Concern for Melanoma
She came for a skin check but left with peace of mind.
A teen female came to clinic for a routine skin check. When asked about a family history of skin cancer, she said “no” to both the staff and the dermatologist.
A full-body skin check was unremarkable. All of her moles were normal on exam. However, when looking at her PRO scores, her emotional Skindex score was the highest seen all day (higher scores are worse).
PRO – Dermatology Scores
Skindex-16 Emotions 48
Skindex-16 Symptoms 0
Skindex-16 Functioning 6
Based on the high emotional score, the dermatologist asked, “what’s bothering you about your skin?” Only then did the patient admit that her grandfather had recently died of metastatic melanoma, and the patient was convinced that the 3 benign moles on her abdomen were all melanoma.
The dermatologist was able to reassure the patient and provide education on what to look for when monitoring her moles. The patient left much happier than she would have had the dermatologist not seen her worry reflected in her PRO scores.
Horrible Hailey-Hailey
It all begins with an idea.
An older male came in for a consultation with a new dermatologist. Over the past 5 years, he had suffered with an extremely painful and extremely rare blistering rash called Hailey-Hailey disease that was worst in his armpits and on his belly. He had seen several dermatologists already, had skin biopsies done, and had tried many different medications without much success at all. He came in frustrated that none of the prior treatments had worked.
First Visit – PRO – Dermatology Scores
Skindex-16 Emotions 40
Skindex-16 Symptoms 62
Skindex-16 Functioning 44
The dermatologist spent a lot of time reassuring the patient that, though this rash was rare, there were treatment options he hadn’t tried as well as a blistering rash clinic that specializes in rashes like his rash. The dermatologist had him try a couple of new medications and follow-up in one month.
One month later – PRO – Dermatology Scores
Skindex-16 Emotions 78
Skindex-16 Symptoms 91
Skindex-16 Functioning 60
Given that the patient’s rash appeared about the same, or a bit better, than the month prior, the dermatologist was confused why his PRO scores were much worse. The patient explained that he didn’t have much hope at his first visit, because he had tried and failed so many treatments and dermatologists already. Because he was given hope at his first visit, he explained that he wanted to be fully honest with his baseline scores in how much this rash really affected him. He was ready to work together to get his skin (and those PRO scores) better.
How Well Does Accutane Work?
She came for a skin check but left with peace of mind.
Isotretinoin (the medication commonly known as Accutane) has been around since the 1970s. Research and millions of patients have confirmed that it is the most effective treatment for acne, especially scarring acne. But, until recently, no research has shown how quickly it works from the patient’s perspective. We used Skindex-16 scores (PRO scores) at monthly visits in nearly 60 patients to answer a few key questions about Accutane.
First, we learned that patients see about 50% improvement by month 2. This is important, because patients starting Accutane really want to know how quickly they will see improvement, and now we can answer that question.
Next, everyone sees improvement in their acne on Accutane. On average, by the end of a course of Accutane (usually 5-6 months), patients see about 80% improvement in how acne affects their quality of life.
Finally, acne is primarily a skin issue that affects us emotionally or socially. It usually doesn’t hurt or itch, we just really don’t like how it looks. We saw this with our PRO scores. The emotional Skindex-16 scores were the highest at the start of an Accutane course, and they saw the greatest improvement. The most likely reason why patients on Accutane don’t have their Skindex-16 drop to zero is because scarring is often still visible on the skin even after the acne has cleared, and this scarring, called post-inflammatory hyperpigmentation, can take months to fully clear. Also, Accutane causes a lot of dryness to the skin, especially the lips, causing them to crack and peel. Near the end of a course of Accutane, the acne is usually gone, but the dryness from the Accutane still exists, meaning that the patients’ skin is still bothering them a bit.
My Psoriasis is Fine
It all begins with an idea.
An adult female with severe psoriasis came to clinic for follow-up while taking ustekinumab, a biologic medication. Her dermatologist has all psoriasis patients change into a gown after being roomed to help the dermatologist assess how much the psoriasis is improving on treatment.
When the dermatologist entered the room, the patient was still in her active wear and told the doctor that her psoriasis is “doing fine” on ustekinumab. The dermatologist figured the psoriasis was much better, which explained why they patient hadn’t changed into a gown. However, her PRO scores were as follows:
PRO – Dermatology Scores
Skindex-16 Emotions 52
Skindex-16 Symptoms 78
Skindex-16 Functioning 16
Based on these surprisingly high scores, the dermatologist asked about how her psoriasis was really doing, and the patient started to cry. She explained that the dermatologist had been so positive about how well this medication worked that she didn’t want to disappoint the doctor. She didn’t think any medication would work for her, so she planned to just stay on the ustekinumab.
Ustekinumab currently costs about $25,000 per injection, so the dermatologist switched the patient to a newer, and likely, more effective biologic.
Your Scores are Telling Me What Your Lips are Not
It all begins with an idea.
A young adult female came to clinic with a 5-year history of facial acne with scarring on her face, upper back and upper chest. She could not tolerate birth control pills and did not want to start Accutane. Her PRO scores at her first visit were:
First Visit – PRO – Dermatology Scores
Skindex-16 Emotions 88
Skindex-16 Symptoms 63
Skindex-16 Functioning 50
After discussing treatment options, she wanted to start oral antibiotics for her acne. Two months later, she returned for a follow-up visit. Her new PRO scores were:
Second Visit – PRO – Dermatology Scores
Skindex-16 Emotions 36
Skindex-16 Symptoms 21
Skindex-16 Functioning 10
The patient reports that her acne is much better and that she is much happier with it. Her improvement in PRO scores match what she is telling the dermatologist. The plan is to keep her on the same treatment for a couple more months to see what additional improvement can be achieved.
Third Visit – PRO – Dermatology Scores
Skindex-16 Emotions 40
Skindex-16 Symptoms 29
Skindex-16 Functioning 13
At her third visit, the dermatologist wanted to wean her off the oral antibiotics. The patient told the dermatologist that her acne had gotten much better from her second visit. However, the dermatologist saw that her PRO scores had not improved at all. When asked about her scores, the patient admitted that she hadn’t seen more improvement since last visit, but she was happy with where her acne was and didn’t want to wean off the medication.
Because the dermatologist had all the relevant information, the patient was continued on the oral antibiotics and a discussion was started about transitioning to another long-term oral acne treatment option.
Three new bumps
It all begins with an idea.
An older male came in for a skin check. His mother died years ago of a melanoma on her leg. He tells the dermatologist that he is here for 3 new raised bumps on his left arm and both legs.
PRO – Dermatology Scores
Skindex-16 Emotions 10
Skindex-16 Symptoms 0
Skindex-16 Functioning 0
The dermatologist can quickly tell from these low scores that these 3 new spots don’t really bother the patient - he doesn’t seem to think they are melanoma or his emotional score would be much higher (see HERE for the opposite example) - he just wants reassurance that these spots are all fine. All 3 spots are age spots (seborrheic keratoses).
Acne Doesn’t Fix Itself
It all begins with an idea.
A teenage boy came in with his mother for mild acne on his face. His mother is very, very concerned about his acne, but he is not, as seen with his PRO scores:
PRO – Dermatology Scores
Skindex-16 Emotions 3
Skindex-16 Symptoms 0
Skindex-16 Functioning 0
The dermatologist explains to the patient’s mom that topical acne regimens are sometimes complicated, time-consuming, and expensive. Based on his PRO scores, the patient is not bothered by his acne at this point in his life and it doesn’t appear to be scarring, so he should just use over-the-counter medicated washes and come back when the acne bothers him. Mom was highly disappointed by this recommendation.
A year and a half later, the patient and his mother returned for his acne. Here are his new PRO scores:
PRO – Dermatology Scores
Skindex-16 Emotions 56
Skindex-16 Symptoms 10
Skindex-16 Functioning 7
The patient is now much more bothered by his acne, and he’s ready to start a more complicated, prescription regimen.
Dermatologists Should Screen for Depression
She came for a skin check but left with peace of mind.
Depression is common in modern society. It is real and treatable. If left untreated, it affects more than just one’s mental health. Depression affects our relationships with others, our ability to learn and work, and - physicians needs to understand this - depression affects their patients’ ability to stick with treatment plans.
Research has found that about 30% of all dermatology patients also suffers from a mental health disorder. Other researchers have shown how important screening for depression is for acne, eczema, and psoriasis patients. This is not surprising, as so much of how we feel about ourselves is tied to how we look or or how others see us, especially in teens and young adults.
We recently advocated for dermatologists to screen for depression using PROs in their clinics. Patients who have a PRO score concerning for depression can then be referred to a primary care physician or mental health expert to discuss treatment options, including counseling and medication. This not only helps the patients get the mental health help they need, but also helps them stick with a treatment plan that will help get their skin better as well.