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JMIR Dermatology
Technologies, devices, apps, and informatics applications for patient education in dermatology, including preventative interventions, and clinical care for people with dermatological conditions
An 88-year old female presented with axillary lesions on both sides that have developed over a year. She has been asymptomatic, but it was causing cosmetic concerns. There was no significant medical history and she was not taking any medications. Physical exam showed 1-6mm firm yellow dermal papules scattered over the axillae. Initial differential diagnoses included Fox-Fordyce disease and sebaceous cysts. First skin biopsy showed perivascular lymphocytes, extravasated red cells, and skin atrophy thought to be within the normal range expected of an elderly patient. There was some loss of elastic fibres within papillary dermis on Verhoeff-Van Gieson stain, but no clear diagnosis could be made. A second skin biopsy was performed which showed diminution of collagen fibres in reticular dermis and areas in papillary dermis lacking elastic fibres. Differential diagnoses were revised to include pseudoxanthoma-like papillary dermal elastolysis, but histopathology results were not definitive for the diagnosis. The diagnosis of pseudoxanthoma-like papillary dermal elastolysis was made based on the morphology and location of the lesions, epidemiological factors, and histopathological findings. No treatment was initiated, but the patient was content with knowing the diagnosis and agreed to vigilant monitoring of the lesions. This case discourages the sole reliance on histopathological evidence and reminds the importance of gathering clinical evidence to support the diagnosis of pseudoxanthoma-like papillary dermal elastolysis.
Journal Description
JMIR Dermatology (JDerm) is a new sister journal of JMIR (the leading open-access journal in health informatics), focusing on technologies, medical devices, apps, engineering, informatics applications for patient education in dermatology, including preventative interventions (e.g. skin cancer prevention) and clinical care for people with dermatological conditions.
As an open access journal, we are read by clinicians and patients alike and have (as with all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).
During a limited period of time, there are no fees to publish in this journal. Articles are carefully copyedited and XML-tagged, ready for submission in PubMed Central.
Background: Clinical practice guidelines are evidence-based recommendations used by physicians to improve patient care. These guidelines provide the physician with an assessment of the benefits and harms of a treatment and its alternatives. Therefore, it is essential that the clinical practice guidelines be based on the strongest available evidence. Numerous studies in a variety of different fields of medicine have demonstrated that recommendations supported by weak evidence are a common theme in clinical practice guidelines. A clinical guideline based solely on weak evidence has the capability to reduce the quality of care provided by physicians.
Objective: Our primary objective is to evaluate the levels of evidence supporting the recommendations constituting the American Academy of Dermatology clinical practice guidelines.
Methods: Using a cross-sectional study design, authors SM and RO located all current clinical practice guidelines on the American Academy of Dermatology website on June 10, 2017, and December 11, 2019. Each recommendation and its corresponding evidence rating were extracted in a duplicate and blinded fashion. A consensus meeting was planned a priori to resolve disagreements in extractions or stratifications.
Results: In total, 6 clinical guidelines and their subsections were screened and 899 recommendations were identified. Our final data set included 841 recommendations, as 58 recommendations contained no level of evidence and were excluded from calculations. Many recommendations were supported by a moderate level of evidence and therefore received a B rating (346/841, 41.1%). Roughly one-third of the recommendations were supported by a strong level of evidence and were given an A rating (n=307, 36.5%). The clinical practice guideline with the highest overall strength of evidence was regarding the treatment of acne, which had 17 of 35 (48.6%) recommendations supported by strong evidence and only 2 (5.7%) supported by weak evidence. The clinical practice guideline with the fewest recommendations supported by strong evidence was melanoma (13/63, 20.6%).
Conclusions: Clinical practice guidelines that lack strong supporting evidence could negatively affect patient care, and dermatologists should be mindful that not all recommendations are supported by the strongest level of evidence. An increased quantity of quality research needs to be performed in the field of dermatology to improve the evidence supporting the American Academy of Dermatology clinical practice guidelines.
Background: There is a lack of psychological support for individuals with skin conditions, and few low-intensity self-help interventions are available.
Objective: This study aimed to test the acceptability and usability of a support website and its embedded self-help resources.
Methods: A mixed methods approach was utilized. A total of 583 participants (426 with a skin condition, 97 relatives and friends, and 60 dermatology professionals) viewed the British Association of Dermatologist’s SkinSupport website and then completed a survey about their well-being and the usability of the website. A comparison group comprising 816 participants also completed the well-being measures. In total, 37 participants (19 living with a skin condition, and the relatives and friends of individuals with a skin condition, and 18 dermatology professionals) viewed the SkinSupport website and then took part in focus groups. Participants were recruited via social media, professional networks, and volunteer lists. Data from the survey were analyzed using descriptive and inferential statistics and qualitative content analysis.
Results: Both quantitative and qualitative responses suggest that the SkinSupport website was viewed positively by both patients and health professionals. Overall, 79.8% (417/523) of individuals with a skin condition, and the relatives and friends of individuals with a skin condition, said that they would use the website again; and 86.7% (52/60) of dermatology professionals said that they would recommend the site to somebody with a skin condition. Qualitative responses related to the website fell into 4 key themes: (1) appearance, (2) use and navigation, (3) information, and (4) areas for development.
Conclusions: The SkinSupport website was considered acceptable and usable. A range of areas requiring modification were identified. The website provides a useful resource that patients can access freely. Given the lack of services available to patients with skin conditions, health care professionals could routinely inform patients of this resource at assessment.
Background: Striae distensae, or stretch marks, are a common and distressing condition affecting females two-and-a-half times more frequently than males. Despite the numerous products available for stretch mark prevention and treatment, there have been few studies that consider consumer product preference.
Objective: The aim of this study was to determine which products were preferred by consumers for the prevention and treatment of stretch marks based on product vehicle and product ingredients.
Methods: In January 2020, a search was conducted on internet retailer Amazon for products related to stretch marks. The top products were identified as those with 100 reviews or greater and a rating of 4 or higher. The products were classified as either stretch mark–specific or non stretch mark–specific. Price, rating, type of vehicle, and specific ingredients of both product groups were compared. Vehicle-type and ingredients in both product groups were compared with two-tailed two-sample proportion tests to determine if certain vehicles or ingredients were more likely to be found in stretch mark–specific products. P<.05 indicated statistical significance.
Results: Out of over 10,000 products, 184 were selected as the top products according to the review and rating criteria of which 117 (63.6%) were stretch mark–specific and 67 (36.4%) were non stretch mark–specific. Oil was the most common vehicle (131/184, 71.2%) while vitamin E was the most common ingredient (58/184, 31.5%). Oil, as a vehicle, was more likely to be found in stretch mark–specific products than in non stretch mark–specific products (P=.001). Olive oil (P=.02) and cocoa butter (P=.08), Centella asiatica (P=.01), and shea butter (P=.003) were the ingredients more likely to be found in stretch mark–specific products than in non stretch mark–specific products.
Conclusions: This study demonstrated that there are many products available for the prevention and treatment of stretch marks and identified specific ingredients in the products preferred by customers. There are few studies investigating the effectiveness of the major ingredients in the stretch mark products that are preferred by consumers. Future studies can focus on the effectiveness of the ingredients found in the products that are preferred by consumers.
Background: Sunscreen use is a popular sun protection method; however, application of sunscreen rarely meets the standards recommended for effectiveness. Access to information about how to effectively use sunscreen may play a role in proper sunscreen application. The internet is a common health information source; however, the quality of sunscreen-related content varies.
Objective: The objective of this study was to examine information about sunscreen in YouTube videos by video source.
Methods: In November 2017, the authors identified the 20 most popular YouTube videos (sorted by view count and relevance) for each of these 5 search terms: sunscreen cancer, sunscreen health, sunscreen information, sunscreen ingredients, and sunscreen natural. The inclusion criteria were English language and view count >1000 (N=111 unique videos). We double-coded videos for standard recommendations for sunscreen use (eg, apply 20 minutes before sun exposure), use of outdated terminology, and recommendation of complementary sun safety strategies.
Results: The view counts ranged from 1100 to 671,142 (median 17,774, SD 109,651) and the average daily views ranged from 1 to 1448 (median 23, SD 234). End users (46/111, 41.4%) and health care providers (24/111, 21.6%) were the most common sources, and none of the most popular videos were produced by federal agencies or cancer-related nongovernmental organizations. Health care provider videos included marginally more recommendations than end user videos (mean 1.46, SD 1.96 vs mean 1.05, SD 1.20), but few (19/111, 17.1%) mentioned reapplication. The videos were generally positive toward sunscreen (82/111, 73.9%); however, some videos were negative (29/111, 26.1%), with warnings about the health risks of chemical sunscreens and their ingredients. Do-it-yourself sunscreen tutorials represented 19/111 (17.1%) of the sample.
Conclusions: YouTube is a potential source for disseminating sun safety messages; however, the quality of its sunscreen content varies. Most of the videos in our study failed to include important sunscreen use recommendations. Clinicians should be prepared to address the information needs of patients by discussing effective, evidence-based sunscreen application and recommending a combined sun safety approach.
Background: Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses are considered significant indicators of the quality of care and patient satisfaction. There is a pressing need to improve patient satisfaction rates as CAHPS survey responses are considered when determining the amount a facility will be reimbursed by the Centers of Medicare and Medicaid each year. Low overall CAHPS scores for an academic medical center’s dermatology clinics were anecdotally attributed to clinic type. However, it was unclear whether clinic type was contributing to the low scores or whether there were other factors.
Objective: This study aimed to determine where the efforts of patient satisfaction improvement should be focused for two different types of dermatology clinics (private and rapid access clinics).
Methods: This study used a concurrent mixed methods design. Secondary data derived from the University of Alabama at Birmingham Hospital’s Press Ganey website were analyzed for clinic type comparisons and unstructured data were qualitatively analyzed to further enrich the quantitative findings. The University of Alabama at Birmingham Hospital is an academic medical center. The data were analyzed to determine the contributors responsible for each clinic not meeting national benchmarks. Thereafter, a review of these contributing factors was further performed to assess the difference in CAHPS scores between the private and rapid access clinics to determine if clinic type was a contributing factor to the overall scores.
Results: The data sample included 821 responses from May 2017 to May 2018. Overall, when both private clinics and rapid access clinics were viewed collectively, majority of the patients reported stewardship of patient resources as the most poorly rated factor (367/549, 66.8%) and physician communication quality as the most positively rated factor (581/638, 91.0%). However, when private clinics and rapid access clinics were viewed individually, rapid access clinics contributed slightly to the overall lower dermatology scores at the academic medical center.
Conclusions: This study determined that different factors were responsible for lower CAHPS scores for the two different dermatology clinics. Some of the contributing factors were associated with the mission of the clinic. It was suspected that the mission had not been properly communicated to patients, leading to misaligned expectations of care at each clinic.
Background: Skin cancer is the most common cancer and is often ignored by people at an early stage. There are 5.4 million new cases of skin cancer worldwide every year. Deaths due to skin cancer could be prevented by early detection of the mole.
Objective: We propose a skin lesion classification system that has the ability to detect such moles at an early stage and is able to easily differentiate between a cancerous and noncancerous mole. Using this system, we would be able to save time and resources for both patients and practitioners.
Methods: We created a deep convolutional neural network using an Inceptionv3 and DenseNet-201 pretrained model.
Results: We found that using the concepts of fine-tuning and the ensemble learning model yielded superior results. Furthermore, fine-tuning the whole model helped models converge faster compared to fine-tuning only the top layers, giving better accuracy overall.
Conclusions: Based on our research, we conclude that deep learning algorithms are highly suitable for classifying skin cancer images.
Background: In the United States, melanoma is the fifth most common type of cancer. Reducing UV radiation (UVR) exposure is essential for the prevention of melanoma. The assessment of individual-level UVR exposure using wearable technology is a promising method to monitor and reduce UVR exposure. However, the feasibility and acceptability of using wearable UVR monitoring devices have not been assessed.
Objective: This study aimed to assess the feasibility and acceptability of using a commercially available UVR monitoring wearable device in adults and children.
Methods: We recruited families (1 parent and 1 child) to test a new, commercially available UVR monitoring device (namely, Shade). Participants wore Shade for 2 weeks and completed questionnaires assessing the feasibility and acceptability of wearing the device. Qualitative analyses were conducted to summarize participants’ open-ended responses regarding device feasibility.
Results: A total of 194 individuals (97 adults and 97 children) participated in this study. The participating children were aged, on average, 12.7 years. Overall, adults and children reported moderate satisfaction with wearing Shade. The feasibility of the use of Shade was adequate, with 73% (65/89) of adults and 61% (54/89) of children reporting that they wore the device “all of the time they were outside.” Through open-ended responses, participants reported that the device was easy to use, was compact, and increased their awareness about their exposure to UVR.
Conclusions: Adults and children can feasibly use a wearable UVR monitoring device, and the use of the device was acceptable to participants. The device could be integrated into melanoma preventive interventions to increase individuals’ and families’ awareness of UVR exposure and to facilitate the use of recommended melanoma preventive strategies.
Diagnosis and follow-up of patients in dermatology rely on visual cues. Documentation of skin lesions in dermatology is time-consuming and inaccurate. Digital photography is resource-intensive, difficult to standardize, and has privacy concerns. We propose a simple method—LesionMap—and an electronic health software tool—LesionMapper—for semantically annotating dermatological lesions on a body wireframe. We discuss how the type, distribution, and progression of lesions can be represented in a standardized way. The tool is an open-source JavaScript package that can be integrated into web-based electronic medical records. We believe that LesionMapper will facilitate documentation in dermatology that can be used for machine learning in a privacy-preserving manner.
Background: Social media has emerged as a common source of dermatological information. Monitoring the patterns of social media use and engagement is important to counteract the limitations of social media. However, evidence in Vietnamese dermatology patients is lacking.
Objective: This study aimed to explore social media use and engagement by dermatology patients and to identify factors associated with social media use and engagement.
Methods: A cross-sectional study was conducted with 519 participants at the Vietnam National Hospital of Dermatology and Venereology during September to November 2018. Data about sociodemographic characteristics, social media use, and social media engagement were collected. Multivariate logistic and tobit regression models were used to identify factors associated with social media use and engagement.
Results: Interest in information about “cosmetic, beauty, and skincare techniques” was the greatest (184/519, 46.2%). The mean engagement score was 8.4 points (SD 2.4 points). Female patients were more likely to use social media (odds ratio [OR] 2.23, 95% CI 1.23-4.06) and be interested dermatological information on social media (OR 3.09, 95% CI 1.35-7.09). Women also had higher social media engagement scores (coefficient=0.68, 95% CI 0.17-1.18). Higher social media engagement scores were related with Instagram use (coefficient=0.58, 95% CI 0.00-1.15) and higher credibility scores for “family members” (coefficient=0.15, 95% CI 0.03-0.26) and “dermatology companies” (coefficient=0.22, 95% CI 0.04-0.39).
Conclusions: This study discovered high social media usage among dermatology patients. However, only moderate utilization and credibility levels were reported regarding the use of social media as a source of dermatological information. More efforts should focus on involving dermatologists in the development of individualized information on social media targeting specific groups of dermatology patients.
Background: Spin is the misrepresentation of study findings, which may positively or negatively influence the reader’s interpretation of the results. Little is known regarding the prevalence of spin in abstracts of systematic reviews, specifically systematic reviews pertaining to the management and treatment of acne vulgaris.
Objective: The primary objective of this study was to characterize and determine the frequency of the most severe forms of spin in systematic review abstracts and to evaluate whether various study characteristics were associated with spin.
Methods: Using a cross-sectional study design, we searched PubMed and EMBASE for systematic reviews focusing on the management and treatment of acne vulgaris. Our search returned 316 studies, of which 36 were included in our final sample. To be included, each systematic review must have addressed either pharmacologic or nonpharmacologic treatment of acne vulgaris. These studies were screened, and data were extracted in duplicate by two blinded investigators. We analyzed systematic review abstracts for the nine most severe types of spin.
Results: Spin was present in 31% (11/36) of abstracts. A total of 12 examples of spin were identified in the 11 abstracts containing spin, with one abstract containing two instances of spin. The most common type of spin, selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention, was identified five times (5/12, 42%). A total of 44% (16/36) of studies did not report a risk of bias assessment. Of the 11 abstracts containing spin, six abstracts (55%) had not reported a risk of bias assessment or performed a risk of bias assessment but did not discuss it. Spin in abstracts was not significantly associated with a specific intervention type, funding source, or journal impact factor.
Conclusions: Spin is present in the abstracts of systematic reviews and meta-analyses covering the treatment of acne vulgaris. This paper raises awareness of spin in abstracts and emphasizes the importance of its recognition, which may lead to fewer incidences of spin in future studies.
Background: Infection with the herpes simplex virus (HSV) is common but not well understood. Furthermore, there remains a social stigma surrounding HSV that can have psychosocial implications for those infected. Despite many patients infected with HSV experiencing mild-to-severe physical symptoms, only one subeffective treatment is available. A registry collecting real-world data reported by individuals potentially infected with HSV could help patients to better understand and manage their condition.
Objective: This study aimed to report on the development of a registry to collect real-world data reported by people who might be infected with HSV.
Methods: A case study design was selected as it provides a systematic and in-depth approach to investigating the planning phase of the registry. The case study followed seven stages: plan, design, prepare, collect, analyze, create, and share. We carried out semistructured interviews with experts, which were thematically analyzed and used to build use cases for the proposed registry. These use cases will be used to generate detailed models of how a real-world evidence registry might be perceived and used by different users.
Results: The following key themes were identified in the interviews: (1) stigma and anonymity, (2) selection bias, (3) understanding treatment and outcome gaps, (4) lifestyle factors, (5) individualized versus population-level data, and (6) severe complications of HSV. We developed use cases for different types of users of the registry, including individuals with HSV, members of the public, researchers, and clinicians.
Conclusions: This case study revealed key considerations and insights for the development of an appropriate registry to collect real-world data reported by people who might be infected with HSV. Further development and testing of the registry with different users is required. The registry must also be evaluated for the feasibility and effectiveness of collecting data to support symptom management. This registry has the potential to contribute to the development of vaccines and treatments and provide insights into the impact of HSV on other conditions.
Background: Information-seeking Psoriasis or Psoriatic Arthritis patients are confronted with numerous educational materials when looking through the internet. Literature suggests that only 17.0%-21.4% of (Psoriasis, Psoriatic Arthritis) patients have a good level of knowledge about psoriasis treatment and self-management. A study from 1994 found that English Psoriasis/Psoriatic Arthritis brochures required a reading level between grades 8-12 to be understandable, which was confirmed in a follow-up study 20 years later. As readability of written health-related text material should not exceed the sixth-grade level, Psoriasis/Psoriatic Arthritis material seems to be ill-suited to its target audience. However, no data is available on the readability levels of Psoriasis/Psoriatic Arthritis brochures for German-speaking patients, and both the volume and their scope are unclear.
Objective: This study aimed to analyze freely available educational materials for Psoriasis/Psoriatic Arthritis patients written in German, quantifying their difficulty by assessing both the readability and the vocabulary used in the collected brochures.
Methods: Data collection was conducted manually via an internet search engine for Psoriasis/Psoriatic Arthritis–specific material, published as PDF documents. Next, raw text was extracted, and a computer-based readability and vocabulary analysis was performed on each brochure. For the readability analysis, we applied the Flesch Reading Ease (FRE) metric adapted for the German language, and the fourth Vienna formula (WSTF). To assess the laymen-friendliness of the vocabulary, the computation of an expert level was conducted using a specifically trained Support Vector Machine classifier. A two-sided, two-sample Wilcoxon test was applied to test whether the difficulty of brochures of pair-wise topic groups was different from each other.
Results: In total, 68 brochures were included for readability assessment, of which 71% (48/68) were published by pharmaceutical companies, 22% (15/68) by nonprofit organizations, and 7% (5/68) by public institutions. The collection was separated into four topic groups: basic information on Psoriasis/Psoriatic Arthritis (G1/G2), lifestyle, and behavior with Psoriasis/Psoriatic Arthritis (G3/G4), medication and therapy guidance (G5), and other topics (G6). On average, readability levels were comparatively low, with FRE=31.58 and WSTF=11.84. However, two-thirds of the educational materials (69%; 47/68) achieved a vocabulary score ≤4 (ie, easy, very easy) and were, therefore, suitable for a lay audience. Statistically significant differences between brochure groups G1 and G3 for FRE (P=.0001), WSTF (P=.003), and vocabulary measure (L) (P=.01) exist, as do statistically significant differences for G2 and G4 in terms of FRE (P=.03), WSTF (P=.03) and L (P=.03).
Conclusions: Online Psoriasis/Psoriatic Arthritis patient education materials in German require, on average, a college or university education level. As a result, patients face barriers to understanding the available material, even though the vocabulary used seems appropriate. For this reason, publishers of Psoriasis/Psoriatic Arthritis brochures should carefully revise their educational materials to provide easier and more comprehensible information for patients with lower health literacy levels.
An 88-year old female presented with axillary lesions on both sides that have developed over a year. She has been asymptomatic, but it was causing cosmetic concerns. There was no significant medical h...
An 88-year old female presented with axillary lesions on both sides that have developed over a year. She has been asymptomatic, but it was causing cosmetic concerns. There was no significant medical history and she was not taking any medications. Physical exam showed 1-6mm firm yellow dermal papules scattered over the axillae. Initial differential diagnoses included Fox-Fordyce disease and sebaceous cysts. First skin biopsy showed perivascular lymphocytes, extravasated red cells, and skin atrophy thought to be within the normal range expected of an elderly patient. There was some loss of elastic fibres within papillary dermis on Verhoeff-Van Gieson stain, but no clear diagnosis could be made. A second skin biopsy was performed which showed diminution of collagen fibres in reticular dermis and areas in papillary dermis lacking elastic fibres. Differential diagnoses were revised to include pseudoxanthoma-like papillary dermal elastolysis, but histopathology results were not definitive for the diagnosis. The diagnosis of pseudoxanthoma-like papillary dermal elastolysis was made based on the morphology and location of the lesions, epidemiological factors, and histopathological findings. No treatment was initiated, but the patient was content with knowing the diagnosis and agreed to vigilant monitoring of the lesions. This case discourages the sole reliance on histopathological evidence and reminds the importance of gathering clinical evidence to support the diagnosis of pseudoxanthoma-like papillary dermal elastolysis.
