a noticeable adverse effect in patients who undergo treatment with GLP-1 agonists, especially when used off-label for weight loss. Localized loss of facial fat can result in altered facial proportions and excess skin. There are multiple additional mechanisms that may underlie accelerated facial aging in patients on GLP-1s, and really we are just beginning to scratch the surface of why and how this happens. Understanding these mechanisms will open the door to downstream preventive and therapeutic options. If patients experience new aesthetic concerns, I currently work with them to adjust their medication to slow weight loss, recommend improved nutrition and hydration, encourage exercise and weight training to maintain muscle mass, and engage my cosmetic dermatology colleagues to discuss procedures such as dermal fillers.

All patients starting GLP-1 agonists should be thoroughly counseled on risks and adverse effects of their medication. These are well reported and should be considered carefully. Starting with lower medication dosing in conjunction with slow escalation and careful monitoring can be helpful in combatting these adverse effects.

Are you seeing any increase or trends in cutaneous adverse effects related to the use of GLP-1 agonists in your practice?

DR. SHIELDS: The use of GLP-1 agonists is increasing substantially across numerous populations. Patients are using these medications not only for weight management and diabetes control but also for blood pressure modulation and cardiovascular risk reduction. The market size is expected to grow at a rate of about 6% until 2027. While severe cutaneous adverse effects still are considered relatively rare with GLP-1 agonist use, mild adverse effects are quite common. Dermatologists should be familiar with these effects and how to manage them. Rare but serious cutaneous reactions include morbilliform drug eruptions, dermal hypersensitivity reactions, panniculitis, and bullous pemphigoid. It is thought that some GLP-1 agonists may cause more skin reactions than others; for example, exenatide extended-release has been associated with cutaneous adverse events more frequently than other GLP-1 agonists in a recent comprehensive literature review.

Do you see a role for dermatologists in monitoring or managing the downstream dermatologic effects of GLP-1 agonists over the next few years?

DR. SHIELDS: Absolutely. When patients develop a drug eruption, bullous pemphigoid, or eosinophilic panniculitis, dermatologists are going to be the ones to diagnose and manage therapy. Awareness of these adverse effects is crucial to timely and thoughtful discussions surrounding medication discontinuation vs a “treat through” approach.

Do you recommend coordinating with endocrinologists or obesity medicine specialists when managing shared patients on GLP-1s (particularly if skin concerns arise)?

DR. SHIELDS: Yes. This is crucial to patient success. Co-management can provide clarity around the indication for therapy and allow for a thoughtful risk-benefit discussion with the patient, primary care physician, endocrinologist, cardiologist, etc. In my practice, I have found that many patients do not want to stop therapy even when they develop cutaneous adverse effects. There are options to transition therapy or treat through in some cases, but having a comprehensive monitoring and therapy plan is critical.

Have you encountered cases in which rapid weight loss from GLP-1s worsened conditions such as loose skin, cellulite, or facial lipoatrophy, leading to new aesthetic concerns? How would you recommend counseling and/or treating affected patients?

DR. SHIELDS: Accelerated facial aging is a noticeable adverse effect in patients who undergo treatment with GLP-1 agonists, especially when used off-label for weight loss. Localized loss of facial fat can result in altered facial proportions and excess skin. There are multiple additional mechanisms that may underlie accelerated facial aging in patients on GLP-1s, and really we are just beginning to scratch the surface of why and how this happens. Understanding these mechanisms will open the door to downstream preventive and therapeutic options. If patients experience new aesthetic concerns, I currently work with them to adjust their medication to slow weight loss, recommend improved nutrition and hydration, encourage exercise and weight training to maintain muscle mass, and engage my cosmetic dermatology colleagues to discuss procedures such as dermal fillers.

All patients starting GLP-1 agonists should be thoroughly counseled on risks and adverse effects of their medication. These are well reported and should be considered carefully. Starting with lower medication dosing in conjunction with slow escalation and careful monitoring can be helpful in combatting these adverse effects.

Are you seeing any increase or trends in cutaneous adverse effects related to the use of GLP-1 agonists in your practice?

DR. SHIELDS: The use of GLP-1 agonists is increasing substantially across numerous populations. Patients are using these medications not only for weight management and diabetes control but also for blood pressure modulation and cardiovascular risk reduction. The market size is expected to grow at a rate of about 6% until 2027. While severe cutaneous adverse effects still are considered relatively rare with GLP-1 agonist use, mild adverse effects are quite common. Dermatologists should be familiar with these effects and how to manage them. Rare but serious cutaneous reactions include morbilliform drug eruptions, dermal hypersensitivity reactions, panniculitis, and bullous pemphigoid. It is thought that some GLP-1 agonists may cause more skin reactions than others; for example, exenatide extended-release has been associated with cutaneous adverse events more frequently than other GLP-1 agonists in a recent comprehensive literature review.

Do you see a role for dermatologists in monitoring or managing the downstream dermatologic effects of GLP-1 agonists over the next few years?

DR. SHIELDS: Absolutely. When patients develop a drug eruption, bullous pemphigoid, or eosinophilic panniculitis, dermatologists are going to be the ones to diagnose and manage therapy. Awareness of these adverse effects is crucial to timely and thoughtful discussions surrounding medication discontinuation vs a “treat through” approach.

Do you recommend coordinating with endocrinologists or obesity medicine specialists when managing shared patients on GLP-1s (particularly if skin concerns arise)?

DR. SHIELDS: Yes. This is crucial to patient success. Co-management can provide clarity around the indication for therapy and allow for a thoughtful risk-benefit discussion with the patient, primary care physician, endocrinologist, cardiologist, etc. In my practice, I have found that many patients do not want to stop therapy even when they develop cutaneous adverse effects. There are options to transition therapy or treat through in some cases, but having a comprehensive monitoring and therapy plan is critical.

Have you encountered cases in which rapid weight loss from GLP-1s worsened conditions such as loose skin, cellulite, or facial lipoatrophy, leading to new aesthetic concerns? How would you recommend counseling and/or treating affected patients?

DR. SHIELDS: Accelerated facial aging is a noticeable adverse effect in patients who undergo treatment with GLP-1 agonists, especially when used off-label for weight loss. Localized loss of facial fat can result in altered facial proportions and excess skin. There are multiple additional mechanisms that may underlie accelerated facial aging in patients on GLP-1s, and really we are just beginning to scratch the surface of why and how this happens. Understanding these mechanisms will open the door to downstream preventive and therapeutic options. If patients experience new aesthetic concerns, I currently work with them to adjust their medication to slow weight loss, recommend improved nutrition and hydration, encourage exercise and weight training to maintain muscle mass, and engage my cosmetic dermatology colleagues to discuss procedures such as dermal fillers.

All patients starting GLP-1 agonists should be thoroughly counseled on risks and adverse effects of their medication. These are well reported and should be considered carefully. Starting with lower medication dosing in conjunction with slow escalation and careful monitoring can be helpful in combatting these adverse effects.

Use of artificial intelligence (AI) in dermatology has increased over the past decade, likely driven by advances in deep learning algorithms, computing hardware, and machine learning.¹ Studies comparing the performance of AI algorithms to dermatologists in classifying skin disorders have shown conflicting results.^2,3 In this study, we aimed to analyze AI tools used for diagnosing and classifying skin disease and evaluate the role of dermatologists in the creation of AI technology. We also investigated the number of clinical images used in datasets to train AI programs and compared tools that were created with dermatologist input to those created without dermatologist/clinician involvement.

Methods

A search of PubMed articles indexed for MEDLINE using the terms machine learning, artificial intelligence, and dermatology was conducted on September 18, 2022. Articles were included if they described full-length trials; used machine learning for diagnosis of or screening for dermatologic conditions; and used dermoscopic or gross image datasets of the skin, hair, or nails. Articles were categorized into 4 groups based on the conditions covered: chronic wounds, inflammatory skin diseases, mixed conditions, and pigmented skin lesions. Algorithms were sorted into 4 categories: convolutional/convoluted neural network, deep learning model/deep neural network, AI/artificial neural network, and other. Details regarding Fitzpatrick skin type and skin of color (SoC) inclusion in the articles or AI algorithm datasets were recorded. Univariate and multivariate analyses were performed using Microsoft Excel and SAS Studio 3.8. Sensitivity and specificity were calculated for all included AI technology. Sensitivity, specificity, and the number of clinical images were compared among the included articles using analysis of variance and t tests (α=0.05; P<.05 indicated statistical significance).

Results

Our search yielded 1016 articles, 58 of which met the inclusion criteria. Overall, 25.9% (15/58) of the articles utilized AI to diagnose or classify mixed skin diseases; 22.4% (13/58) for pigmented skin lesions; 19.0% (11/58) for wounds; 17.2% (10/58) for inflammatory skin diseases; and 5.2% (3/58) each for acne, psoriasis, and onychomycosis. Overall, 24.0% (14/58) of articles provided information about Fitzpatrick skin type, and 58.7% (34/58) included clinical images depicting SoC. Furthermore, we found that only 20.7% (12/58) of articles on deep learning models included descriptions of patient ethnicity or race in at least 1 dataset, and only 10.3% (6/58) of studies included any information about skin tone in the dataset. Studies with a dermatologist as the last author (most likely to be supervising the project) were more likely to include clinical images depicting SoC than those without (82.6% [19/23] and 16.7% [3/18], respectively [P=.0411]).

The mean (SD) number of clinical images in the study articles was 28,422 (84,050). Thirty-seven (63.8%) of the study articles included gross images, 17 (29.3%) used dermoscopic images, and 4 (6.9%) used both. Twenty-seven (46.6%) articles used convolutional/convoluted neural networks, 15 (25.9%) used deep learning model/deep neural networks, 8 (13.8%) used other algorithms, 6 (10.3%) used AI/artificial neural network, and 2 (3.4%) used fuzzy algorithms. Most studies were conducted in China (29.3% [17/58]), Germany (12.1% [7/58]), India (10.3% [6/58]), multiple nations (10.3% [6/58]), and the United States (10.3% [6/58]). Overall, 82.8% (48/58) of articles included at least 1 dermatologist coauthor. Sensitivity of the AI models was 0.85, and specificity was 0.85. The average percentage of images in the dataset correctly identified by a physician was 76.87% vs 81.62% of images correctly identified by AI. Average agreement between AI and physician assessment was 77.98%, defined as AI and physician both having the same diagnosis. 

Articles authored by dermatologists contained more clinical images than those without dermatologists in key authorship roles (P<.0001)(eTable). Psoriasis-related algorithms had the fewest (mean [SD]: 3173 [4203]), and pigmented skin lesions had the most clinical images (mean [SD]: 53,19l [155,579]).

Comment

Our results indicated that AI studies with dermatologist authors had significantly more images in their datasets (ie, the set of clinical images of skin lesions used to train AI algorithms in diagnosing or classifying lesions) than those with nondermatologist authors (P<.0001)(eTable). Similarly, in a study of AI technology for skin cancer diagnosis, AI studies with dermatologist authors (ie, included in the development of the AI algorithm) had more images than studies without dermatologist authors.¹ Deep learning textbooks have suggested that 5000 clinical images or training input per output category are needed to produce acceptable algorithm performance, and more than 10 million are needed to produce results superior to human performance.^4-10 Despite advances in AI for dermatologic image analysis, the creation of these models often has been directed by nondermatologists¹; therefore, dermatologist involvement in AI development is necessary to facilitate collection of larger image datasets and optimal performance for image diagnosis/classification tasks.

We found that 20.7% of articles on deep learning models included descriptions of patient ethnicity or race, and only 10.3% of studies included any information about skin tone in the dataset. Furthermore, American investigators primarily trained models using clinical images of patients with lighter skin tones, whereas Chinese investigators exclusively included images depicting darker skin tones. Similarly, in a study of 52 cutaneous imaging deep learning articles, only 17.3% (9/52) reported race and/or Fitzpatrick skin type, and only 7.7% (4/52) of articles included both.^2,6,8 Therefore, dermatologists are needed to contribute images representing diverse populations and collaborate in AI research studies, as their involvement is necessary to ensure the accuracy of AI models in classifying lesions or diagnosing skin lesions across all skin types.

Our search was limited to PubMed, and real-world applications could not be evaluated.

Conclusion

In summary, we found that AI studies with dermatologist authors used larger numbers of clinical images in their datasets and more images representing diverse skin types than studies without. Therefore, we advocate for greater involvement of dermatologists in AI research, which might result in better patient outcomes by improving diagnostic accuracy.

Use of artificial intelligence (AI) in dermatology has increased over the past decade, likely driven by advances in deep learning algorithms, computing hardware, and machine learning.¹ Studies comparing the performance of AI algorithms to dermatologists in classifying skin disorders have shown conflicting results.^2,3 In this study, we aimed to analyze AI tools used for diagnosing and classifying skin disease and evaluate the role of dermatologists in the creation of AI technology. We also investigated the number of clinical images used in datasets to train AI programs and compared tools that were created with dermatologist input to those created without dermatologist/clinician involvement.

Methods

A search of PubMed articles indexed for MEDLINE using the terms machine learning, artificial intelligence, and dermatology was conducted on September 18, 2022. Articles were included if they described full-length trials; used machine learning for diagnosis of or screening for dermatologic conditions; and used dermoscopic or gross image datasets of the skin, hair, or nails. Articles were categorized into 4 groups based on the conditions covered: chronic wounds, inflammatory skin diseases, mixed conditions, and pigmented skin lesions. Algorithms were sorted into 4 categories: convolutional/convoluted neural network, deep learning model/deep neural network, AI/artificial neural network, and other. Details regarding Fitzpatrick skin type and skin of color (SoC) inclusion in the articles or AI algorithm datasets were recorded. Univariate and multivariate analyses were performed using Microsoft Excel and SAS Studio 3.8. Sensitivity and specificity were calculated for all included AI technology. Sensitivity, specificity, and the number of clinical images were compared among the included articles using analysis of variance and t tests (α=0.05; P<.05 indicated statistical significance).

Results

Our search yielded 1016 articles, 58 of which met the inclusion criteria. Overall, 25.9% (15/58) of the articles utilized AI to diagnose or classify mixed skin diseases; 22.4% (13/58) for pigmented skin lesions; 19.0% (11/58) for wounds; 17.2% (10/58) for inflammatory skin diseases; and 5.2% (3/58) each for acne, psoriasis, and onychomycosis. Overall, 24.0% (14/58) of articles provided information about Fitzpatrick skin type, and 58.7% (34/58) included clinical images depicting SoC. Furthermore, we found that only 20.7% (12/58) of articles on deep learning models included descriptions of patient ethnicity or race in at least 1 dataset, and only 10.3% (6/58) of studies included any information about skin tone in the dataset. Studies with a dermatologist as the last author (most likely to be supervising the project) were more likely to include clinical images depicting SoC than those without (82.6% [19/23] and 16.7% [3/18], respectively [P=.0411]).

The mean (SD) number of clinical images in the study articles was 28,422 (84,050). Thirty-seven (63.8%) of the study articles included gross images, 17 (29.3%) used dermoscopic images, and 4 (6.9%) used both. Twenty-seven (46.6%) articles used convolutional/convoluted neural networks, 15 (25.9%) used deep learning model/deep neural networks, 8 (13.8%) used other algorithms, 6 (10.3%) used AI/artificial neural network, and 2 (3.4%) used fuzzy algorithms. Most studies were conducted in China (29.3% [17/58]), Germany (12.1% [7/58]), India (10.3% [6/58]), multiple nations (10.3% [6/58]), and the United States (10.3% [6/58]). Overall, 82.8% (48/58) of articles included at least 1 dermatologist coauthor. Sensitivity of the AI models was 0.85, and specificity was 0.85. The average percentage of images in the dataset correctly identified by a physician was 76.87% vs 81.62% of images correctly identified by AI. Average agreement between AI and physician assessment was 77.98%, defined as AI and physician both having the same diagnosis. 

Articles authored by dermatologists contained more clinical images than those without dermatologists in key authorship roles (P<.0001)(eTable). Psoriasis-related algorithms had the fewest (mean [SD]: 3173 [4203]), and pigmented skin lesions had the most clinical images (mean [SD]: 53,19l [155,579]).

Comment

Our results indicated that AI studies with dermatologist authors had significantly more images in their datasets (ie, the set of clinical images of skin lesions used to train AI algorithms in diagnosing or classifying lesions) than those with nondermatologist authors (P<.0001)(eTable). Similarly, in a study of AI technology for skin cancer diagnosis, AI studies with dermatologist authors (ie, included in the development of the AI algorithm) had more images than studies without dermatologist authors.¹ Deep learning textbooks have suggested that 5000 clinical images or training input per output category are needed to produce acceptable algorithm performance, and more than 10 million are needed to produce results superior to human performance.^4-10 Despite advances in AI for dermatologic image analysis, the creation of these models often has been directed by nondermatologists¹; therefore, dermatologist involvement in AI development is necessary to facilitate collection of larger image datasets and optimal performance for image diagnosis/classification tasks.

We found that 20.7% of articles on deep learning models included descriptions of patient ethnicity or race, and only 10.3% of studies included any information about skin tone in the dataset. Furthermore, American investigators primarily trained models using clinical images of patients with lighter skin tones, whereas Chinese investigators exclusively included images depicting darker skin tones. Similarly, in a study of 52 cutaneous imaging deep learning articles, only 17.3% (9/52) reported race and/or Fitzpatrick skin type, and only 7.7% (4/52) of articles included both.^2,6,8 Therefore, dermatologists are needed to contribute images representing diverse populations and collaborate in AI research studies, as their involvement is necessary to ensure the accuracy of AI models in classifying lesions or diagnosing skin lesions across all skin types.

Our search was limited to PubMed, and real-world applications could not be evaluated.

Conclusion

In summary, we found that AI studies with dermatologist authors used larger numbers of clinical images in their datasets and more images representing diverse skin types than studies without. Therefore, we advocate for greater involvement of dermatologists in AI research, which might result in better patient outcomes by improving diagnostic accuracy.

Use of artificial intelligence (AI) in dermatology has increased over the past decade, likely driven by advances in deep learning algorithms, computing hardware, and machine learning.¹ Studies comparing the performance of AI algorithms to dermatologists in classifying skin disorders have shown conflicting results.^2,3 In this study, we aimed to analyze AI tools used for diagnosing and classifying skin disease and evaluate the role of dermatologists in the creation of AI technology. We also investigated the number of clinical images used in datasets to train AI programs and compared tools that were created with dermatologist input to those created without dermatologist/clinician involvement.

Methods

A search of PubMed articles indexed for MEDLINE using the terms machine learning, artificial intelligence, and dermatology was conducted on September 18, 2022. Articles were included if they described full-length trials; used machine learning for diagnosis of or screening for dermatologic conditions; and used dermoscopic or gross image datasets of the skin, hair, or nails. Articles were categorized into 4 groups based on the conditions covered: chronic wounds, inflammatory skin diseases, mixed conditions, and pigmented skin lesions. Algorithms were sorted into 4 categories: convolutional/convoluted neural network, deep learning model/deep neural network, AI/artificial neural network, and other. Details regarding Fitzpatrick skin type and skin of color (SoC) inclusion in the articles or AI algorithm datasets were recorded. Univariate and multivariate analyses were performed using Microsoft Excel and SAS Studio 3.8. Sensitivity and specificity were calculated for all included AI technology. Sensitivity, specificity, and the number of clinical images were compared among the included articles using analysis of variance and t tests (α=0.05; P<.05 indicated statistical significance).

Results

Our search yielded 1016 articles, 58 of which met the inclusion criteria. Overall, 25.9% (15/58) of the articles utilized AI to diagnose or classify mixed skin diseases; 22.4% (13/58) for pigmented skin lesions; 19.0% (11/58) for wounds; 17.2% (10/58) for inflammatory skin diseases; and 5.2% (3/58) each for acne, psoriasis, and onychomycosis. Overall, 24.0% (14/58) of articles provided information about Fitzpatrick skin type, and 58.7% (34/58) included clinical images depicting SoC. Furthermore, we found that only 20.7% (12/58) of articles on deep learning models included descriptions of patient ethnicity or race in at least 1 dataset, and only 10.3% (6/58) of studies included any information about skin tone in the dataset. Studies with a dermatologist as the last author (most likely to be supervising the project) were more likely to include clinical images depicting SoC than those without (82.6% [19/23] and 16.7% [3/18], respectively [P=.0411]).

The mean (SD) number of clinical images in the study articles was 28,422 (84,050). Thirty-seven (63.8%) of the study articles included gross images, 17 (29.3%) used dermoscopic images, and 4 (6.9%) used both. Twenty-seven (46.6%) articles used convolutional/convoluted neural networks, 15 (25.9%) used deep learning model/deep neural networks, 8 (13.8%) used other algorithms, 6 (10.3%) used AI/artificial neural network, and 2 (3.4%) used fuzzy algorithms. Most studies were conducted in China (29.3% [17/58]), Germany (12.1% [7/58]), India (10.3% [6/58]), multiple nations (10.3% [6/58]), and the United States (10.3% [6/58]). Overall, 82.8% (48/58) of articles included at least 1 dermatologist coauthor. Sensitivity of the AI models was 0.85, and specificity was 0.85. The average percentage of images in the dataset correctly identified by a physician was 76.87% vs 81.62% of images correctly identified by AI. Average agreement between AI and physician assessment was 77.98%, defined as AI and physician both having the same diagnosis. 

Articles authored by dermatologists contained more clinical images than those without dermatologists in key authorship roles (P<.0001)(eTable). Psoriasis-related algorithms had the fewest (mean [SD]: 3173 [4203]), and pigmented skin lesions had the most clinical images (mean [SD]: 53,19l [155,579]).

Comment

Our results indicated that AI studies with dermatologist authors had significantly more images in their datasets (ie, the set of clinical images of skin lesions used to train AI algorithms in diagnosing or classifying lesions) than those with nondermatologist authors (P<.0001)(eTable). Similarly, in a study of AI technology for skin cancer diagnosis, AI studies with dermatologist authors (ie, included in the development of the AI algorithm) had more images than studies without dermatologist authors.¹ Deep learning textbooks have suggested that 5000 clinical images or training input per output category are needed to produce acceptable algorithm performance, and more than 10 million are needed to produce results superior to human performance.^4-10 Despite advances in AI for dermatologic image analysis, the creation of these models often has been directed by nondermatologists¹; therefore, dermatologist involvement in AI development is necessary to facilitate collection of larger image datasets and optimal performance for image diagnosis/classification tasks.

We found that 20.7% of articles on deep learning models included descriptions of patient ethnicity or race, and only 10.3% of studies included any information about skin tone in the dataset. Furthermore, American investigators primarily trained models using clinical images of patients with lighter skin tones, whereas Chinese investigators exclusively included images depicting darker skin tones. Similarly, in a study of 52 cutaneous imaging deep learning articles, only 17.3% (9/52) reported race and/or Fitzpatrick skin type, and only 7.7% (4/52) of articles included both.^2,6,8 Therefore, dermatologists are needed to contribute images representing diverse populations and collaborate in AI research studies, as their involvement is necessary to ensure the accuracy of AI models in classifying lesions or diagnosing skin lesions across all skin types.

Our search was limited to PubMed, and real-world applications could not be evaluated.

Conclusion

In summary, we found that AI studies with dermatologist authors used larger numbers of clinical images in their datasets and more images representing diverse skin types than studies without. Therefore, we advocate for greater involvement of dermatologists in AI research, which might result in better patient outcomes by improving diagnostic accuracy.

Nurse practitioners (NPs) and physician assistants (PAs) often help provide dermatologic care but lack the same mandatory specialized postgraduate training required of board-certified dermatologists (BCDs), which includes at least 3 years of dermatology-focused education in an accredited residency program in addition to an intern year of general medicine, pediatrics, or surgery. Dermatology residency is followed by a certification examination administered by the American Board of Dermatology (ABD) or the American Osteopathic Board of Dermatology, leading to board certification. Some physicians choose to do a fellowship, which typically involves an additional 1 to 2 years of postresidency subspeciality training.

Optional postgraduate dermatology training programs for advanced practice providers (APPs) have been offered by some academic institutions and private practice groups since at least 2003, including Lahey Hospital and Medical Center (Burlington, Massachusetts) as well as the University of Rochester Medical Center (Rochester, New York). Despite a lack of accreditation or standardization, the programs can be beneficial for NPs and PAs to expand their dermatologic knowledge and skills and help bridge the care gap within the specialty. Didactics often are conducted in parallel with the educational activities of the parent institution’s traditional dermatology residency program (eg, lectures, grand rounds). While these programs often are managed by practicing dermatology NPs and PAs, dermatologists also may be involved in their education with didactic instruction, curriculum development, and clinical preceptorship. 

In this cross-sectional study, we identified and evaluated 10 postgraduate dermatology training programs for APPs across the United States. With the growing number of NPs and PAs in the dermatology workforce—both in academic and private practice—it is important for BCDs to be aware of the differences in the dermatology training received in order to ensure safe and effective care is provided through supervisory or collaborative roles (depending on state independent practice laws for APPs and to be aware of the implications these programs may have on the field of dermatology.

Methods

To identify postgraduate dermatology training programs for APPs in the United States, we conducted a cross-sectional study using data obtained via a Google search of various combinations of the following terms: nurse practitioner, NP, physician assistant, PA, advance practice provider, APP, dermatology, postgraduate training, residency, and fellowship. We excluded postgraduate dermatology training programs for APPs that required tuition and did not provide a stipend, as well as programs that lacked the formal structure and credibility needed to qualify as legitimate postgraduate training. Many of the excluded programs operate in a manner that raises ethical concerns, offering pay-to-play opportunities under the guise of education. Information collected on each program included the program name, location, parent institution, program length, class size, curriculum, and any associated salary and benefits.

Results

Ten academic and private practice organizations across the United States that offer postgraduate dermatologic training programs for APPs were identified (eTable). Four (40%) programs were advertised as fellowships. Six (60%) of the programs were offered at academic medical centers, and 4 (40%) were offered by private practices. Most programs were located east of the Mississippi River, and many institutions offered instruction at 1 or more locations within the same state (eFigure). The Advanced Dermatology and Cosmetic Surgery private practice group offered training opportunities in multiple states.

Six programs required APPs to become board-certified NPs or PAs prior to enrolling. Most programs enrolled both NPs and PAs, while some only enrolled NPs (eTable). Only 1 (10%) program required NPs to be board certified as a family NP, while another (10%) recommended that applicants have experience in urgent care, emergency medicine, or trauma medicine. Lahey Hospital & Medical Center required experience as an NP in a general setting for 1 to 2 years prior to applying. No program required prior experience in the field of dermatology.

Program length varied from 6 to 24 months, and cohort size typically was limited to 1 to 2 providers (eTable). Although the exact numbers could not be ascertained, most curricula focused on medical dermatology, including clinical and didactic components, but many offered electives such as cosmetic and procedural dermatology. Two institutions (20%) required independent research. Work typically was limited to 40 hours per week, and most paid a full-time employee salary and provided benefits such as health insurance, retirement, and paid leave (eTable). Kansas Medical Clinic (Topeka, Kansas) required at least 3 years of employment in an underserved community following program completion. The Oasis Dermatology private practice group in Texas required a 1-year teaching commitment after program completion. The Advanced Dermatology and Cosmetic Surgery group offered a full-time position upon program completion.

Comment

There is a large difference in the total number of training and credentialing hours when comparing graduate school training and postgraduate credentialing of medical and osteopathic physicians compared with APPs. A new graduate physician has at least twice as many clinical hours as a PA and 10 times as many clinical hours as an NP prior to starting residency. Physicians also typically complete at least 6 times the number of hours of certification examinations compared to NPs and PAs.¹

Nurse practitioner students typically complete the 500 hours of prelicensure clinical training required for NP school in 2 to 4 years.^2,3 The amount of time required for completion is dependent on the degree and experience of the student upon program entry (eg, bachelor of science in nursing vs master of science in nursing as a terminal degree). Physician assistant students are required to complete 2000 prelicensure clinical hours, and most PA programs are 3 years in duration.⁴ Many NP and PA programs require some degree of clinical experience prior to beginning graduate education.⁵

When comparing prelicensure examinations, questions assessing dermatologic knowledge comprise approximately 6% to 10% of the total questions on the United States Medical Licensing Examination Steps 1 and 2.⁶ The Comprehensive Osteopathic Medical Licensing Examination of the United States Level 1 and Level 2-Cognitive Evaluation both have at least 5% of questions dedicated to dermatology.⁷ Approximately 5% of the questions on the Physician Assistant National Certifying Examination are dedicated to dermatology.⁸ The dermatology content on either of the NP certification examinations is unclear.^2,3 In the states of California, Indiana, and New York, national certification through the American Association of Nurse Practitioners or American Nurses Credentialing Center is not required for NPs to practice in their respective states.⁹

Regarding dermatologic board certification, a new graduate NP may obtain certification from the Dermatology Nurse Practitioner Certification Board with 3000 hours of general dermatology practice that may occur during normal working hours.¹⁰ These hours do not have to occur in one of the previously identified postgraduate APP training programs. The National Board of Dermatology Physician Assistants was founded in 2018 and has since dissolved. The National Board of Dermatology Physician Assistants was not accredited and required at least 3 years of training in dermatology with the same dermatologist in addition to completing a 125-question multiple-choice examination.¹¹ Of note, this examination was opposed by both the ABD and the Society for Dermatology Physician Associates.¹² A PA also may become a Diplomate Fellow with the Society of Dermatology Physician Associates after completion of 64.5 hours of online continuing education modules.⁴ Some PAs may choose to obtain a Certificate of Added Qualifications, which is a voluntary credential that helps document specialty experience and expertise in dermatology or other specialties.

In contrast, a dermatology resident physician requires nearly 11,000 to 13,000 hours of clinical training hours, which last 3 to 4 years following medical school.¹³ This training involves direct patient care under supervision in various settings, including hospitals, outpatient clinics, and surgical procedures. In addition to this clinical experience, dermatology residents must pass a 3-step certification examination process administered by the ABD.¹³ This process includes approximately 20 hours of examinations designed to assess both knowledge and practical skills. For those who wish to further specialize, additional fellowship training in areas such as pediatric dermatology, dermatopathology, or Mohs surgery may follow residency; such fellowships involve an extra 2500 to 3500 hours of training and culminate in another certification examination, further refining a resident’s expertise in a specific dermatologic field. Osteopathic physicians may opt out of the ABD 3-step pathway and obtain board certification through the American Osteopathic Board of Dermatology.¹⁴

Many of the programs we evaluated integrate APP trainees into resident education, allowing participation in equivalent didactic curricula, clinical rotations, and departmental academic activities. The salary and benefits associated with these programs are somewhat like those of resident physicians.^15,16 While most tuition-based programs were excluded from our study due to their lack of credibility and alignment with our study criteria, we identified 2 specific programs that stood out as credible despite requiring students to pay tuition. These programs demonstrated a structured and rigorous curriculum with a clear focus on comprehensive dermatologic training, meeting our standards for inclusion. These programs offer dermatologic training for graduates of NP and PA programs at a cost to the student.^15,16 The program at the Florida Atlantic University, Boca Raton, is largely online,¹⁵ and the program at the University of Miami, Florida, offers no direct clinical contact.¹⁶ These programs illustrate the variety of postgraduate dermatology curricula available nationally in comparison to resident salaries; however, they were not included in our formal analysis because they do not provide structured, in-person clinical training consistent with our inclusion criteria. Neither of these programs would enable participants to qualify for credentialing with the Dermatology Nurse Practitioner Certification Board after completion. While this study identified postgraduate training programs for APPs in dermatology advertised online, it is possible some were omitted or not advertised online.

While many of the postgraduate programs we evaluated provide unique educational opportunities for APPs, it is unknown if graduating providers are equipped to handle the care of patients with complex dermatologic needs. Regardless, the increased utilization of APPs by BCDs has been well documented over the past 2 decades.^17-20 It has been suggested that a higher ratio of APPs to dermatologists can decrease the time it takes for a patient to be seen in a clinic.^21-23 However, investigators have expressed concerns that APPs lack standardized surgical training and clinical hour requirements in the field of dermatology.²⁴ Despite these concerns, Medicare claims data show that APPs are performing advanced surgical and cosmetic procedures at increasing rates.^17,18 Other authors have questioned the cost-effectiveness of APPs, as multiple studies have shown that the number of biopsies needed to diagnose 1 case of skin cancer is higher for midlevel providers than for dermatologists.^25-27

Conclusion

With the anticipated expansion of private equity in dermatology and the growth of our Medicare-eligible population, we are likely to see increased utilization of APPs to address the shortage of BCDs.^28,29 Understanding the prelicensure and postlicensure clinical training requirements, examination hours, and extent of dermatology-focused education among APPs and BCDs can help dermatologists collaborate more effectively and ensure safe, high-quality patient care. Standardizing, improving, and providing high-quality education and promoting lifelong learning in the field of dermatology should be celebrated, and dermatologists are the skin experts best equipped to lead dermatologic education forward.

Nurse practitioners (NPs) and physician assistants (PAs) often help provide dermatologic care but lack the same mandatory specialized postgraduate training required of board-certified dermatologists (BCDs), which includes at least 3 years of dermatology-focused education in an accredited residency program in addition to an intern year of general medicine, pediatrics, or surgery. Dermatology residency is followed by a certification examination administered by the American Board of Dermatology (ABD) or the American Osteopathic Board of Dermatology, leading to board certification. Some physicians choose to do a fellowship, which typically involves an additional 1 to 2 years of postresidency subspeciality training.

Optional postgraduate dermatology training programs for advanced practice providers (APPs) have been offered by some academic institutions and private practice groups since at least 2003, including Lahey Hospital and Medical Center (Burlington, Massachusetts) as well as the University of Rochester Medical Center (Rochester, New York). Despite a lack of accreditation or standardization, the programs can be beneficial for NPs and PAs to expand their dermatologic knowledge and skills and help bridge the care gap within the specialty. Didactics often are conducted in parallel with the educational activities of the parent institution’s traditional dermatology residency program (eg, lectures, grand rounds). While these programs often are managed by practicing dermatology NPs and PAs, dermatologists also may be involved in their education with didactic instruction, curriculum development, and clinical preceptorship. 

In this cross-sectional study, we identified and evaluated 10 postgraduate dermatology training programs for APPs across the United States. With the growing number of NPs and PAs in the dermatology workforce—both in academic and private practice—it is important for BCDs to be aware of the differences in the dermatology training received in order to ensure safe and effective care is provided through supervisory or collaborative roles (depending on state independent practice laws for APPs and to be aware of the implications these programs may have on the field of dermatology.

Methods

To identify postgraduate dermatology training programs for APPs in the United States, we conducted a cross-sectional study using data obtained via a Google search of various combinations of the following terms: nurse practitioner, NP, physician assistant, PA, advance practice provider, APP, dermatology, postgraduate training, residency, and fellowship. We excluded postgraduate dermatology training programs for APPs that required tuition and did not provide a stipend, as well as programs that lacked the formal structure and credibility needed to qualify as legitimate postgraduate training. Many of the excluded programs operate in a manner that raises ethical concerns, offering pay-to-play opportunities under the guise of education. Information collected on each program included the program name, location, parent institution, program length, class size, curriculum, and any associated salary and benefits.

Results

Ten academic and private practice organizations across the United States that offer postgraduate dermatologic training programs for APPs were identified (eTable). Four (40%) programs were advertised as fellowships. Six (60%) of the programs were offered at academic medical centers, and 4 (40%) were offered by private practices. Most programs were located east of the Mississippi River, and many institutions offered instruction at 1 or more locations within the same state (eFigure). The Advanced Dermatology and Cosmetic Surgery private practice group offered training opportunities in multiple states.

Six programs required APPs to become board-certified NPs or PAs prior to enrolling. Most programs enrolled both NPs and PAs, while some only enrolled NPs (eTable). Only 1 (10%) program required NPs to be board certified as a family NP, while another (10%) recommended that applicants have experience in urgent care, emergency medicine, or trauma medicine. Lahey Hospital & Medical Center required experience as an NP in a general setting for 1 to 2 years prior to applying. No program required prior experience in the field of dermatology.

Program length varied from 6 to 24 months, and cohort size typically was limited to 1 to 2 providers (eTable). Although the exact numbers could not be ascertained, most curricula focused on medical dermatology, including clinical and didactic components, but many offered electives such as cosmetic and procedural dermatology. Two institutions (20%) required independent research. Work typically was limited to 40 hours per week, and most paid a full-time employee salary and provided benefits such as health insurance, retirement, and paid leave (eTable). Kansas Medical Clinic (Topeka, Kansas) required at least 3 years of employment in an underserved community following program completion. The Oasis Dermatology private practice group in Texas required a 1-year teaching commitment after program completion. The Advanced Dermatology and Cosmetic Surgery group offered a full-time position upon program completion.

Comment

There is a large difference in the total number of training and credentialing hours when comparing graduate school training and postgraduate credentialing of medical and osteopathic physicians compared with APPs. A new graduate physician has at least twice as many clinical hours as a PA and 10 times as many clinical hours as an NP prior to starting residency. Physicians also typically complete at least 6 times the number of hours of certification examinations compared to NPs and PAs.¹

Nurse practitioner students typically complete the 500 hours of prelicensure clinical training required for NP school in 2 to 4 years.^2,3 The amount of time required for completion is dependent on the degree and experience of the student upon program entry (eg, bachelor of science in nursing vs master of science in nursing as a terminal degree). Physician assistant students are required to complete 2000 prelicensure clinical hours, and most PA programs are 3 years in duration.⁴ Many NP and PA programs require some degree of clinical experience prior to beginning graduate education.⁵

When comparing prelicensure examinations, questions assessing dermatologic knowledge comprise approximately 6% to 10% of the total questions on the United States Medical Licensing Examination Steps 1 and 2.⁶ The Comprehensive Osteopathic Medical Licensing Examination of the United States Level 1 and Level 2-Cognitive Evaluation both have at least 5% of questions dedicated to dermatology.⁷ Approximately 5% of the questions on the Physician Assistant National Certifying Examination are dedicated to dermatology.⁸ The dermatology content on either of the NP certification examinations is unclear.^2,3 In the states of California, Indiana, and New York, national certification through the American Association of Nurse Practitioners or American Nurses Credentialing Center is not required for NPs to practice in their respective states.⁹

Regarding dermatologic board certification, a new graduate NP may obtain certification from the Dermatology Nurse Practitioner Certification Board with 3000 hours of general dermatology practice that may occur during normal working hours.¹⁰ These hours do not have to occur in one of the previously identified postgraduate APP training programs. The National Board of Dermatology Physician Assistants was founded in 2018 and has since dissolved. The National Board of Dermatology Physician Assistants was not accredited and required at least 3 years of training in dermatology with the same dermatologist in addition to completing a 125-question multiple-choice examination.¹¹ Of note, this examination was opposed by both the ABD and the Society for Dermatology Physician Associates.¹² A PA also may become a Diplomate Fellow with the Society of Dermatology Physician Associates after completion of 64.5 hours of online continuing education modules.⁴ Some PAs may choose to obtain a Certificate of Added Qualifications, which is a voluntary credential that helps document specialty experience and expertise in dermatology or other specialties.

In contrast, a dermatology resident physician requires nearly 11,000 to 13,000 hours of clinical training hours, which last 3 to 4 years following medical school.¹³ This training involves direct patient care under supervision in various settings, including hospitals, outpatient clinics, and surgical procedures. In addition to this clinical experience, dermatology residents must pass a 3-step certification examination process administered by the ABD.¹³ This process includes approximately 20 hours of examinations designed to assess both knowledge and practical skills. For those who wish to further specialize, additional fellowship training in areas such as pediatric dermatology, dermatopathology, or Mohs surgery may follow residency; such fellowships involve an extra 2500 to 3500 hours of training and culminate in another certification examination, further refining a resident’s expertise in a specific dermatologic field. Osteopathic physicians may opt out of the ABD 3-step pathway and obtain board certification through the American Osteopathic Board of Dermatology.¹⁴

Many of the programs we evaluated integrate APP trainees into resident education, allowing participation in equivalent didactic curricula, clinical rotations, and departmental academic activities. The salary and benefits associated with these programs are somewhat like those of resident physicians.^15,16 While most tuition-based programs were excluded from our study due to their lack of credibility and alignment with our study criteria, we identified 2 specific programs that stood out as credible despite requiring students to pay tuition. These programs demonstrated a structured and rigorous curriculum with a clear focus on comprehensive dermatologic training, meeting our standards for inclusion. These programs offer dermatologic training for graduates of NP and PA programs at a cost to the student.^15,16 The program at the Florida Atlantic University, Boca Raton, is largely online,¹⁵ and the program at the University of Miami, Florida, offers no direct clinical contact.¹⁶ These programs illustrate the variety of postgraduate dermatology curricula available nationally in comparison to resident salaries; however, they were not included in our formal analysis because they do not provide structured, in-person clinical training consistent with our inclusion criteria. Neither of these programs would enable participants to qualify for credentialing with the Dermatology Nurse Practitioner Certification Board after completion. While this study identified postgraduate training programs for APPs in dermatology advertised online, it is possible some were omitted or not advertised online.

While many of the postgraduate programs we evaluated provide unique educational opportunities for APPs, it is unknown if graduating providers are equipped to handle the care of patients with complex dermatologic needs. Regardless, the increased utilization of APPs by BCDs has been well documented over the past 2 decades.^17-20 It has been suggested that a higher ratio of APPs to dermatologists can decrease the time it takes for a patient to be seen in a clinic.^21-23 However, investigators have expressed concerns that APPs lack standardized surgical training and clinical hour requirements in the field of dermatology.²⁴ Despite these concerns, Medicare claims data show that APPs are performing advanced surgical and cosmetic procedures at increasing rates.^17,18 Other authors have questioned the cost-effectiveness of APPs, as multiple studies have shown that the number of biopsies needed to diagnose 1 case of skin cancer is higher for midlevel providers than for dermatologists.^25-27

Conclusion

With the anticipated expansion of private equity in dermatology and the growth of our Medicare-eligible population, we are likely to see increased utilization of APPs to address the shortage of BCDs.^28,29 Understanding the prelicensure and postlicensure clinical training requirements, examination hours, and extent of dermatology-focused education among APPs and BCDs can help dermatologists collaborate more effectively and ensure safe, high-quality patient care. Standardizing, improving, and providing high-quality education and promoting lifelong learning in the field of dermatology should be celebrated, and dermatologists are the skin experts best equipped to lead dermatologic education forward.

Nurse practitioners (NPs) and physician assistants (PAs) often help provide dermatologic care but lack the same mandatory specialized postgraduate training required of board-certified dermatologists (BCDs), which includes at least 3 years of dermatology-focused education in an accredited residency program in addition to an intern year of general medicine, pediatrics, or surgery. Dermatology residency is followed by a certification examination administered by the American Board of Dermatology (ABD) or the American Osteopathic Board of Dermatology, leading to board certification. Some physicians choose to do a fellowship, which typically involves an additional 1 to 2 years of postresidency subspeciality training.

Optional postgraduate dermatology training programs for advanced practice providers (APPs) have been offered by some academic institutions and private practice groups since at least 2003, including Lahey Hospital and Medical Center (Burlington, Massachusetts) as well as the University of Rochester Medical Center (Rochester, New York). Despite a lack of accreditation or standardization, the programs can be beneficial for NPs and PAs to expand their dermatologic knowledge and skills and help bridge the care gap within the specialty. Didactics often are conducted in parallel with the educational activities of the parent institution’s traditional dermatology residency program (eg, lectures, grand rounds). While these programs often are managed by practicing dermatology NPs and PAs, dermatologists also may be involved in their education with didactic instruction, curriculum development, and clinical preceptorship. 

In this cross-sectional study, we identified and evaluated 10 postgraduate dermatology training programs for APPs across the United States. With the growing number of NPs and PAs in the dermatology workforce—both in academic and private practice—it is important for BCDs to be aware of the differences in the dermatology training received in order to ensure safe and effective care is provided through supervisory or collaborative roles (depending on state independent practice laws for APPs and to be aware of the implications these programs may have on the field of dermatology.

Methods

To identify postgraduate dermatology training programs for APPs in the United States, we conducted a cross-sectional study using data obtained via a Google search of various combinations of the following terms: nurse practitioner, NP, physician assistant, PA, advance practice provider, APP, dermatology, postgraduate training, residency, and fellowship. We excluded postgraduate dermatology training programs for APPs that required tuition and did not provide a stipend, as well as programs that lacked the formal structure and credibility needed to qualify as legitimate postgraduate training. Many of the excluded programs operate in a manner that raises ethical concerns, offering pay-to-play opportunities under the guise of education. Information collected on each program included the program name, location, parent institution, program length, class size, curriculum, and any associated salary and benefits.

Results

Ten academic and private practice organizations across the United States that offer postgraduate dermatologic training programs for APPs were identified (eTable). Four (40%) programs were advertised as fellowships. Six (60%) of the programs were offered at academic medical centers, and 4 (40%) were offered by private practices. Most programs were located east of the Mississippi River, and many institutions offered instruction at 1 or more locations within the same state (eFigure). The Advanced Dermatology and Cosmetic Surgery private practice group offered training opportunities in multiple states.

Six programs required APPs to become board-certified NPs or PAs prior to enrolling. Most programs enrolled both NPs and PAs, while some only enrolled NPs (eTable). Only 1 (10%) program required NPs to be board certified as a family NP, while another (10%) recommended that applicants have experience in urgent care, emergency medicine, or trauma medicine. Lahey Hospital & Medical Center required experience as an NP in a general setting for 1 to 2 years prior to applying. No program required prior experience in the field of dermatology.

Program length varied from 6 to 24 months, and cohort size typically was limited to 1 to 2 providers (eTable). Although the exact numbers could not be ascertained, most curricula focused on medical dermatology, including clinical and didactic components, but many offered electives such as cosmetic and procedural dermatology. Two institutions (20%) required independent research. Work typically was limited to 40 hours per week, and most paid a full-time employee salary and provided benefits such as health insurance, retirement, and paid leave (eTable). Kansas Medical Clinic (Topeka, Kansas) required at least 3 years of employment in an underserved community following program completion. The Oasis Dermatology private practice group in Texas required a 1-year teaching commitment after program completion. The Advanced Dermatology and Cosmetic Surgery group offered a full-time position upon program completion.

Comment

There is a large difference in the total number of training and credentialing hours when comparing graduate school training and postgraduate credentialing of medical and osteopathic physicians compared with APPs. A new graduate physician has at least twice as many clinical hours as a PA and 10 times as many clinical hours as an NP prior to starting residency. Physicians also typically complete at least 6 times the number of hours of certification examinations compared to NPs and PAs.¹

Nurse practitioner students typically complete the 500 hours of prelicensure clinical training required for NP school in 2 to 4 years.^2,3 The amount of time required for completion is dependent on the degree and experience of the student upon program entry (eg, bachelor of science in nursing vs master of science in nursing as a terminal degree). Physician assistant students are required to complete 2000 prelicensure clinical hours, and most PA programs are 3 years in duration.⁴ Many NP and PA programs require some degree of clinical experience prior to beginning graduate education.⁵

When comparing prelicensure examinations, questions assessing dermatologic knowledge comprise approximately 6% to 10% of the total questions on the United States Medical Licensing Examination Steps 1 and 2.⁶ The Comprehensive Osteopathic Medical Licensing Examination of the United States Level 1 and Level 2-Cognitive Evaluation both have at least 5% of questions dedicated to dermatology.⁷ Approximately 5% of the questions on the Physician Assistant National Certifying Examination are dedicated to dermatology.⁸ The dermatology content on either of the NP certification examinations is unclear.^2,3 In the states of California, Indiana, and New York, national certification through the American Association of Nurse Practitioners or American Nurses Credentialing Center is not required for NPs to practice in their respective states.⁹

Regarding dermatologic board certification, a new graduate NP may obtain certification from the Dermatology Nurse Practitioner Certification Board with 3000 hours of general dermatology practice that may occur during normal working hours.¹⁰ These hours do not have to occur in one of the previously identified postgraduate APP training programs. The National Board of Dermatology Physician Assistants was founded in 2018 and has since dissolved. The National Board of Dermatology Physician Assistants was not accredited and required at least 3 years of training in dermatology with the same dermatologist in addition to completing a 125-question multiple-choice examination.¹¹ Of note, this examination was opposed by both the ABD and the Society for Dermatology Physician Associates.¹² A PA also may become a Diplomate Fellow with the Society of Dermatology Physician Associates after completion of 64.5 hours of online continuing education modules.⁴ Some PAs may choose to obtain a Certificate of Added Qualifications, which is a voluntary credential that helps document specialty experience and expertise in dermatology or other specialties.

In contrast, a dermatology resident physician requires nearly 11,000 to 13,000 hours of clinical training hours, which last 3 to 4 years following medical school.¹³ This training involves direct patient care under supervision in various settings, including hospitals, outpatient clinics, and surgical procedures. In addition to this clinical experience, dermatology residents must pass a 3-step certification examination process administered by the ABD.¹³ This process includes approximately 20 hours of examinations designed to assess both knowledge and practical skills. For those who wish to further specialize, additional fellowship training in areas such as pediatric dermatology, dermatopathology, or Mohs surgery may follow residency; such fellowships involve an extra 2500 to 3500 hours of training and culminate in another certification examination, further refining a resident’s expertise in a specific dermatologic field. Osteopathic physicians may opt out of the ABD 3-step pathway and obtain board certification through the American Osteopathic Board of Dermatology.¹⁴

Many of the programs we evaluated integrate APP trainees into resident education, allowing participation in equivalent didactic curricula, clinical rotations, and departmental academic activities. The salary and benefits associated with these programs are somewhat like those of resident physicians.^15,16 While most tuition-based programs were excluded from our study due to their lack of credibility and alignment with our study criteria, we identified 2 specific programs that stood out as credible despite requiring students to pay tuition. These programs demonstrated a structured and rigorous curriculum with a clear focus on comprehensive dermatologic training, meeting our standards for inclusion. These programs offer dermatologic training for graduates of NP and PA programs at a cost to the student.^15,16 The program at the Florida Atlantic University, Boca Raton, is largely online,¹⁵ and the program at the University of Miami, Florida, offers no direct clinical contact.¹⁶ These programs illustrate the variety of postgraduate dermatology curricula available nationally in comparison to resident salaries; however, they were not included in our formal analysis because they do not provide structured, in-person clinical training consistent with our inclusion criteria. Neither of these programs would enable participants to qualify for credentialing with the Dermatology Nurse Practitioner Certification Board after completion. While this study identified postgraduate training programs for APPs in dermatology advertised online, it is possible some were omitted or not advertised online.

While many of the postgraduate programs we evaluated provide unique educational opportunities for APPs, it is unknown if graduating providers are equipped to handle the care of patients with complex dermatologic needs. Regardless, the increased utilization of APPs by BCDs has been well documented over the past 2 decades.^17-20 It has been suggested that a higher ratio of APPs to dermatologists can decrease the time it takes for a patient to be seen in a clinic.^21-23 However, investigators have expressed concerns that APPs lack standardized surgical training and clinical hour requirements in the field of dermatology.²⁴ Despite these concerns, Medicare claims data show that APPs are performing advanced surgical and cosmetic procedures at increasing rates.^17,18 Other authors have questioned the cost-effectiveness of APPs, as multiple studies have shown that the number of biopsies needed to diagnose 1 case of skin cancer is higher for midlevel providers than for dermatologists.^25-27

Conclusion

With the anticipated expansion of private equity in dermatology and the growth of our Medicare-eligible population, we are likely to see increased utilization of APPs to address the shortage of BCDs.^28,29 Understanding the prelicensure and postlicensure clinical training requirements, examination hours, and extent of dermatology-focused education among APPs and BCDs can help dermatologists collaborate more effectively and ensure safe, high-quality patient care. Standardizing, improving, and providing high-quality education and promoting lifelong learning in the field of dermatology should be celebrated, and dermatologists are the skin experts best equipped to lead dermatologic education forward.