DataDerm: Improving trends in performance measurement

BACKGROUND

Medicare's legacy quality reporting programs were consolidated into the Merit-Based Incentive Payment System (MIPS) in 2015.

PURPOSE

The DataDerm registry of the American Academy of Dermatology was examined to understand the potential for and subsequent rate of improvement across 23 performance measures.

METHODS

We examined the level of performance across 23 performance measures with at least 20 clinicians reporting on at least 50 patients' experience. We calculated the following values: the aggregate performance rate for each measure and the overall aggregate performance rate.

RESULTS

The aggregate performance rate for each measure ranged from 20.4% for AAD 1 (Psoriasis: Assessment of Disease Activity), to 99.9% for measure ACMS 1 (Avoidance of Opioid Prescriptions for Reconstruction After Skin Resection). Three of 23 measures had an aggregate performance over 95%. The overall aggregate performance rate across all 23 measures was 81.2%, indicating an aggregate potential for improvement of 18.8% across the 23 measures. Nine performance measures reported across the first five years of DataDerm's existence were tracked through time to understand trends in performance through time. The performance across the nine performance measures meeting the inclusion criteria consistently improved in the initial years (2016 through 2018) of DataDerm participation and showed some variation in 2019 and 2020.

CONCLUSIONS

These data provide evidence that the very act of participation in a multi-institutional registry and tracking compliance with performance measures can lead to improvements in compliance with the performance measures and therefore improvements in quality of care.

Barriers and Facilitators Affecting Long-Term Antibiotic Prescriptions for Acne Treatment

Importance

Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice.

Objective

To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Design, Setting, and Participants

This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024.

Main Outcomes and Measures

Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Results

Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship.

Conclusions and Relevance

The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.

The 2022 Annual Report of DataDerm: The database of the American Academy of Dermatology

The American Academy of Dermatology (AAD) launched DataDerm in 2016 as the clinical data registry platform of AAD. DataDerm has evolved to be the largest database containing information about dermatology patients in the world. As of December 31, 2021, DataDerm contained data from 13.2 million unique patients and 47.0 million unique patient visits, with 403 practices representing 1670 clinicians actively participating in DataDerm in 2021. Of the 1670 clinicians participating in DataDerm in 2021, the majority were dermatologists (978) followed by physician assistants (375) and nurse practitioners (163) who are employed by AAD members and meet the AAD definition of the AAD DermCare team. Furthermore, in 2021, 834 clinicians submitted data via DataDerm to the Merit-based Incentive Payment System of the Centers for Medicare & Medicaid Services. This article is the third annual report about the status of DataDerm. This year's 2022 annual report presents the progress DataDerm has made over the past year in conjunction with OM1, the data analytics partner of DataDerm, as well as the current status and future plans of DataDerm.

The Changing Tasks of Medicine and Dermatology in the Twenty-First Century: The Need for Improved Information Capture Tools and Processes

The delivery of dermatology services has undergone dramatic changes in the past century. The goals and timelines of care have evolved as have the diagnostic and therapeutic tools, resulting in the need to capture and manage information differently, both qualitatively and quantitatively. The predominant and basic office-based ambulatory care model has remained relatively unchanged. Patients and providers interact with minimal pre-visit preparation using the "agenda-less" meeting model. This care model is ill-suited to manage the vastly expanded data capture and processing requirement of twenty-first century dermatology. We have developed novel tools to automate pre-visit data collection which allows for more robust information capture which moves data capture outside of the time-constrained clinic visit. These tools capture structured data, integrate into electronic health records, and create summary reports in real time to assist decision-making. These tools, if scaled, can facilitate the information management needs of dermatology care.

Patient-Reported Outcome Measures and Their Clinical Applications in Dermatology

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

Achieving consensus on patient-reported outcome measures in clinical practice for inflammatory skin disorders

BACKGROUND

International Dermatology Outcome Measures and the American Academy of Dermatology recently agreed on a physician-reported global severity measure to demonstrate quality of care in inflammatory dermatoses.

OBJECTIVE

Because patient-reported outcome measures are also important, we aimed to achieve consensus on 1 of these measures for clinical practice.

METHODS

Patients and providers participated in a consensus-building study involving a modified-Delphi technique. Voting was focused on identifying a minimal set of assessments for clinical practice, patient global assessments (PtGAs), Skindex instruments, and final instrument selection for quality improvement.

RESULTS

Among 53 stakeholders, >70% agreed that identification of patient goals, assessment of treatment harm, and assessment of the adequacy of treatment response were the minimal assessments needed for clinical practice. The most preferred PtGA was a 5-point PtGA (scale 0-4; 0 = clear, 4 = severe) having an optional check-box for worst ever. A new metric to assess change since treatment initiation, which we called a trajectory measure, was proposed. Stakeholders preferred Skindex instruments over PtGAs and a trajectory measure for clinical practice.

LIMITATIONS

A small number of patients and caregivers were involved and a consensus was not reached on all items.

CONCLUSION

PtGAs as standalone measures do not adequately capture the patient's assessment of disease severity or the effect of care. The combination of a PtGA with a Skindex instrument or another measure of health-related quality of life might provide a more comprehensive evaluation of patients in clinical practice.

Atezolizumab (programmed cell death-ligand 1 antibody)-induced inflammation of actinic keratosis: A case report

Atezolizumab is a programmed cell death-ligand 1 antibody that modulates the immune system response and has shown great promise in treating malignancies. Cutaneous toxicities from immune checkpoint inhibitors are the most commonly reported immune-related adverse events, although toxicities related to immunotherapy are still being characterized. Herein, we present a novel case of inflamed actinic keratoses in a patient after receiving atezolizumab therapy that resolved without requirement of dose adjustment or discontinuation of treatment.

2021 Annual Report of DataDerm™: The Database of The American Academy of Dermatology (AAD)

The American Academy of Dermatology (AAD) launched DataDerm™ in 2016 as the clinical data registry platform of AAD. DataDerm has evolved to be the largest database containing information about dermatology patients in the world. As of December 31, 2020, DataDerm contained data from 11.3 million unique patients and 40.0 million unique patient visits, with 782 practices representing 2,290 clinicians actively participating in DataDerm. This article is the second in a series of annual reports about the status of DataDerm. While last year's 2020 first annual report presented the history of DataDerm as well as the rationale for creation, maintenance, and expansion of DataDerm, this year's 2021 annual report presents the progress DataDerm has made over the past year along with its current status and future plans.

Validation of the Three-Item Skindex-Mini Among Hidradenitis Suppurativa Patients With Diverse Racial Backgrounds

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that severely impairs patients' quality of life (QoL). Instruments such as the 10-item Dermatology Life Quality Index and 16-item Skindex-16 have been used to assess QoL in HS; however, it is unknown whether the shorter 3-item Skindex-mini can also provide an accurate assessment of skin-related QoL in patients with HS.

OBJECTIVES

The aim was to assess how well the Skindex-16 correlates with its shorter adaptation, the Skindex-mini, in capturing QoL among patients with HS.

METHODS

This retrospective cross-sectional study included all HS patients seen in the HS Clinic at The Emory Clinic between January 1, 2019, and August 16, 2019. We compared the correlation between the symptom, emotion, and function domains of the Skindex-16 and Skindex-mini using Pearson correlation coefficients (CC). Secondary outcome measures included individual survey item analysis, ItchyQuant scores, and numeric rating scale of pain.

RESULTS

We identified 108 encounters among 75 unique hidradenitis suppurativa patients (43 black/African American, 18 white, 5 Asian/Pacific Islander, 3 Latino, 4 Other, 2 unknown). Pearson CC between the Skindex-16 and Skindex-mini domain scores for all encounters were 0.770 (P < .001), 0.787 (P < .001), and 0.801 (P < .001) for the symptom, emotion, and function domains, respectively. The mean pain and ItchyQuant scores were 4.14 (SD 3.31) and 3.55 (SD 3.34), respectively.

CONCLUSIONS

The Skindex-mini correlated highly with the Skindex-16 in a racially diverse group of patients with HS. The Skindex-mini is a streamlined QoL instrument that could be practically implemented into routine clinical care among diverse patients presenting to dermatology.

The Completeness and Accuracy of DataDerm™: The Database of The American Academy of Dermatology (AAD)

The utility of any database or registry depends on the completeness and accuracy of the data it contains. This report documents the validity of data elements within DataDerm, the clinical registry database of The American Academy of Dermatology (AAD). An external audit of DataDerm, performed by a third-party vendor, involved the manual review of 1,098 individual patient charts from calendar year 2018 from 8 different dermatology practices that utilized 4 different electronic health records (EHRs). At each site, 142 discrete data fields were assessed, comparing the data within DataDerm to the source data within the EHR. Data that were audited included three domains of data elements (diagnoses, medications, procedures), and a performance measure (i.e., "Biopsy Reporting Time - Clinician to Patient"), which is one of several measures used by DataDerm as a Qualified Clinical Data Registry (QCDR). Completeness of data was 95.3% overall, with a range among practices of 90.6% to 98.5%. Accuracy of data was 89.8% overall, with a range of accuracy among practices of 81.2% to 94.1%. These levels of completeness and accuracy exceed rates in the literature for EHR-based registries and provide validation regarding the excellent quality of data in DataDerm.

Differences in Outpatient Dermatology Encounter Work Relative Value Units and Net Payments by Patient Race, Sex, and Age

Importance

Clinical productivity measures may be factors in financial incentives for providing care to specific patient populations and thus may perpetuate inequitable health care.

Objective

To identify the association of patient race, age, and sex with work relative value units (wRVUs) generated by outpatient dermatology encounters.

Design, Setting, and Participants

This cross-sectional study obtained demographic and billing data for outpatient dermatology encounters (ie, an encounter performed within a department of dermatology) from September 1, 2016, to March 31, 2020, at the Emory Clinic, an academic dermatologic practice in Atlanta, Georgia. Participants included adults aged 18 years or older with available age, race, and sex data in the electronic health record system.

Main Outcomes and Measures

The primary outcome was wRVUs generated per encounter.

Results

A total of 66 463 encounters among 30 036 unique patients were included. Patients had a mean (SD) age of 55.9 (18.5) years and were predominantly White (46 575 [70.1%]) and female (39 598 [59.6%]) individuals. In the general dermatologic practice, the mean (SD) wRVUs per encounter was 1.40 (0.71). In adjusted analysis, Black, Asian, and other races (eg, American Indian or Native American, Native Hawaiian or Other Pacific Islander, and multiple races); female sex; and younger age were associated with fewer wRVUs per outpatient dermatology encounter. Compared with general dermatologic visits with White patients, visits with Black patients generated 0.27 (95% CI, 0.25-0.28) fewer wRVUs per encounter, visits with Asian patients generated 0.22 (95% CI, 0.20-0.25) fewer wRVUs per encounter, and visits with patients of other race generated 0.19 (95% CI, 0.14-0.24) fewer wRVUs per encounter. Female sex was also associated with 0.11 (95% CI, 0.10-0.12) fewer wRVUs per encounter, and wRVUs per encounter increased by 0.006 (95% CI, 0.006-0.006) with each 1-year increase in age. In the general dermatologic practice excluding Mohs surgeons, destruction of premalignant lesions and biopsies were mediators for the observed differences in race (56.2% [95% CI, 53.1%-59.3%] for Black race, 53.2% [95% CI, 45.6%-63.8%] for Asian race, and 53.6% [95% CI, 40.4%-77.4%] for other races), age (65.6%; 95% CI, 60.5%-71.4%), and sex (82.3%; 95% CI, 72.7%-93.1%). In a data set including encounters with Mohs surgeons, the race, age, and sex differences in wRVUs per encounter were greater than in the general dermatologic data set. Mohs surgery for basal cell and squamous cell carcinomas was a mediator for the observed differences in race (46.0% [95% CI, 42.6%-49.4%] for Black race, 41.9% [95% CI, 35.5%-49.2%] for Asian race, and 34.6% [95% CI, 13.8%-51.5%] for other races), age (49.2%; 95% CI, 44.9%-53.7%), and sex (47.9%; 95% CI, 42.0%-54.6%).

Conclusions and Relevance

This cross-sectional study found that dermatology encounters with racial minority groups, women, and younger patients generated fewer wRVUs than encounters with older White male patients. This finding suggests that physician compensation based on wRVUs may encourage the provision of services that exacerbate disparities in access to dermatologic care.

The 2020 annual report of DataDerm: The database of the American Academy of Dermatology

The American Academy of Dermatology launched DataDerm in 2016 as the clinical data registry platform of the American Academy of Dermatology. DataDerm is approved by the Centers for Medicare & Medicaid Services as a Qualified Clinical Data Registry for the Merit-Based Incentive Payment System. The ultimate purpose of DataDerm is to provide dermatologists with a registry and database that will serve as a vehicle to advance the specialty in the domains of science, discovery, education, quality assessment, quality improvement, advocacy, and practice management. DataDerm is currently the largest clinical registry and database of patients receiving dermatologic care in the world. As of December 31, 2019, DataDerm contained data from 10,618,879 unique patients and 32,309,389 unique patient visits. Depending on the reporting period, 800 to 900 practices (representing 2400-2600 clinicians) actively participate in DataDerm by submitting data. This article provides the first of a planned series of annual updates of the status of DataDerm. The purpose of this article is to present the rationale for the creation, maintenance, history, and current status of DataDerm, as well as the future plans for DataDerm.

Pyoderma gangrenosum underrepresentation in non-dermatological literature

Background

Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI).

Methods

We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF).

Results

Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis.

Conclusions

There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.

Use and Cost of Actinic Keratosis Destruction in the Medicare Part B Fee-for-Service Population, 2007 to 2015

Importance

Actinic keratosis is prevalent and has the potential to progress to keratinocyte carcinoma. Changes in the use and costs of actinic keratosis treatment are not well understood in the aging population.

Objective

To evaluate trends in the use and costs of actinic keratosis destruction in Medicare patients.

Design, Setting, and Participants

A billing claims analysis was performed of the Medicare Part B Physician/Supplier Procedure Summary Master Files and National Summary Data of premalignant skin lesion destructions performed from 2007 to 2015 among Medicare Part B fee-for-service beneficiaries.

Main Outcomes and Measures

Mean number of actinic keratosis lesions destroyed and associated treatment payments in 2015 US dollars estimated per 1000 Medicare Part B fee-for-service beneficiaries. Data analysis was performed from November 2017 to July 2018.

Results

More than 35.6 million actinic keratosis lesions were treated in 2015, increasing from 29.7 million in 2007. Treated actinic keratosis lesions per 1000 beneficiaries increased from 917 in 2007 to 1051 in 2015, while mean inflation-adjusted payments per 1000 patients decreased from $11 749 to $10 942 owing to reimbursement cuts. The proportion of actinic keratosis lesions treated by independently billing nurse practitioners and physician assistants increased from 4.0% in 2007 to 13.5% in 2015.

Conclusions and Relevance

This study's findings suggest that actinic keratosis imposes continuously increasing levels of treatment burden in the Medicare fee-for-service population. Reimbursement decreases have been used to control rising costs of actinic keratosis treatment. Critical research may be warranted to optimize access to actinic keratosis treatment and value for prevention of keratinocyte carcinoma.

Phosphoinositide 3-Kinase Signaling Can Modulate MHC Class I and II Expression

Molecular events activating the PI3K pathway are frequently detected in human tumors and the activation of PI3K signaling alters numerous cellular processes including tumor cell proliferation, survival, and motility. More recent studies have highlighted the impact of PI3K signaling on the cellular response to interferons and other immunologic processes relevant to antitumor immunity. Given the ability of IFNγ to regulate antigen processing and presentation and the pivotal role of MHC class I (MHCI) and II (MHCII) expression in T-cell-mediated antitumor immunity, we sought to determine the impact of PI3K signaling on MHCI and MHCII induction by IFNγ. We found that the induction of cell surface MHCI and MHCII molecules by IFNγ is enhanced by the clinical grade PI3K inhibitors dactolisib and pictilisib. We also found that PI3K inhibition increases STAT1 protein levels following IFNγ treatment and increases accessibility at genomic STAT1-binding motifs. Conversely, we found that pharmacologic activation of PI3K signaling can repress the induction of MHCI and MHCII molecules by IFNγ, and likewise, the loss of PTEN attenuates the induction of MHCI, MHCII, and STAT1 by IFNγ. Consistent with these in vitro studies, we found that within human head and neck squamous cell carcinomas, intratumoral regions with high phospho-AKT IHC staining had reduced MHCI IHC staining. IMPLICATIONS: Collectively, these findings demonstrate that MHC expression can be modulated by PI3K signaling and suggest that activation of PI3K signaling may promote immune escape via effects on antigen presentation.

Information technologies in health care delivery and policy: giant steps and missteps

The influences of information technology have touched almost all aspects of our lives, and health care delivery has been no exception. Law, policy, and regulation have driven the adoption of electronic medical records, particularly over the past decade, driving fundamental changes to the practice of medicine in general and dermatology in particular. This article reviews the history of these changes, the regulations that drove these changes, the intended and unintended consequences of these initiatives, and our insights into the appropriate roles for policy and regulation to drive positive change.

Keratoelastoidosis Marginalis

Background:

Keratoelastoidosis marginalis is a rare disease that is a variant of solar elastosis. Long-term ultraviolet radiation exposure and chronic trauma secondary to manual labor are considered to be inciting factors.

Objective:

To outline the clinical and histological features of this disorder.

Methods:

We report two cases and review the literature.

Results:

Both patients had persistence of their disease despite multiple topical treatment regimens.

Conclusion:

Keratoelastoidosis marginalis is a chronic and progressive disease that is difficult to treat. The differential includes focal acral hyperkeratosis and acrokeratoelastoidosis.

Super-Resolution Microscopy Reveals Altered Desmosomal Protein Organization in Tissue from Patients with Pemphigus Vulgaris

Pemphigus vulgaris (PV) is an autoimmune epidermal blistering disease in which autoantibodies (IgG) are directed against the desmosomal cadherin desmoglein 3 (Dsg3). In order to better understand how PV IgG alters desmosome morphology and function in vivo, PV patient biopsies were analyzed by structured illumination microscopy (SIM), a form of super-resolution fluorescence microscopy. In patient tissue, desmosomal proteins were aberrantly clustered and localized to PV IgG-containing endocytic linear arrays. Patient IgG also colocalized with markers for lipid rafts and endosomes. Additionally, steady-state levels of Dsg3 were decreased and desmosomes were reduced in size in patient tissue. Desmosomes at blister sites were occasionally split, with PV IgG decorating the extracellular faces of split desmosomes. Desmosome splitting was recapitulated in vitro by exposing cultured keratinocytes both to PV IgG and to mechanical stress, demonstrating that splitting at the blister interface in patient tissue is due to compromised desmosomal adhesive function. These findings indicate that Dsg3 clustering and endocytosis are associated with reduced desmosome size and adhesion defects in PV patient tissue. Further, this study reveals that super-resolution optical imaging is powerful approach for studying epidermal adhesion structures in normal and diseased skin.

The International Dermatology Outcome Measures initiative as applied to psoriatic disease outcomes: a report from the GRAPPA 2013 meeting

In the United States, access to care is the number one issue facing our patients with dermatological conditions. In part, this is because we do not have outcome measures that are useful in clinical practice and available in databases where payers and governmental agencies can compare the performance of physicians and treatments. There is a growing recognition that insufficient attention has been paid to the outcomes measured in clinical trials and subsequently in clinical practice. The International Dermatology Outcome Measures group includes all willing stakeholders: patients, physicians, payers, and pharmaceutical scientists. As reported herein, the group's goal is to develop outcome measures in dermatology that address the needs of all involved.

Practical guidelines for the use of steroid-sparing agents in the treatment of chronic pruritus

Chronic pruritus in the adult patient is both an underappreciated and a difficult to treat condition. In the vast majority of cases, itch is the result of inflammatory skin disease and therefore may be responsive to systemic anti-inflammatory therapies. Urticarial dermatitis is an under-recognized cause of chronic itch in the adult population. Patients with this disorder are characterized by prolonged, prednisone-responsive pruritus, often in the absence of substantial cutaneous findings. Skin findings, when present, can range from subtle, persistent urticarial lesions to excoriated papules, often intermixed with urticaria, eczematous change, and lichenification secondary to chronic scratching. Hereby, we describe our algorithm for evaluation and management of adult patients with refractory pruritus (urticarial dermatitis in particular), including evaluation for other etiologies of pruritus, pre-immunosuppression workup, and the use of azathioprine and other steroid-sparing agents for treatment of recalcitrant itch.

Medication dyes as a source of drug allergy

Excipients are defined as inert substances added to a drug or food to confer a suitable consistency, appearance, or form. They may be added for bulk, to change dissolution or the kinetics of absorption, to improve stability, to influence palatability, or to create a distinctive appearance. The last function may depend heavily on the use of coloring agents, especially when there are multiple dosages (such as with warfarin), and dose confusion may result in profound complications. While described as inert, excipients have been associated with triggering immunological reactions, although this is almost never considered in common practice when patients have reactions to medications, even when they appear to react to many different and distinct drugs. We have found a cohort of 11 patients with chronic, unexplained pruritic skin disorders that have responded to medication changes centered around avoidance of coloring agents, particularly FD&C Blue No. 1 (bright blue) and Blue No. 2 (indigo carmine). We believe that reactions to agents that color medications and foods may be more common than previously appreciated and that recognition of this phenomenon may provide therapeutic alternatives to patients with intractable pruritic disorders.

Azathioprine in dermatology: The past, the present, and the future

For several decades, dermatologists have utilized azathioprine to treat numerous debilitating skin diseases. This synthetic purine analog is derived from 6-mercaptopurine. It is thought to act by disrupting nucleic acid synthesis and has recently been found to interfere with T-cell activation. The most recognized uses of azathioprine in dermatology are for immunobullous diseases, generalized eczematous disorders, and photodermatoses. In this comprehensive review, the authors present recent advancements in the understanding of azathioprine and address aspects not covered in prior reviews. They (1) summarize the history of azathioprine; (2) discuss metabolism, integrating information from recent publications; (3) review the mechanism of action with attention paid to the activities of azathioprine not mediated by its 6-mercaptopurine metabolites and review new data about inhibition by azathioprine of the CD28 signal transduction pathway; (4) thoroughly examine thiopurine s-methyltransferase genetics, its clinical relevance, and interethnic variations; (5) review prior uses of azathioprine in the field of dermatology and grade the level of evidence; (6) discuss the use of azathioprine in pregnancy and pediatrics; review (7) key drug interactions and (8) adverse effects; (9) suggest a dosing and monitoring approach different from prior recommendations; and (10) explore the future of azathioprine, focusing on laboratory considerations and therapeutic application.