Vascular cutaneous manifestations of COVID-19 and RNA viral pathogens: a systematic review

BACKGROUND

COVID-19, the widely recognized and highly contagious respiratory tract infection, has had a substantial impact on the field of dermatology since its emergence in 2019. SARS-CoV-2, the causative virus of COVID-19, is classified as an RNA virus. Various skin-related symptoms have been reported in patients with COVID-19, most notably the distinctive purple-red acral rash resembling chilblain lesions, commonly referred to as 'COVID toe'; similarly, skin-related symptoms have been observed in connection with other RNA viruses.

OBJECTIVES

To explore the relationship between RNA viruses and their associated vascular cutaneous manifestations vs. those observed in patients infected with SARS-CoV-2.

METHODS

A systematic literature review was conducted using PubMed and medical subject heading terms related to RNA viruses and related skin manifestations.

RESULTS

In total, 3994 patients diagnosed with COVID-19 presenting with skin rashes were included. Chilblain-like lesions were most frequently observed (30.2%), followed by erythematous maculopapular/morbilliform rashes (9.1%) and urticarial rashes (4.7%). Of 8362 patients diagnosed with RNA viruses, more than half of the skin findings reported were erythematous/maculopapular/morbilliform rashes (52.3%), followed by unspecified (11.3%) and purpuric rashes (10.6%).

CONCLUSIONS

When comparing RNA viral infections with COVID-19 infection, we observed similarities in the reported skin manifestations and their presumed pathways, with many implicated in the proinflammatory response. Owing to the wide range of cutaneous symptoms associated with RNA viruses and our currently limited understanding of the underlying mechanisms, additional research is warranted to investigate the pathology behind viral-induced skin lesions.

Kaposi Sarcoma Associated with Tofacitinib Use in a Patient with Rheumatoid Arthritis

Kaposi sarcoma is a rare vascular malignancy associated with HHV-8 infection. Four variants of Kaposi sarcoma have been described: Classic, African, HIV-associated, and iatrogenic. Iatrogenic Kaposi sarcoma is typically associated with immunosuppression and organ transplantation. We present a case of iatrogenic Kaposi sarcoma associated with tofacitinib therapy. A 69-year-old woman with rheumatoid arthritis receiving tofacitinib presented with multiple firm, purple-red nodules and brown plaques on the left lower extremity and a single lesion on the right medial calf. Clinicopathologic correlation confirmed a diagnosis of Kaposi sarcoma. Tofacitinib was discontinued and she was started on Alitretinoin 0.1% gel bid. The purple-red Kaposi sarcoma nodules decreased 50% in size after 4 months and resolved at 1 year off the tofacitinib and initiation of alitretinoin gel. As the use of immunomodulators and biologics continues to expand, awareness of this association is important for prompt diagnosis and management.

Psychology of Aesthetics: Beauty, Social Media, and Body Dysmorphic Disorder

The perception of beauty is fluid within society and can morph based on cultural practices and societal interaction, such as social media exposure. The exposure to digital conference platforms has increased significantly, leading users to check their appearance constantly and find flaws in their perceived virtual appearance. Studies have shown that frequent social media use may lead to unrealistic body image ideals, a significant concern with appearance, and anxiety. Also, social media exposure can worsen body image dissatisfaction, social networking site addiction, and comorbidities of body dysmorphic disorder (BDD) such as depression and eating disorders. Additionally, excessive social media use can increase preoccupation with imagined image defects among BDD patients leading them to pursue minimally invasive cosmetic and plastic surgery procedures. This contribution aims to provide an overview of the evidence surrounding the perception of beauty, cultural aspects of aesthetics, and social media's consequences, especially on BDD's clinical specifics.

Beauty Perception: A Historic and Contemporary Review

The power of beauty influences many aspects of modern society and daily life-perceptions surrounding beauty date to ancient philosophers and have evolved significantly throughout history. Still, there appear to be universally accepted physical characteristics of beauty that span different cultures. Human beings have an inherent ability to distinguish between attractive and non-attractive based on physical features that include facial averageness, symmetry, skin homogeneity, and sexual dimorphism (sex-typical characteristics). Although beauty standards have changed over time, youthful appearance has remained a permanent influential component of facial attractiveness. Each person's perception of beauty is influenced by environment and perceptual adaptation, an experience-based process. Perception of beauty varies by race and ethnicity. We discuss typical features of Caucasian, Asian, Black, and Latino beauty. We also review the effects of globalization on spreading foreign beauty culture and discuss how social media change traditional beauty stereotypes within the different races and ethnicities.

Impact of Direct-to-Consumer Advertising of Cosmetic Procedures on Consumers

BACKGROUND

Direct-to-consumer (DTC) advertising is a prominent type of health care communication.

OBJECTIVE

This study aims to determine the impact of DTC advertisements on consumer opinion.

METHODS

A total of 203 participants were recruited from dermatology clinics at an urban academic center. Participants viewed 2 cosmetically oriented DTC advertisements, and prequestionnaires and postquestionnaires were administered to assess consumer opinion.

RESULTS

Postquestionnaire data highlight a 18.8% and 24.6% increase in participants reporting using commercials as an information source (p < .001) and seeking out additional medical knowledge (p < .001), respectively. After watching the advertisements, there was a 14.4% increase in participants who believed advertisements facilitate better discussions between patients and physicians (p < .001) and a 33% increase in patients reporting they would discuss the procedures with their doctors (p < .001). Of the participants, 60% believed the advertisements did not provide enough information about the possible risks of the product and 39.4% believed a physician was not required to perform cosmetic procedures.

CONCLUSION

Direct-to-consumer advertisements instill meaningful information to patients and promote patient-physician communication. They also seem to exaggerate the benefits while making the procedures seem simple and without risks, suggesting trained medical professionals are not needed for administration.

Skin-Lightening Products: Consumer Preferences and Costs

Disorders of skin hyperpigmentation have an appreciable impact on quality of life, carrying social and cultural importance that influences widespread consumer demand for cosmetic lightening products. We sought to investigate product factors that may influence consumer preference when choosing an over-the-counter cream for skin-lightening purposes. The keyword “lightening cream” was searched in the "Beauty and Personal Care category" of online retailer Amazon.com. The top fifth percentile of products was determined by filtering the search results for a minimum of four out of five stars from customer reviews, and then further filtered by products with over 100 reviews. Number of reviews, rating, price per unit, vehicle, application instructions, ingredients, and review attributes were evaluated. Over 2,900 products were catalogued as “lightening cream” on Amazon.com. There were 40 products rated >4 stars and >100 reviews, constituting the top 1.34% of entries. Tocopheryl was present in 58% of the top 40 products, ascorbic acid in 40%, and niacinamide in 20%. Notably, 22.5% of the top 40 products contained no known skin-lightening ingredient. There was a moderate positive correlation (R²=0.378) between price and consumer rating, with kojic acid being the most expensive per ounce ($24.89) and salicylic acid being the most highly rated (4.54 stars; $15.00/oz). This study provides insight on the factors influencing the choice, preferences, and satisfaction of consumer that sought Amazon for the purchase of lightening products. 

Impact of Social Media on Skin Cancer Prevention

Despite the increasing prevalence of social media usage in health care contexts, its impact on skin cancer prevention and awareness has not been largely investigated. We conducted a review of literature on this topic with the objective of summarizing and analyzing the role of social media in skin cancer and sun damage awareness and to identify the uses, benefits, and limitations of different social media platforms on skin cancer prevention. In today’s technological society, it is critical to understand and study the best form of communication. Specific platforms like Instagram, Twitter, Facebook, YouTube, and TikTok vary in originators of material, target demographics, messaging strategies, and reliability of information with regards to skin cancer, sun, and indoor tanning damage. Our results demonstrate that social media interventions have shown promise in skin cancer prevention and continue to escalate by the day. Dermatologists should keep pace with the latest dermatological content on social media and examine its evolution to target the right audience with the proper messages. Further research is needed to evaluate the effectiveness and true impact of social media on meaningful and lasting behavior change for skin cancer prevention.

The Burden of Skin and Subcutaneous Diseases in the United States From 1990 to 2017

Importance

Skin and subcutaneous diseases affect the health of millions of individuals in the US. Data are needed that highlight the geographic trends and variations of skin disease burden across the country to guide health care decision-making.

Objective

To characterize trends and variations in the burden of skin and subcutaneous tissue diseases across the US from 1990 to 2017.

Design, Setting, and Participants

For this cohort study, data were obtained from the Global Burden of Disease (GBD), a study with an online database that incorporates current and previous epidemiological studies of disease burden, and from GBD 2017, which includes more than 90 000 data sources such as systematic reviews, surveys, population-based disease registries, hospital inpatient and outpatient data, cohort studies, and autopsy data. The GBD separated skin conditions into 15 subcategories according to incidence, prevalence, adequacy of data, and standardized disease definitions. GBD 2017 also estimated the burden from melanoma of the skin and keratinocyte carcinoma. Data analysis for the present study was conducted from September 9, 2019, to March 31, 2020.

Main Outcomes and Measures

Primary study outcomes included age-standardized disability-adjusted life-years (DALYs), incidence, and prevalence. The data were stratified by US states with the highest and lowest age-standardized DALY rate per 100 000 people, incidence, and prevalence of each skin condition. The percentage change in DALY rates in each state was calculated from 1990 to 2017.

Results

Overall, age-standardized DALY rates for skin and subcutaneous diseases increased from 1990 (821.6; 95% uncertainty interval [UI], 570.3-1124.9) to 2017 (884.2; 95% UI, 614.0-1207.9) in all 50 states and the District of Columbia. The degree of increase varied according to geographic location, with the largest percentage change of 0.12% (95% UI, 0.09%-0.15%) in New York and the smallest percentage change of 0.04% (95% UI, 0.02%-0.07%) in Colorado, 0.04% (95% UI, 0.01%-0.06%) in Nevada, 0.04% (95% UI, 0.02%-0.07%) in New Mexico, and 0.04% (95% UI, 0.02%-0.07%) in Utah. The age-standardized DALY rate, incidence, and prevalence of specific skin conditions differed among the states. New York had the highest age-standardized DALY rate for skin and subcutaneous disease in 2017 (1097.0 [95% UI, 764.9-1496.1]), whereas Wyoming had the lowest age-standardized DALY rate (672.9 [95% UI, 465.6-922.3]). In all 50 states and the District of Columbia, women had higher age-standardized DALY rates for overall skin and subcutaneous diseases than men (women: 971.20 [95% UI, 676.76-1334.59] vs men: 799.23 [95% UI, 559.62-1091.50]). However, men had higher DALY rates than women for malignant melanoma (men: 80.82 [95% UI, 51.68-123.18] vs women: 42.74 [95% UI, 34.05-70.66]) and keratinocyte carcinomas (men: 37.56 [95% UI, 29.35-49.52] vs women: 14.42 [95% UI, 10.01-20.66]).

Conclusions and Relevance

Data from the GBD suggest that the burden of skin and subcutaneous disease was large and that DALY rate trends varied across the US; the age-standardized DALY rate for keratinocyte carcinoma appeared greater in men. These findings can be used by states to target interventions and meet the needs of their population.

The global burden of atopic dermatitis: lessons from the Global Burden of Disease Study 1990-2017

BACKGROUND

The Global Burden of Disease (GBD) Study provides an annually updated resource to study disease-related morbidity and mortality worldwide.

OBJECTIVES

Here we present the burden estimates for atopic dermatitis (AD), including data from inception of the GBD project in 1990 until 2017.

METHODS

Data on the burden of AD were obtained from the GBD Study.

RESULTS

Atopic dermatitis (AD) ranks 15th among all nonfatal diseases and has the highest disease burden among skin diseases as measured by disability-adjusted life-years (DALYs). Overall, the global DALY rate for AD in 1990 was 121 [95% uncertainty interval (UI) 65·4-201] and remained similar in 2017 at 123 (95% UI 66·8-205). The three countries with the highest DALY rates of AD were Sweden (327, 95% UI 178-547), the UK (284, 95% UI 155-478) and Iceland (277, 95% UI 149-465), whereas Uzbekistan (85·1, 95% UI 45·2-144), Armenia (85·1, 95% UI 45·8-143) and Tajikistan (85·1, 95% UI 46·1-143) ranked lowest.

CONCLUSIONS

The global prevalence rate of AD has remained stable from 1990 to 2017. However, the distribution of AD by age groups shows a bimodal curve with the highest peak in early childhood, decreasing in prevalence among young adults, and a second peak in middle-aged and older populations. We also found a moderate positive correlation between a country's gross domestic product and disease burden. GBD data confirm the substantial worldwide burden of AD, which has remained stable since 1990 but shows significant geographical variation. Lifestyle factors, partially linked to affluence, are likely important disease drivers. However, the GBD methodology needs to be developed further to incorporate environmental risk factors, such as ultraviolet exposure, to understand better the geographical and age-related variations in disease burden.

Hair Aging in Different Races and Ethnicities

BACKGROUND: Aging is an unavoidable biological process with many influencing factors, accounting for a multitude of visible manifestations on the hair as well as the skin. As the population ages while becoming more diverse, it is increasingly important to better understand the hair aging process. METHODS: A literature search was performed to review what is known about changes in hair structure over time, focusing on the differences in hair aging according to ethnic background. RESULTS: Sixty-nine publications were selected and information regarding hair structure, aging characteristics, and responses to extrinsic damage together with differences between races and ethnicities was collected. Hair-graying onset varies with race, with the average age for Caucasians being mid-thirties, that for Asians being late thirties, and that for Africans being mid-forties. Caucasians and Asians typically experience damage to the distal hair shaft, while African-Americans see damage occurring closer to the hair root. Postmenopausal changes include decreased anagen hairs in the frontal scalp, lower growth rates, and smaller hair diameters. CONCLUSION: There is a paucity of literature examining the characteristics of hair aging across all races. The unique characteristics of hair aging in different ethnicities provides information that will aid in a culturally sensitive approach and recommendations.

Holistic dermatology: An evidence-based review of modifiable lifestyle factor associations with dermatologic disorders

BACKGROUND

Holistic dermatology focuses on treating the human body as a whole and implementing lifestyle changes to enhance the treatment and prognosis of skin disease. Understanding the interplay between modifiable lifestyle factors and patients' dermatologic health will help physicians better inform patients on self-care methods to mitigate the burden of their skin disease(s).

OBJECTIVE

To review the current scientific literature on the relationship between modifiable lifestyle factors and the dermatologic outcome of skin disorders.

METHODS

A systematic literature search on PubMed, Cochrane, and Web of Science was conducted to identify research articles examining the relationship between dermatology and 6 major categories of modifiable lifestyle factors: diet, sleep, exercise, stress, alcohol, and smoking.

RESULTS

A substantial amount of evidence supports the relationship between modifiable lifestyle factors and dermatologic outcomes. There were the most studies on diet, stress, alcohol, and smoking, but all lifestyle factors were supported by some degree of scientific evidence.

CONCLUSION

All modifiable lifestyle factors explored in this review play a critical role in modulating the onset and progression of skin disease. We anticipate more research studies in the future and an increasing integration of holistic dermatology into patient care.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with morphea/systemic sclerosis

Morphea and systemic sclerosis are inflammatory, sclerosing disorders. Morphea primarily affects the dermis and subcutaneous fat, while systemic sclerosis typically involves the skin and internal organs. Functional impairment and cosmetic disfigurement are common in both diseases. Treatment options to mitigate disease progression remain limited. Both functional impairment and cosmetic deficits negatively impact quality of life and psychological well-being in this patient population. While the number of cosmetic procedures performed in the United States continues to rise each year, limited data exist regarding best practices for correcting aesthetic deficits caused by autoimmune conditions. There is scarce information to guide safety decisions regarding laser parameters, soft tissue augmentation, treatment intervals, and the concurrent use of immune-modifying or immune-suppressing medications. Given the fears of disease reactivation and exacerbation from postprocedural inflammation along with limited data, it is difficult for clinicians to provide evidence-based cosmetic treatment with realistic expectations with regard to short- and long-term outcomes. In the first article in this continuing medical education series, we attempt to address this practice gap.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with lupus erythematosus

The cutaneous manifestations of lupus, especially chronic cutaneous lupus erythematosus, are a source of significant morbidity and can negatively impact patient quality of life. While the active inflammatory component of the disease may be adequately treated, patients are frequently left with residual skin damage and disfiguring aesthetic deficits. Dermatologists lack guidelines regarding the use and safety of various reconstructive and cosmetic interventions in this patient population. Laser treatments are largely avoided in the lupus population because of the possible photodamaging effects of ultraviolet and visible light. Similarly, given the autoimmune nature of this disease, some physicians avoid injectable treatment and grafts because of the concern for disease reactivation via antigenic stimulation. In the second article in this continuing medical education series we compile available data on this topic with the goal of providing evidence-based guidance on the cosmetic treatment of patients with lupus erythematosus with a focus on chronic cutaneous lupus erythematosus.

Leprosy: Treatment and management of complications

In the second article in this continuing medical education series, we review the treatment of leprosy, its immunologic reactions, and important concepts, including disease relapse and drug resistance. A fundamental understanding of the treatment options and management of neuropathic sequelae are essential to reduce disease burden and improve patients' quality of life.

Leprosy: Clinical aspects and diagnostic techniques

Leprosy, also known as Hansen's disease, is a curable infectious disease that remains endemic in >140 countries around the world. Despite being declared "eliminated" as a global public health problem by the World Health Organization in the year 2000, approximately 200,000 new cases were reported worldwide in 2017. Widespread migration may bring leprosy to nonendemic areas, such as North America. In addition, there are areas in the United States where autochthonous (person-to-person) transmission of leprosy is being reported among Americans without a history of foreign exposure. In the first article in this continuing medical education series, we review leprosy epidemiology, transmission, classification, clinical features, and diagnostic challenges.

Common Skin Disorders in Pediatric Skin of Color

Children with skin of color represent a large proportion of the pediatric population. There are numerous skin conditions that commonly occur in this population, including but not limited to acne, atopic dermatitis, pityriasis alba, tinea versicolor, progressive macular hypomelanosis, traction alopecia, and confluent and reticulated papillomatosis. This article highlights the clinical presentations of these conditions in skin of color and briefly addresses pathophysiology and treatment modalities.

Primary Language in Relation to Knowledge of Diagnosis and Sun-Related Behaviors in Adults with Sun-Exacerbated Dermatoses

Objective: To evaluate how patients’ primary spoken language influences the understanding of their disorder and their subsequent sun-related behaviors. Methods: This was a cross-sectional study conducted between February 2015 and July 2016 in two outpatient dermatology clinics among 419 adults with a sun-exacerbated dermatosis. The primary outcome was a successful match between the patient-reported diagnosis on a survey and the dermatologist-determined diagnosis. Results: Of participants, 42% were native English speakers, and 68% did not know their diagnosis. Fewer non-native English speakers identified one risk factor for their condition (46% versus 54%, p < 0.01). A greater number of non-native English speakers were less familiar with medical terminology. Native English speakers were 2.5 times more likely to know their diagnosis compared to non-native speakers (adjusted odds (aOR) 2.5, 95% confidence interval, 1.32 to 4.5; p = 0.005). Additional factors associated with higher odds of knowing the diagnosis included: Higher education, sunscreen use, female gender, symptoms for 1–5 years, and diagnosis of melasma and postinflammatory hyperpigmentation (PIH). Conclusions: Knowledge of the diagnosis and understanding of factors that may influence skin disease may promote conscious sun behavior. Patients who knew that their diagnosis was sun-exacerbated had higher odds of wearing sunscreen.

Characteristics of keratinocyte carcinomas in Hispanics compared to non-Hispanic whites: A retrospective 5-year study

BACKGROUND

Hispanics are one of the fastest growing populations in the United States. Few studies have characterized the patterns of keratinocyte carcinoma presentation in Hispanics.

OBJECTIVE

The study aimed to compare the clinical and histologic characteristics of keratinocyte carcinomas in Hispanics and non-Hispanic whites.

MATERIALS AND METHODS

A five-year retrospective chart review was conducted at a single academic center to identify all histologically-confirmed cases of keratinocyte carcinomas. Tumor characteristics were then compared between Hispanics and non-Hispanic whites.

RESULTS

A total of 197 tumors were identified of which 76% occurred in non-Hispanic whites and 24% in Hispanics. Tumor diameter was not larger and histologic subtype was not more aggressive in Hispanics compared to non-Hispanic whites. Age of diagnosis of basal cell carcinoma was younger among Hispanics compared to non-Hispanic whites (P < .05).

CONCLUSION

Hispanics were not more likely to present with more high-risk keratinocyte carcinomas compared to non-Hispanic whites in terms of tumor diameter, differentiation and subtype.

The malleability of beauty: perceptual adaptation

Beauty has many facets, and research shows that there are many biologic, psychologic, cultural, and social aspects that influence how beauty and attractiveness are perceived. Beauty preferences are, in part, an effect of a rudimentary cognitive process that appears quite early in life, with humans having a seemingly automatic ability to categorize a person as beautiful or not. This instantaneous capability of human beauty categorization is partially determined by a function of physical features, such as facial averageness, symmetry, and skin homogeneity. For decades, the mass media platform has introduced certain criteria to what establishes beauty, and more recently, social media, instant photo sharing, and editing apps have further influenced how society adapts to beauty principles.

Willingness-to-pay and Time Trade-off: The Burden of Disease in Patients with Benign Hyperpigmentation

Objective: We assessed willingness-to-pay (WTP) and time trade-off (TTO) as methods to quantify the disease burden of benign hyperpigmentation. Design: This was a cross-sectional pilot study that included 85 adults. A paper survey was used to collect demographic and health utility information; an accompanying dermatological exam assessed disease severity. Setting: This was a single-site study performed at an urban dermatology clinic. Participants: Adults 18 years of age or older who spoke English, Spanish, or Portuguese were included. Measurements: Utility measures included WTP, TTO, and time spent concealing the condition; correlation with quality of life was also assessed. Results: Mean WTP for 25-percent improvement (WTP25) of the skin condition was $38.95; for a 50-percent improvement (WTP50), $83.18. Participants were willing to give up 1.4 hours per day to receive a therapy that would completely cure their condition. The average proportion of monthly income that participants were willing to spend on a therapy that could cure their condition was 13.3 percent. Daily concealment time was, on average, 20.8 minutes, which correlated with a worsened quality of life. Conclusion: Disease burden was high, overall, for benign hyperpigmentation conditions. Health utilities offer a patient-centered method of assessing impact on quality of life.

Effect of stimuli on sun protective habits: A randomized double-blind controlled study

BACKGROUND

Visual imagery has been shown to improve adherence to health messages but has scarcely been investigated in sun protection campaigns.

OBJECTIVE

To determine the effectiveness of pictorial- and textual-based sun protective messages in a largely Hispanic population.

METHODS

One hundred and forty-five participants received standard of care (SOC) as defined as sun protective counseling and were then randomized to receive either (a) images of sun damage, (b) a textual pamphlet about sun damage, or (c) no further messages. Analysis-of-variance tests for repeated measures were used to estimate the effects of the different stimuli on participants' knowledge and intention to sun protect.

RESULTS

All stimulus groups demonstrated an improvement in perceived effectiveness of sun protective habits (p < 0.05). However, pictorial and textual stimuli were both more effective than SOC in improving intentions to sun protect (p < 0.05), but there was no differential effect between the two.

CONCLUSIONS

Both pictorial and textual stimuli were more effective than SOC in improving intentions to sun protect, but there was no differential effect between the two.

Appearance-based vs health-based sun protective messages: A randomized, double-blind controlled study

BACKGROUND

Appearance-based messages have shown promise in improving sun protection habits among Caucasians but have scarcely been investigated in Hispanic populations.

OBJECTIVE

To compare the effectiveness of appearance-based vs health-based messages in an ethnic patient population, where hyperpigmentation disorders are prevalent and often cosmetically concerning.

METHODS

One hundred thirty-seven patients were randomized to receive images of (a) skin cancer, (b) hyperpigmentation, or (c) wrinkles. Analysis of variance tests for repeated measures were used to estimate the effects of the different stimuli on participants' knowledge and intention to sun protect.

RESULTS

Appearance-based interventions were more effective in improving intentions to sun protect among both Hispanics and non-Hispanic Whites (P < 0.05). They were furthermore more effective among younger patient populations (≤40 years old) and patients who thought that a tanned appearance is attractive (P < 0.05).

CONCLUSIONS

Appearance-based photos of sun damage were more effective than health-based messages among Hispanics, younger patient populations, and those who find tanned appearances to be attractive.

Patterns of Over-the-counter Lightening Agent Use among Patients with Hyperpigmentation Disorders: A United States-based Cohort Study

Background: Over-the-counter (OTC) lightening agents are commonly used to treat hyperpigmentation disorders. Objective: We sought to determine the characteristics, trends, and preferences of patients with hyperpigmentation disorders seeking OTC agents in the United States. Design: The study was a cross-sectional study of consecutive patients with a disorder of hyperpigmentation seen in a United States-based outpatient dermatology clinic. Multivariable logistic regression models were used to identify factors associated with the use of OTC lightening agents. Setting: The study setting was an outpatient US-based dermatology clinic in Boston, Massachusetts. Results: Of the 406 patients studied, the majority were women (88.9%) with Fitzpatrick Skin Types IV to VI (64.5%). The most frequent diagnoses were melasma (42.9%) and post-inflammatory hyperpigmentation (PIH, 33.9%). Of our responders, 51.0 percent reported use of OTC agents and 44.9 percent reported use of prescription lightening products. Hydroquinone was the most commonly used cream (59.1%), followed by triple combination cream (fluocinolone acetonide, hydroquinone, and tretinoin, 16.3%). Of the cohort, 28.9 percent felt that the greater expense of the product correlated with greater efficacy. After multivariable adjustment, factors associated with a greater odds of using an OTC lightening agent included having a diagnosis of melasma (odds ratio [OR] 5.36; 95% CI: 2.98, 9.63; P<0.01) or PIH (OR 2.38; 95% CI: 1.25, 4.53; P≤0.01). Conclusion: The use of OTC lightening agents is widespread among those patients with hyperpigmentation disorders who reside in the United States. Those with melasma and PIH were more likely to use an OTC lightening cream. The majority of patients believed that OTC creams were safe to use without physician supervision. In those who had also tried prescription products, triple combination was deemed most effective compared to other lightening agents.