Mixed Topics

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.

Social media is rife with content promoting colon cleansing as a way to shed toxins and fix everything from chronic fatigue and overweight to weak immunity and skin problems.

Even doctors who aren’t hip to the latest TikTok trends may not be able to avoid the hype. That’s because patients are bringing up colon cleansing during their office visit.

“Patients often raise questions about colonics or detox teas, especially when these gain traction on social media platforms like TikTok,” said Tauseef Ali, MD, AGAF, medical executive director of SSM Health Digestive Care at St. Anthony Hospital in Oklahoma City. “Interest typically comes in waves, closely tied to the latest online trends.”

That means gastroenterologists need to be prepared when they’re asked if the latest product — whether it’s colon hydrotherapy, a detox drink or pill, or an enema — being touted by influencers is good for their health. And it’s not just patients who are asking.

“Sometimes we’ll get a message from primary care,” Mohammad Bilal, MD, associate professor of medicine and director of Bariatric and Third Space Endoscopy at the University of Colorado Anschutz Medical Campus in Aurora, Colorado, told GI & Hepatology News. They’re getting the same questions from patients, and they want to know if colon cleansing that’s not connected with a colonoscopy exam has any benefits for overall health or specific health conditions.

The answer is no, and patients are more likely to believe that when physicians explain it using good information. Here is how Ali, Bilal, and professional organizations advise doctors to approach the issue.

 

What Exactly Is a Colon Cleanse?

Colon cleanses come in a variety of forms. Colonic irrigation, also called colon hydrotherapy, involves inserting a tube into the rectum and flushing out the colon with a large amount of fluid. Enemas do the same but use a small amount of liquid, and some product instructions tell the user to “hold it” for a designated amount of time before expelling colon contents.

Other cleanses, often called detoxing cleanses, are laxatives or herbal teas that users drink — and then stay close to the bathroom. Detox regimens and diets also are mentioned as a way to remove toxins from the body, improve health, and promote well-being.

 

Why Do Patients Use Them?

“Many patients describe a desire for ‘cleanliness,’ ‘detoxification,’ or to ‘feel lighter,’” Ali told GI & Hepatology News.

The claims on social media promote all of this and more — and well-known influencers make it all sound even more attractive.

“These motivations are often rooted in the cultural belief that the colon accumulates harmful toxins that must be flushed out,” Ali said. “This idea is not supported by scientific evidence. The body’s natural detox systems, primarily the liver and kidneys, already perform this function effectively.”

Bilal said that in recent years, he has noticed more awareness in general about the importance of gut health. “When there’s awareness, people often go to the other extreme,” he said.

Where Is the Evidence?

The National Center for Complementary and Integrative Health (NCCIH), part of the National Institutes of Health, warns on an information page that both cleansing and detox programs can be unsafe and falsely advertised.

While searches of medical literature turn up few studies, the NCCIH information points to a 2014 review that concluded that there is no compelling research to support the use of detox diets for managing weight or eliminating toxins. A 2017 review found juicing and detox regimens can cause weight loss initially but then lead to weight gain once a normal diet is resumed.

A systematic review of research on the safety and effectiveness of self-administered coffee enemas found nine case reports describing adverse events: seven reported colitis after the enema, and two reported more critical adverse events. All nine reports warned against the procedure. The researchers found no study reporting the effectiveness of coffee enemas.

The NCCIH information also notes that there is “limited clinical evidence validating colonic irrigation and insufficient evidence for its prescribed uses.”

 

Are Cleanses Regulated?

Some over-the-counter colon cleansing products are viewed as dietary supplements, giving the FDA authority to regulate them and take action under the Dietary Supplement Health and Education Act of 1994.

Certain products promoted as colon cleanses, such as laxatives, are regulated by the FDA as over-the-counter drugs and must meet safety and other requirements.

Colonic irrigation systems meant for cleansing before radiologic or endoscopic exams are class II devices — subject to 510(k) premarket notification requirements before marketing — whereas systems intended for other uses, such as routine colon cleansing for general well-being, are regarded as class III devices — subject to premarket approval requirements — according to an FDA spokesperson. To date, the FDA has not approved any colonic irrigation devices for the latter use, the spokesperson said.

For instance, the FDA warned consumers not to use a product promoted for colon cleansing after finding it contained tadalafil, the active ingredient in an FDA-approved drug for erectile dysfunction. The FDA has also issued numerous warning letters to the makers of colon cleansing devices, as they are not approved for this purpose.

The Federal Trade Commission can also take action specifically if the claims about the benefits and safety of products — including supplements, foods, over-the-counter drugs, or health equipment — are false, misleading, or not supported by science.

 

What Are the Dangers?

Cleanse and detox products come with many risks, including electrolyte imbalances, dehydration, and infections, Ali said. With colonic irrigation, there is a risk for rectal perforation. Products also may disrupt the gut microbiome, and some can interact with medications or worsen underlying health conditions, he added.

“It’s important for patients to be aware of these risks before considering nonmedical ‘cleaning’ methods,” he said.

At worst, patients risk fatality, Ali noted. He recalled a young patient who began using a vegetable enema as a detox. As it was being administered, the colon ruptured. The patient was admitted as a medical emergency and required surgery. Fortunately, the patient survived, but the incident could have proven fatal, Ali said.

 

Educating Patients

Because patients often don’t think of herbal cleanses, detox teas, and over-the-counter powders as supplements, Ali said it’s important to ask them about everything they take.

One way to frame this question is to ask if they are consuming any over-the-counter supplements or any other remedies, he said, and perhaps ask directly about any cleanses they are doing.

When patients ask him about colon cleanses, Ali explains the difference between evidence-based colonoscopy preparation and unregulated “cleanses.” Most patients respond to that approach, he said. Indeed, AGA and other GI societies updated their recommendations on optimizing bowel preparation quality for colonoscopy.

“Still, the appeal of quick fixes of social media trends can sometimes outweigh medical advice,” Ali said. He depends on building trusted relationships and reinforcing the message over time and finds that helps patients make informed and healthier choices.

Bilal, too, explains to patients that cleanses are unnecessary and educates them about what to do instead:

• Eat a  containing the recommended amount of  (22-34 g, depending on age and gender).
• For , follow a bowel regimen advised by your doctor.
• If gastrointestinal issues persist, get a medical checkup.
• Get any unexplained constipation or  checked out by a doctor.

Taking a careful history can pay off, Ali has found. He questioned a patient complaining of abdominal discomfort whose testing found unexpectedly elevated liver enzymes and found she had been using an herbal “cleanse tea” found online. Within 4 weeks of stopping it, her liver enzymes normalized. “Thankfully, she made a full recovery — and she never touched those remedies again,” he said.

Ali had no relevant disclosures. Bilal reported consulting for Boston Scientific, Cook Medical, and Steris.

 

A version of this article appeared on Medscape.com.

Social media is rife with content promoting colon cleansing as a way to shed toxins and fix everything from chronic fatigue and overweight to weak immunity and skin problems.

Even doctors who aren’t hip to the latest TikTok trends may not be able to avoid the hype. That’s because patients are bringing up colon cleansing during their office visit.

“Patients often raise questions about colonics or detox teas, especially when these gain traction on social media platforms like TikTok,” said Tauseef Ali, MD, AGAF, medical executive director of SSM Health Digestive Care at St. Anthony Hospital in Oklahoma City. “Interest typically comes in waves, closely tied to the latest online trends.”

That means gastroenterologists need to be prepared when they’re asked if the latest product — whether it’s colon hydrotherapy, a detox drink or pill, or an enema — being touted by influencers is good for their health. And it’s not just patients who are asking.

“Sometimes we’ll get a message from primary care,” Mohammad Bilal, MD, associate professor of medicine and director of Bariatric and Third Space Endoscopy at the University of Colorado Anschutz Medical Campus in Aurora, Colorado, told GI & Hepatology News. They’re getting the same questions from patients, and they want to know if colon cleansing that’s not connected with a colonoscopy exam has any benefits for overall health or specific health conditions.

The answer is no, and patients are more likely to believe that when physicians explain it using good information. Here is how Ali, Bilal, and professional organizations advise doctors to approach the issue.

 

What Exactly Is a Colon Cleanse?

Colon cleanses come in a variety of forms. Colonic irrigation, also called colon hydrotherapy, involves inserting a tube into the rectum and flushing out the colon with a large amount of fluid. Enemas do the same but use a small amount of liquid, and some product instructions tell the user to “hold it” for a designated amount of time before expelling colon contents.

Other cleanses, often called detoxing cleanses, are laxatives or herbal teas that users drink — and then stay close to the bathroom. Detox regimens and diets also are mentioned as a way to remove toxins from the body, improve health, and promote well-being.

 

Why Do Patients Use Them?

“Many patients describe a desire for ‘cleanliness,’ ‘detoxification,’ or to ‘feel lighter,’” Ali told GI & Hepatology News.

The claims on social media promote all of this and more — and well-known influencers make it all sound even more attractive.

“These motivations are often rooted in the cultural belief that the colon accumulates harmful toxins that must be flushed out,” Ali said. “This idea is not supported by scientific evidence. The body’s natural detox systems, primarily the liver and kidneys, already perform this function effectively.”

Bilal said that in recent years, he has noticed more awareness in general about the importance of gut health. “When there’s awareness, people often go to the other extreme,” he said.

Where Is the Evidence?

The National Center for Complementary and Integrative Health (NCCIH), part of the National Institutes of Health, warns on an information page that both cleansing and detox programs can be unsafe and falsely advertised.

While searches of medical literature turn up few studies, the NCCIH information points to a 2014 review that concluded that there is no compelling research to support the use of detox diets for managing weight or eliminating toxins. A 2017 review found juicing and detox regimens can cause weight loss initially but then lead to weight gain once a normal diet is resumed.

A systematic review of research on the safety and effectiveness of self-administered coffee enemas found nine case reports describing adverse events: seven reported colitis after the enema, and two reported more critical adverse events. All nine reports warned against the procedure. The researchers found no study reporting the effectiveness of coffee enemas.

The NCCIH information also notes that there is “limited clinical evidence validating colonic irrigation and insufficient evidence for its prescribed uses.”

 

Are Cleanses Regulated?

Some over-the-counter colon cleansing products are viewed as dietary supplements, giving the FDA authority to regulate them and take action under the Dietary Supplement Health and Education Act of 1994.

Certain products promoted as colon cleanses, such as laxatives, are regulated by the FDA as over-the-counter drugs and must meet safety and other requirements.

Colonic irrigation systems meant for cleansing before radiologic or endoscopic exams are class II devices — subject to 510(k) premarket notification requirements before marketing — whereas systems intended for other uses, such as routine colon cleansing for general well-being, are regarded as class III devices — subject to premarket approval requirements — according to an FDA spokesperson. To date, the FDA has not approved any colonic irrigation devices for the latter use, the spokesperson said.

For instance, the FDA warned consumers not to use a product promoted for colon cleansing after finding it contained tadalafil, the active ingredient in an FDA-approved drug for erectile dysfunction. The FDA has also issued numerous warning letters to the makers of colon cleansing devices, as they are not approved for this purpose.

The Federal Trade Commission can also take action specifically if the claims about the benefits and safety of products — including supplements, foods, over-the-counter drugs, or health equipment — are false, misleading, or not supported by science.

 

What Are the Dangers?

Cleanse and detox products come with many risks, including electrolyte imbalances, dehydration, and infections, Ali said. With colonic irrigation, there is a risk for rectal perforation. Products also may disrupt the gut microbiome, and some can interact with medications or worsen underlying health conditions, he added.

“It’s important for patients to be aware of these risks before considering nonmedical ‘cleaning’ methods,” he said.

At worst, patients risk fatality, Ali noted. He recalled a young patient who began using a vegetable enema as a detox. As it was being administered, the colon ruptured. The patient was admitted as a medical emergency and required surgery. Fortunately, the patient survived, but the incident could have proven fatal, Ali said.

 

Educating Patients

Because patients often don’t think of herbal cleanses, detox teas, and over-the-counter powders as supplements, Ali said it’s important to ask them about everything they take.

One way to frame this question is to ask if they are consuming any over-the-counter supplements or any other remedies, he said, and perhaps ask directly about any cleanses they are doing.

When patients ask him about colon cleanses, Ali explains the difference between evidence-based colonoscopy preparation and unregulated “cleanses.” Most patients respond to that approach, he said. Indeed, AGA and other GI societies updated their recommendations on optimizing bowel preparation quality for colonoscopy.

“Still, the appeal of quick fixes of social media trends can sometimes outweigh medical advice,” Ali said. He depends on building trusted relationships and reinforcing the message over time and finds that helps patients make informed and healthier choices.

Bilal, too, explains to patients that cleanses are unnecessary and educates them about what to do instead:

• Eat a  containing the recommended amount of  (22-34 g, depending on age and gender).
• For , follow a bowel regimen advised by your doctor.
• If gastrointestinal issues persist, get a medical checkup.
• Get any unexplained constipation or  checked out by a doctor.

Taking a careful history can pay off, Ali has found. He questioned a patient complaining of abdominal discomfort whose testing found unexpectedly elevated liver enzymes and found she had been using an herbal “cleanse tea” found online. Within 4 weeks of stopping it, her liver enzymes normalized. “Thankfully, she made a full recovery — and she never touched those remedies again,” he said.

Ali had no relevant disclosures. Bilal reported consulting for Boston Scientific, Cook Medical, and Steris.

 

A version of this article appeared on Medscape.com.

Social media is rife with content promoting colon cleansing as a way to shed toxins and fix everything from chronic fatigue and overweight to weak immunity and skin problems.

Even doctors who aren’t hip to the latest TikTok trends may not be able to avoid the hype. That’s because patients are bringing up colon cleansing during their office visit.

“Patients often raise questions about colonics or detox teas, especially when these gain traction on social media platforms like TikTok,” said Tauseef Ali, MD, AGAF, medical executive director of SSM Health Digestive Care at St. Anthony Hospital in Oklahoma City. “Interest typically comes in waves, closely tied to the latest online trends.”

That means gastroenterologists need to be prepared when they’re asked if the latest product — whether it’s colon hydrotherapy, a detox drink or pill, or an enema — being touted by influencers is good for their health. And it’s not just patients who are asking.

“Sometimes we’ll get a message from primary care,” Mohammad Bilal, MD, associate professor of medicine and director of Bariatric and Third Space Endoscopy at the University of Colorado Anschutz Medical Campus in Aurora, Colorado, told GI & Hepatology News. They’re getting the same questions from patients, and they want to know if colon cleansing that’s not connected with a colonoscopy exam has any benefits for overall health or specific health conditions.

The answer is no, and patients are more likely to believe that when physicians explain it using good information. Here is how Ali, Bilal, and professional organizations advise doctors to approach the issue.

 

What Exactly Is a Colon Cleanse?

Colon cleanses come in a variety of forms. Colonic irrigation, also called colon hydrotherapy, involves inserting a tube into the rectum and flushing out the colon with a large amount of fluid. Enemas do the same but use a small amount of liquid, and some product instructions tell the user to “hold it” for a designated amount of time before expelling colon contents.

Other cleanses, often called detoxing cleanses, are laxatives or herbal teas that users drink — and then stay close to the bathroom. Detox regimens and diets also are mentioned as a way to remove toxins from the body, improve health, and promote well-being.

 

Why Do Patients Use Them?

“Many patients describe a desire for ‘cleanliness,’ ‘detoxification,’ or to ‘feel lighter,’” Ali told GI & Hepatology News.

The claims on social media promote all of this and more — and well-known influencers make it all sound even more attractive.

“These motivations are often rooted in the cultural belief that the colon accumulates harmful toxins that must be flushed out,” Ali said. “This idea is not supported by scientific evidence. The body’s natural detox systems, primarily the liver and kidneys, already perform this function effectively.”

Bilal said that in recent years, he has noticed more awareness in general about the importance of gut health. “When there’s awareness, people often go to the other extreme,” he said.

Where Is the Evidence?

The National Center for Complementary and Integrative Health (NCCIH), part of the National Institutes of Health, warns on an information page that both cleansing and detox programs can be unsafe and falsely advertised.

While searches of medical literature turn up few studies, the NCCIH information points to a 2014 review that concluded that there is no compelling research to support the use of detox diets for managing weight or eliminating toxins. A 2017 review found juicing and detox regimens can cause weight loss initially but then lead to weight gain once a normal diet is resumed.

A systematic review of research on the safety and effectiveness of self-administered coffee enemas found nine case reports describing adverse events: seven reported colitis after the enema, and two reported more critical adverse events. All nine reports warned against the procedure. The researchers found no study reporting the effectiveness of coffee enemas.

The NCCIH information also notes that there is “limited clinical evidence validating colonic irrigation and insufficient evidence for its prescribed uses.”

 

Are Cleanses Regulated?

Some over-the-counter colon cleansing products are viewed as dietary supplements, giving the FDA authority to regulate them and take action under the Dietary Supplement Health and Education Act of 1994.

Certain products promoted as colon cleanses, such as laxatives, are regulated by the FDA as over-the-counter drugs and must meet safety and other requirements.

Colonic irrigation systems meant for cleansing before radiologic or endoscopic exams are class II devices — subject to 510(k) premarket notification requirements before marketing — whereas systems intended for other uses, such as routine colon cleansing for general well-being, are regarded as class III devices — subject to premarket approval requirements — according to an FDA spokesperson. To date, the FDA has not approved any colonic irrigation devices for the latter use, the spokesperson said.

For instance, the FDA warned consumers not to use a product promoted for colon cleansing after finding it contained tadalafil, the active ingredient in an FDA-approved drug for erectile dysfunction. The FDA has also issued numerous warning letters to the makers of colon cleansing devices, as they are not approved for this purpose.

The Federal Trade Commission can also take action specifically if the claims about the benefits and safety of products — including supplements, foods, over-the-counter drugs, or health equipment — are false, misleading, or not supported by science.

 

What Are the Dangers?

Cleanse and detox products come with many risks, including electrolyte imbalances, dehydration, and infections, Ali said. With colonic irrigation, there is a risk for rectal perforation. Products also may disrupt the gut microbiome, and some can interact with medications or worsen underlying health conditions, he added.

“It’s important for patients to be aware of these risks before considering nonmedical ‘cleaning’ methods,” he said.

At worst, patients risk fatality, Ali noted. He recalled a young patient who began using a vegetable enema as a detox. As it was being administered, the colon ruptured. The patient was admitted as a medical emergency and required surgery. Fortunately, the patient survived, but the incident could have proven fatal, Ali said.

 

Educating Patients

Because patients often don’t think of herbal cleanses, detox teas, and over-the-counter powders as supplements, Ali said it’s important to ask them about everything they take.

One way to frame this question is to ask if they are consuming any over-the-counter supplements or any other remedies, he said, and perhaps ask directly about any cleanses they are doing.

When patients ask him about colon cleanses, Ali explains the difference between evidence-based colonoscopy preparation and unregulated “cleanses.” Most patients respond to that approach, he said. Indeed, AGA and other GI societies updated their recommendations on optimizing bowel preparation quality for colonoscopy.

“Still, the appeal of quick fixes of social media trends can sometimes outweigh medical advice,” Ali said. He depends on building trusted relationships and reinforcing the message over time and finds that helps patients make informed and healthier choices.

Bilal, too, explains to patients that cleanses are unnecessary and educates them about what to do instead:

• Eat a  containing the recommended amount of  (22-34 g, depending on age and gender).
• For , follow a bowel regimen advised by your doctor.
• If gastrointestinal issues persist, get a medical checkup.
• Get any unexplained constipation or  checked out by a doctor.

Taking a careful history can pay off, Ali has found. He questioned a patient complaining of abdominal discomfort whose testing found unexpectedly elevated liver enzymes and found she had been using an herbal “cleanse tea” found online. Within 4 weeks of stopping it, her liver enzymes normalized. “Thankfully, she made a full recovery — and she never touched those remedies again,” he said.

Ali had no relevant disclosures. Bilal reported consulting for Boston Scientific, Cook Medical, and Steris.

 

A version of this article appeared on Medscape.com.

THE DIAGNOSIS: Gouty Tophus

The lesion was excised and sent for histopathologic examination (eFigures 1 and 2), revealing aggregates of feathery, amorphous, pale-pink material, which confirmed the diagnosis of gouty tophus. The surgical site was left to heal by secondary intention. Upon further evaluation, the patient reported recurrent monoarticular joint pain in the ankles and feet, and laboratory workup revealed elevated serum uric acid. He was advised to follow up with his primary care physician to discuss systemic treatment options for gout.

Gout is an inflammatory arthritis characterized by the deposition of monosodium urate monohydrate crystals in the joints, soft tissue, and bone due to elevated serum uric acid. Uric acid is the final product of purine metabolism, and serum levels may be elevated due to excess production or underexcretion. Multiple genetic, environmental, and metabolic factors influence these processes.¹ Collections of monosodium urate crystals may develop intra- or extra-articularly, the latter of which are known as gouty tophi. These nodules have a classic chalklike consistency and typically are seen in patients with untreated gout starting approximately 10 years after the first flare. The most common locations for subcutaneous gouty tophi are acral sites (eg, fingertips, ears) as well as the wrists, knees, and elbows (olecranon bursae). Rarely, gouty panniculitis also may develop.²

Histopathology of gouty tophi reveals nodular aggregates of acellular, amorphous, pale-pink material surrounded by palisading histiocytes and multinucleated giant cells. The presence of needlelike monosodium urate crystals, which display negative birefringence, is diagnostic. Unfortunately, these crystals are destroyed in routine formalin processing.³

There are limited data regarding treatment of gouty tophi. Urate-lowering systemic medications such as pegloticase may be beneficial, but more data are needed.⁴ We pursued surgical excision in our case for definitive diagnosis; however, it is not a common treatment for gouty tophi. Typically, urate-lowering therapy is utilized to resolve or shrink lesions over time.⁵

The differential diagnosis for gouty tophi includes epidermal inclusion cyst (EIC), the most common type of cutaneous cyst. Though EICs can manifest anywhere on the body, they are not as common on the ears as gouty tophi. Epidermal inclusion cysts clinically manifest as soft subcutaneous nodules, and a central punctum often is noted. These lesions are derived from the follicular infundibulum and histologically are characterized by a cystic cavity lined by a stratified squamous epithelium with a granular layer. The cavity contains loose laminated keratin material.⁶

Pseudocyst of the auricle is a benign cystic swelling of the pinna that can develop spontaneously but most often manifests following trauma to the area, which is believed to separate the tissue planes in the cartilage, allowing fluid to accumulate. This lesion typically is asymptomatic, though some patients report mild tenderness.⁷ Histology shows a cystic structure within the cartilage without an epithelial lining, and a perivascular inflammatory response often is observed.⁸

Pilomatricoma, also known as pilomatrixoma, is a benign tumor derived from the hair follicle matrix that manifests as a firm, slow-growing, painless subcutaneous nodule. It most often is found on the head and neck, commonly in the periauricular area.⁹ Though rare, it has been found on the auricle and external auditory canal.¹⁰ Histologically, pilomatricomas are well-defined tumors containing internal trabeculae. They contain populations of basaloid and ghost cells and often calcify, sometimes with resultant bone formation.⁹

Dermoid cysts are benign tumors that develop along lines of embryonic closure and often are diagnosed at birth or in early childhood. They most commonly manifest on the head and neck, typically in the supraorbital area. Rarely, they have been reported on the ear.⁶ Dermoid cysts may resemble EICs clinically and histopathologically, except that the cyst wall contains mature adnexal structures such as hair follicles and sebaceous glands.

THE DIAGNOSIS: Gouty Tophus

The lesion was excised and sent for histopathologic examination (eFigures 1 and 2), revealing aggregates of feathery, amorphous, pale-pink material, which confirmed the diagnosis of gouty tophus. The surgical site was left to heal by secondary intention. Upon further evaluation, the patient reported recurrent monoarticular joint pain in the ankles and feet, and laboratory workup revealed elevated serum uric acid. He was advised to follow up with his primary care physician to discuss systemic treatment options for gout.

Gout is an inflammatory arthritis characterized by the deposition of monosodium urate monohydrate crystals in the joints, soft tissue, and bone due to elevated serum uric acid. Uric acid is the final product of purine metabolism, and serum levels may be elevated due to excess production or underexcretion. Multiple genetic, environmental, and metabolic factors influence these processes.¹ Collections of monosodium urate crystals may develop intra- or extra-articularly, the latter of which are known as gouty tophi. These nodules have a classic chalklike consistency and typically are seen in patients with untreated gout starting approximately 10 years after the first flare. The most common locations for subcutaneous gouty tophi are acral sites (eg, fingertips, ears) as well as the wrists, knees, and elbows (olecranon bursae). Rarely, gouty panniculitis also may develop.²

Histopathology of gouty tophi reveals nodular aggregates of acellular, amorphous, pale-pink material surrounded by palisading histiocytes and multinucleated giant cells. The presence of needlelike monosodium urate crystals, which display negative birefringence, is diagnostic. Unfortunately, these crystals are destroyed in routine formalin processing.³

There are limited data regarding treatment of gouty tophi. Urate-lowering systemic medications such as pegloticase may be beneficial, but more data are needed.⁴ We pursued surgical excision in our case for definitive diagnosis; however, it is not a common treatment for gouty tophi. Typically, urate-lowering therapy is utilized to resolve or shrink lesions over time.⁵

The differential diagnosis for gouty tophi includes epidermal inclusion cyst (EIC), the most common type of cutaneous cyst. Though EICs can manifest anywhere on the body, they are not as common on the ears as gouty tophi. Epidermal inclusion cysts clinically manifest as soft subcutaneous nodules, and a central punctum often is noted. These lesions are derived from the follicular infundibulum and histologically are characterized by a cystic cavity lined by a stratified squamous epithelium with a granular layer. The cavity contains loose laminated keratin material.⁶

Pseudocyst of the auricle is a benign cystic swelling of the pinna that can develop spontaneously but most often manifests following trauma to the area, which is believed to separate the tissue planes in the cartilage, allowing fluid to accumulate. This lesion typically is asymptomatic, though some patients report mild tenderness.⁷ Histology shows a cystic structure within the cartilage without an epithelial lining, and a perivascular inflammatory response often is observed.⁸

Pilomatricoma, also known as pilomatrixoma, is a benign tumor derived from the hair follicle matrix that manifests as a firm, slow-growing, painless subcutaneous nodule. It most often is found on the head and neck, commonly in the periauricular area.⁹ Though rare, it has been found on the auricle and external auditory canal.¹⁰ Histologically, pilomatricomas are well-defined tumors containing internal trabeculae. They contain populations of basaloid and ghost cells and often calcify, sometimes with resultant bone formation.⁹

Dermoid cysts are benign tumors that develop along lines of embryonic closure and often are diagnosed at birth or in early childhood. They most commonly manifest on the head and neck, typically in the supraorbital area. Rarely, they have been reported on the ear.⁶ Dermoid cysts may resemble EICs clinically and histopathologically, except that the cyst wall contains mature adnexal structures such as hair follicles and sebaceous glands.

THE DIAGNOSIS: Gouty Tophus

The lesion was excised and sent for histopathologic examination (eFigures 1 and 2), revealing aggregates of feathery, amorphous, pale-pink material, which confirmed the diagnosis of gouty tophus. The surgical site was left to heal by secondary intention. Upon further evaluation, the patient reported recurrent monoarticular joint pain in the ankles and feet, and laboratory workup revealed elevated serum uric acid. He was advised to follow up with his primary care physician to discuss systemic treatment options for gout.

Gout is an inflammatory arthritis characterized by the deposition of monosodium urate monohydrate crystals in the joints, soft tissue, and bone due to elevated serum uric acid. Uric acid is the final product of purine metabolism, and serum levels may be elevated due to excess production or underexcretion. Multiple genetic, environmental, and metabolic factors influence these processes.¹ Collections of monosodium urate crystals may develop intra- or extra-articularly, the latter of which are known as gouty tophi. These nodules have a classic chalklike consistency and typically are seen in patients with untreated gout starting approximately 10 years after the first flare. The most common locations for subcutaneous gouty tophi are acral sites (eg, fingertips, ears) as well as the wrists, knees, and elbows (olecranon bursae). Rarely, gouty panniculitis also may develop.²

Histopathology of gouty tophi reveals nodular aggregates of acellular, amorphous, pale-pink material surrounded by palisading histiocytes and multinucleated giant cells. The presence of needlelike monosodium urate crystals, which display negative birefringence, is diagnostic. Unfortunately, these crystals are destroyed in routine formalin processing.³

There are limited data regarding treatment of gouty tophi. Urate-lowering systemic medications such as pegloticase may be beneficial, but more data are needed.⁴ We pursued surgical excision in our case for definitive diagnosis; however, it is not a common treatment for gouty tophi. Typically, urate-lowering therapy is utilized to resolve or shrink lesions over time.⁵

The differential diagnosis for gouty tophi includes epidermal inclusion cyst (EIC), the most common type of cutaneous cyst. Though EICs can manifest anywhere on the body, they are not as common on the ears as gouty tophi. Epidermal inclusion cysts clinically manifest as soft subcutaneous nodules, and a central punctum often is noted. These lesions are derived from the follicular infundibulum and histologically are characterized by a cystic cavity lined by a stratified squamous epithelium with a granular layer. The cavity contains loose laminated keratin material.⁶

Pseudocyst of the auricle is a benign cystic swelling of the pinna that can develop spontaneously but most often manifests following trauma to the area, which is believed to separate the tissue planes in the cartilage, allowing fluid to accumulate. This lesion typically is asymptomatic, though some patients report mild tenderness.⁷ Histology shows a cystic structure within the cartilage without an epithelial lining, and a perivascular inflammatory response often is observed.⁸

Pilomatricoma, also known as pilomatrixoma, is a benign tumor derived from the hair follicle matrix that manifests as a firm, slow-growing, painless subcutaneous nodule. It most often is found on the head and neck, commonly in the periauricular area.⁹ Though rare, it has been found on the auricle and external auditory canal.¹⁰ Histologically, pilomatricomas are well-defined tumors containing internal trabeculae. They contain populations of basaloid and ghost cells and often calcify, sometimes with resultant bone formation.⁹

Dermoid cysts are benign tumors that develop along lines of embryonic closure and often are diagnosed at birth or in early childhood. They most commonly manifest on the head and neck, typically in the supraorbital area. Rarely, they have been reported on the ear.⁶ Dermoid cysts may resemble EICs clinically and histopathologically, except that the cyst wall contains mature adnexal structures such as hair follicles and sebaceous glands.

Hi, everyone. I’m Dr Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

The receding of the pandemic and the understandable desire to return to normalcy has made COVID-19 vaccines a lower priority for many of our patients. However, family physicians should keep in mind that from October 1, 2024, to September 6, 2025, COVID-19 was responsible for an estimated 3.2 to 4.6 million outpatient visits, 360,000 to 520,000 hospitalizations, and 42,000 to 60,000 deaths.

In a previous commentary, I discussed the worsening disconnect between the evidence supporting the effectiveness and safety of vaccinations and increasing reluctance of patients and parents to receive them, fueled by misinformation from federal health agencies and the packing of the Advisory Committee on Immunization Practices (ACIP) with vaccine skeptics. Since then, Secretary of Health and Human Services (HHS), Robert F. Kennedy, Jr, has fired Dr Susan Monarez, his handpicked director of the CDC. This caused three senior CDC officials to resign in protest and precipitated further turmoil at the embattled agency. 

The FDA has approved 3 updated COVID-19 vaccines targeted to currently circulating strains: an mRNA vaccine from Moderna (Spikevax) for those aged 6 months or older; an mRNA vaccine from Pfizer/BioNTech (Comirnaty) for those aged ≥ 5 years; and a protein subunit vaccine from Novavax (Nuvaxovid) for those aged ≥ 12 years. However, approvals restricting the scope of these approvals to certain high-risk groups, combined with the ACIP’s recent decision to not explicitly recommend them for any group, have complicated access for many patients.

Medical groups, including the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG), have published their own recommendations (Table). Of note, in opposition to the FDA and ACIP, the AAP and AAFP strongly recommend routine vaccination for children aged 6 to 23 months because they have the highest risk for hospitalization. The AAFP and ACOG both recommend COVID-19 vaccination in pregnancy to protect the pregnant patient and provide passive antibody protection to their infants up to 6 months of age. The Vaccine Integrity Project’s review of 12 safety studies published since June 2024 found that mRNA vaccines were not associated with increases in any adverse maternal or infant outcomes and had a possible protective effect against preterm birth.

In my previous commentary, 70% of Medscape readers indicated that they would follow vaccination recommendations from AAP even if they differed from CDC guidance. Administering vaccines outside of FDA labeling indications (i.e., “off label”) typically requires a physician’s prescription, which will almost certainly reduce COVID-19 vaccine uptake in children and pregnant patients, given that most people received these shots in pharmacies during the 2024-25 season. CVS and Walgreens, the country’s two largest pharmacy chains, are requiring physician prescriptions or waiting for ACIP guidance to make the new vaccines available in many states. However, an increasing number of states have implemented executive orders or passed legislation to permit pharmacists to provide vaccines to anyone who wants them. For example, the Pennsylvania State Board of Pharmacy voted unanimously to issue guidance that would allow pharmacists to administer any vaccines recommended by AAFP, AAP, or ACOG.

Erosion of vaccine uptake could easily worsen the burden of illness for our patients and the health system. Navigating the unnecessarily complex landscape of COVID-19 vaccines will be challenging, but it remains worthwhile.
 

Kenneth W. Lin, MD, MPH, Associate Director, Department of Family Medicine, Lancaster General Hospital, Lancaster, Pennsylvania, has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: UpToDate; American Academy of Family Physicians; Archdiocese of Washington; Association of Prevention Teaching and Research.

A version of this article appeared on Medscape.com.

Hi, everyone. I’m Dr Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

The receding of the pandemic and the understandable desire to return to normalcy has made COVID-19 vaccines a lower priority for many of our patients. However, family physicians should keep in mind that from October 1, 2024, to September 6, 2025, COVID-19 was responsible for an estimated 3.2 to 4.6 million outpatient visits, 360,000 to 520,000 hospitalizations, and 42,000 to 60,000 deaths.

In a previous commentary, I discussed the worsening disconnect between the evidence supporting the effectiveness and safety of vaccinations and increasing reluctance of patients and parents to receive them, fueled by misinformation from federal health agencies and the packing of the Advisory Committee on Immunization Practices (ACIP) with vaccine skeptics. Since then, Secretary of Health and Human Services (HHS), Robert F. Kennedy, Jr, has fired Dr Susan Monarez, his handpicked director of the CDC. This caused three senior CDC officials to resign in protest and precipitated further turmoil at the embattled agency. 

The FDA has approved 3 updated COVID-19 vaccines targeted to currently circulating strains: an mRNA vaccine from Moderna (Spikevax) for those aged 6 months or older; an mRNA vaccine from Pfizer/BioNTech (Comirnaty) for those aged ≥ 5 years; and a protein subunit vaccine from Novavax (Nuvaxovid) for those aged ≥ 12 years. However, approvals restricting the scope of these approvals to certain high-risk groups, combined with the ACIP’s recent decision to not explicitly recommend them for any group, have complicated access for many patients.

Medical groups, including the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG), have published their own recommendations (Table). Of note, in opposition to the FDA and ACIP, the AAP and AAFP strongly recommend routine vaccination for children aged 6 to 23 months because they have the highest risk for hospitalization. The AAFP and ACOG both recommend COVID-19 vaccination in pregnancy to protect the pregnant patient and provide passive antibody protection to their infants up to 6 months of age. The Vaccine Integrity Project’s review of 12 safety studies published since June 2024 found that mRNA vaccines were not associated with increases in any adverse maternal or infant outcomes and had a possible protective effect against preterm birth.

In my previous commentary, 70% of Medscape readers indicated that they would follow vaccination recommendations from AAP even if they differed from CDC guidance. Administering vaccines outside of FDA labeling indications (i.e., “off label”) typically requires a physician’s prescription, which will almost certainly reduce COVID-19 vaccine uptake in children and pregnant patients, given that most people received these shots in pharmacies during the 2024-25 season. CVS and Walgreens, the country’s two largest pharmacy chains, are requiring physician prescriptions or waiting for ACIP guidance to make the new vaccines available in many states. However, an increasing number of states have implemented executive orders or passed legislation to permit pharmacists to provide vaccines to anyone who wants them. For example, the Pennsylvania State Board of Pharmacy voted unanimously to issue guidance that would allow pharmacists to administer any vaccines recommended by AAFP, AAP, or ACOG.

Erosion of vaccine uptake could easily worsen the burden of illness for our patients and the health system. Navigating the unnecessarily complex landscape of COVID-19 vaccines will be challenging, but it remains worthwhile.
 

Kenneth W. Lin, MD, MPH, Associate Director, Department of Family Medicine, Lancaster General Hospital, Lancaster, Pennsylvania, has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: UpToDate; American Academy of Family Physicians; Archdiocese of Washington; Association of Prevention Teaching and Research.

A version of this article appeared on Medscape.com.

Hi, everyone. I’m Dr Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

The receding of the pandemic and the understandable desire to return to normalcy has made COVID-19 vaccines a lower priority for many of our patients. However, family physicians should keep in mind that from October 1, 2024, to September 6, 2025, COVID-19 was responsible for an estimated 3.2 to 4.6 million outpatient visits, 360,000 to 520,000 hospitalizations, and 42,000 to 60,000 deaths.

In a previous commentary, I discussed the worsening disconnect between the evidence supporting the effectiveness and safety of vaccinations and increasing reluctance of patients and parents to receive them, fueled by misinformation from federal health agencies and the packing of the Advisory Committee on Immunization Practices (ACIP) with vaccine skeptics. Since then, Secretary of Health and Human Services (HHS), Robert F. Kennedy, Jr, has fired Dr Susan Monarez, his handpicked director of the CDC. This caused three senior CDC officials to resign in protest and precipitated further turmoil at the embattled agency. 

The FDA has approved 3 updated COVID-19 vaccines targeted to currently circulating strains: an mRNA vaccine from Moderna (Spikevax) for those aged 6 months or older; an mRNA vaccine from Pfizer/BioNTech (Comirnaty) for those aged ≥ 5 years; and a protein subunit vaccine from Novavax (Nuvaxovid) for those aged ≥ 12 years. However, approvals restricting the scope of these approvals to certain high-risk groups, combined with the ACIP’s recent decision to not explicitly recommend them for any group, have complicated access for many patients.

Medical groups, including the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG), have published their own recommendations (Table). Of note, in opposition to the FDA and ACIP, the AAP and AAFP strongly recommend routine vaccination for children aged 6 to 23 months because they have the highest risk for hospitalization. The AAFP and ACOG both recommend COVID-19 vaccination in pregnancy to protect the pregnant patient and provide passive antibody protection to their infants up to 6 months of age. The Vaccine Integrity Project’s review of 12 safety studies published since June 2024 found that mRNA vaccines were not associated with increases in any adverse maternal or infant outcomes and had a possible protective effect against preterm birth.

In my previous commentary, 70% of Medscape readers indicated that they would follow vaccination recommendations from AAP even if they differed from CDC guidance. Administering vaccines outside of FDA labeling indications (i.e., “off label”) typically requires a physician’s prescription, which will almost certainly reduce COVID-19 vaccine uptake in children and pregnant patients, given that most people received these shots in pharmacies during the 2024-25 season. CVS and Walgreens, the country’s two largest pharmacy chains, are requiring physician prescriptions or waiting for ACIP guidance to make the new vaccines available in many states. However, an increasing number of states have implemented executive orders or passed legislation to permit pharmacists to provide vaccines to anyone who wants them. For example, the Pennsylvania State Board of Pharmacy voted unanimously to issue guidance that would allow pharmacists to administer any vaccines recommended by AAFP, AAP, or ACOG.

Erosion of vaccine uptake could easily worsen the burden of illness for our patients and the health system. Navigating the unnecessarily complex landscape of COVID-19 vaccines will be challenging, but it remains worthwhile.
 

Kenneth W. Lin, MD, MPH, Associate Director, Department of Family Medicine, Lancaster General Hospital, Lancaster, Pennsylvania, has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: UpToDate; American Academy of Family Physicians; Archdiocese of Washington; Association of Prevention Teaching and Research.

A version of this article appeared on Medscape.com.