Article

THE DIAGNOSIS: Rhabdomyomatous Mesenchymal Hamartoma

Histopathologic examination of the excised tissue revealed haphazardly arranged bundles of mature striated muscle within the dermis and subcutaneous tissue admixed with adipose tissue, adnexal structures, blood vessels, and nerves. The presence of the lesion since birth, midline clinical presentation, and histologic findings were consistent with a diagnosis of rhabdomyomatous mesenchymal hamartoma (RMH).

Also referred to as striated muscle hamartoma, RMH is a rare benign lesion thought to have embryonic origin due to its midline presentation.¹ The etiology of RMH is unknown but is hypothesized to be due to abnormal migration or growth of embryonic mesenchymal tissue. Rhabdomyomatous mesenchymal hamartoma typically manifests in infancy or early childhood as a solitary midline papule on the head or neck, although there have been rare reports of development in adulthood.^2-4 Lesions often are polypoid or exophytic but may manifest as smooth papules or subcutaneous nodules.² Although benign, RMH may be associated with other congenital abnormalities and conditions, such as Delleman syndrome, which is caused by a sporadic genetic abnormality and results in defects of the eye, central nervous system, and skin.⁵ Treatment for RMH is not needed, but surgical excision for cosmetic purposes can be performed with low risk for recurrence. Histologically, RMH demonstrates a normal epidermis overlying disorganized bundles of skeletal muscle accompanied by varying amounts of other mature dermal and subcutaneous tissues including nerves, blood vessels, adipose tissue, and other adnexal structures.^2,6 Myoglobin and desmin are positive within the skeletal muscle bundles.⁷

Fibrous hamartoma of infancy (FHI) often manifests as a movable, ill-defined nodule within the subcutaneous tissue. While also occurring in young children—typically within the first 2 years of life—FHI primarily is found on the upper arms, back, and axillae, in contrast to FHI.⁸ The classic histopathologic presentation of FHI consists of a triphasic morphology consisting of undifferentiated mesenchymal cells and dense fibroblastic/myofibroblastic tissue with mature adipose tissue woven throughout in islands (Figure 1).⁹ Skeletal muscle is not a component of this tumor.

Neurofibromas also may manifest clinically as papules or nodules and arise from the peripheral nerve sheath. There are 3 major subtypes of neurofibromas—localized, diffuse, and plexiform—with the last being strongly associated with neurofibromatosis type 1.¹⁰ The plexiform type has a rare risk for malignant transformation. The typical histopathologic finding of a localized cutaneous neurofibroma is a dermal proliferation of spindle cells with wavy nuclei within a variably myxoid stroma (Figure 2).¹¹ Interspersed mast cells also can be seen. A plexiform neurofibroma typically involves multiple nerve fascicles and comprises multinodular or tortuous bundles of cytologically bland spindle cells. Compared to RMH, skeletal muscle is not a component of this tumor.

Nevus lipomatosus superficialis is a benign hamartoma that can manifest as a pedunculated or exophytic papule. The lesions may be solitary or multiple and, unlike RMH, are most common on the buttocks, upper thighs, and trunk.¹² The histopathologic features of nevus lipomatosus superficialis include clusters of mature adipose tissue in the superficial dermis admixed with collagen fibers and variably increased vasculature (Figure 3).¹³ Nevus lipomatosus superficialis does not contain skeletal muscle within the tumor in comparison to RMH.

It is important to distinguish rhabdomyosarcoma (RMS) from RMH, as it is associated with increased mortality and morbidity. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children and is derived from mesenchyme with variable degrees of skeletal muscle differentiation.¹⁴ Due to its mesenchymal origin, these tumors can manifest in a variety of places but most commonly on the head and neck and in the genital region.¹⁵ The most common subtype is embryonal rhabdomyosarcoma. Histologically, embryonal RMS shows a moderately cellular tumor composed of sheets of spindle-shaped or round cells with scant or eosinophilic cytoplasm (Figure 4). The absence of genetic translocation in the paired box-forkhead box protein 01 (PAX-FOXO1) gene helps distinguish it from solid alveolar RMS, the second most common and more aggressive subtype.¹² Positive immunohistochemical staining for desmin, myoblast determination protein 1 (MyoD1), and myogenin supports myogenic differentiation.¹⁴

THE DIAGNOSIS: Rhabdomyomatous Mesenchymal Hamartoma

Histopathologic examination of the excised tissue revealed haphazardly arranged bundles of mature striated muscle within the dermis and subcutaneous tissue admixed with adipose tissue, adnexal structures, blood vessels, and nerves. The presence of the lesion since birth, midline clinical presentation, and histologic findings were consistent with a diagnosis of rhabdomyomatous mesenchymal hamartoma (RMH).

Also referred to as striated muscle hamartoma, RMH is a rare benign lesion thought to have embryonic origin due to its midline presentation.¹ The etiology of RMH is unknown but is hypothesized to be due to abnormal migration or growth of embryonic mesenchymal tissue. Rhabdomyomatous mesenchymal hamartoma typically manifests in infancy or early childhood as a solitary midline papule on the head or neck, although there have been rare reports of development in adulthood.^2-4 Lesions often are polypoid or exophytic but may manifest as smooth papules or subcutaneous nodules.² Although benign, RMH may be associated with other congenital abnormalities and conditions, such as Delleman syndrome, which is caused by a sporadic genetic abnormality and results in defects of the eye, central nervous system, and skin.⁵ Treatment for RMH is not needed, but surgical excision for cosmetic purposes can be performed with low risk for recurrence. Histologically, RMH demonstrates a normal epidermis overlying disorganized bundles of skeletal muscle accompanied by varying amounts of other mature dermal and subcutaneous tissues including nerves, blood vessels, adipose tissue, and other adnexal structures.^2,6 Myoglobin and desmin are positive within the skeletal muscle bundles.⁷

Fibrous hamartoma of infancy (FHI) often manifests as a movable, ill-defined nodule within the subcutaneous tissue. While also occurring in young children—typically within the first 2 years of life—FHI primarily is found on the upper arms, back, and axillae, in contrast to FHI.⁸ The classic histopathologic presentation of FHI consists of a triphasic morphology consisting of undifferentiated mesenchymal cells and dense fibroblastic/myofibroblastic tissue with mature adipose tissue woven throughout in islands (Figure 1).⁹ Skeletal muscle is not a component of this tumor.

Neurofibromas also may manifest clinically as papules or nodules and arise from the peripheral nerve sheath. There are 3 major subtypes of neurofibromas—localized, diffuse, and plexiform—with the last being strongly associated with neurofibromatosis type 1.¹⁰ The plexiform type has a rare risk for malignant transformation. The typical histopathologic finding of a localized cutaneous neurofibroma is a dermal proliferation of spindle cells with wavy nuclei within a variably myxoid stroma (Figure 2).¹¹ Interspersed mast cells also can be seen. A plexiform neurofibroma typically involves multiple nerve fascicles and comprises multinodular or tortuous bundles of cytologically bland spindle cells. Compared to RMH, skeletal muscle is not a component of this tumor.

Nevus lipomatosus superficialis is a benign hamartoma that can manifest as a pedunculated or exophytic papule. The lesions may be solitary or multiple and, unlike RMH, are most common on the buttocks, upper thighs, and trunk.¹² The histopathologic features of nevus lipomatosus superficialis include clusters of mature adipose tissue in the superficial dermis admixed with collagen fibers and variably increased vasculature (Figure 3).¹³ Nevus lipomatosus superficialis does not contain skeletal muscle within the tumor in comparison to RMH.

It is important to distinguish rhabdomyosarcoma (RMS) from RMH, as it is associated with increased mortality and morbidity. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children and is derived from mesenchyme with variable degrees of skeletal muscle differentiation.¹⁴ Due to its mesenchymal origin, these tumors can manifest in a variety of places but most commonly on the head and neck and in the genital region.¹⁵ The most common subtype is embryonal rhabdomyosarcoma. Histologically, embryonal RMS shows a moderately cellular tumor composed of sheets of spindle-shaped or round cells with scant or eosinophilic cytoplasm (Figure 4). The absence of genetic translocation in the paired box-forkhead box protein 01 (PAX-FOXO1) gene helps distinguish it from solid alveolar RMS, the second most common and more aggressive subtype.¹² Positive immunohistochemical staining for desmin, myoblast determination protein 1 (MyoD1), and myogenin supports myogenic differentiation.¹⁴

THE DIAGNOSIS: Rhabdomyomatous Mesenchymal Hamartoma

Histopathologic examination of the excised tissue revealed haphazardly arranged bundles of mature striated muscle within the dermis and subcutaneous tissue admixed with adipose tissue, adnexal structures, blood vessels, and nerves. The presence of the lesion since birth, midline clinical presentation, and histologic findings were consistent with a diagnosis of rhabdomyomatous mesenchymal hamartoma (RMH).

Also referred to as striated muscle hamartoma, RMH is a rare benign lesion thought to have embryonic origin due to its midline presentation.¹ The etiology of RMH is unknown but is hypothesized to be due to abnormal migration or growth of embryonic mesenchymal tissue. Rhabdomyomatous mesenchymal hamartoma typically manifests in infancy or early childhood as a solitary midline papule on the head or neck, although there have been rare reports of development in adulthood.^2-4 Lesions often are polypoid or exophytic but may manifest as smooth papules or subcutaneous nodules.² Although benign, RMH may be associated with other congenital abnormalities and conditions, such as Delleman syndrome, which is caused by a sporadic genetic abnormality and results in defects of the eye, central nervous system, and skin.⁵ Treatment for RMH is not needed, but surgical excision for cosmetic purposes can be performed with low risk for recurrence. Histologically, RMH demonstrates a normal epidermis overlying disorganized bundles of skeletal muscle accompanied by varying amounts of other mature dermal and subcutaneous tissues including nerves, blood vessels, adipose tissue, and other adnexal structures.^2,6 Myoglobin and desmin are positive within the skeletal muscle bundles.⁷

Fibrous hamartoma of infancy (FHI) often manifests as a movable, ill-defined nodule within the subcutaneous tissue. While also occurring in young children—typically within the first 2 years of life—FHI primarily is found on the upper arms, back, and axillae, in contrast to FHI.⁸ The classic histopathologic presentation of FHI consists of a triphasic morphology consisting of undifferentiated mesenchymal cells and dense fibroblastic/myofibroblastic tissue with mature adipose tissue woven throughout in islands (Figure 1).⁹ Skeletal muscle is not a component of this tumor.

Neurofibromas also may manifest clinically as papules or nodules and arise from the peripheral nerve sheath. There are 3 major subtypes of neurofibromas—localized, diffuse, and plexiform—with the last being strongly associated with neurofibromatosis type 1.¹⁰ The plexiform type has a rare risk for malignant transformation. The typical histopathologic finding of a localized cutaneous neurofibroma is a dermal proliferation of spindle cells with wavy nuclei within a variably myxoid stroma (Figure 2).¹¹ Interspersed mast cells also can be seen. A plexiform neurofibroma typically involves multiple nerve fascicles and comprises multinodular or tortuous bundles of cytologically bland spindle cells. Compared to RMH, skeletal muscle is not a component of this tumor.

Nevus lipomatosus superficialis is a benign hamartoma that can manifest as a pedunculated or exophytic papule. The lesions may be solitary or multiple and, unlike RMH, are most common on the buttocks, upper thighs, and trunk.¹² The histopathologic features of nevus lipomatosus superficialis include clusters of mature adipose tissue in the superficial dermis admixed with collagen fibers and variably increased vasculature (Figure 3).¹³ Nevus lipomatosus superficialis does not contain skeletal muscle within the tumor in comparison to RMH.

It is important to distinguish rhabdomyosarcoma (RMS) from RMH, as it is associated with increased mortality and morbidity. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children and is derived from mesenchyme with variable degrees of skeletal muscle differentiation.¹⁴ Due to its mesenchymal origin, these tumors can manifest in a variety of places but most commonly on the head and neck and in the genital region.¹⁵ The most common subtype is embryonal rhabdomyosarcoma. Histologically, embryonal RMS shows a moderately cellular tumor composed of sheets of spindle-shaped or round cells with scant or eosinophilic cytoplasm (Figure 4). The absence of genetic translocation in the paired box-forkhead box protein 01 (PAX-FOXO1) gene helps distinguish it from solid alveolar RMS, the second most common and more aggressive subtype.¹² Positive immunohistochemical staining for desmin, myoblast determination protein 1 (MyoD1), and myogenin supports myogenic differentiation.¹⁴

The treatment of metastatic solid tumors has been based historically on systemic therapies, with the goal of delaying progression and extend life as long as possible, with tolerable treatment-related adverse events. Some exceptions were made for local treatment with surgery or radiotherapy (RT), often for patients with a single metastasis. A 1939 report describes a patient with renal adenocarcinoma and a solitary lung metastasis who underwent RT to the lung lesion after nephrectomy and subsequently partial lobectomy after the metastatic lesion progressed. The authors argued that if a metastasis appears solitary and accessible, it is plausible to remove it in addition to the primary growth.¹

In 1995 Hellman and Weichselbaum proposed oligometastatic disease (OMD). They reasoned that malignancy exists along a spectrum from localized disease to widely disseminated disease, with OMD existing in between with a still-restricted tumor metastatic capacity. Appropriately selected patients with OMD may be candidates for prolonged disease-free survival or cure with the addition of local therapy to systemic therapy.²

The EORTC 4004 phase 2 randomized control trial (RCT) analyzed radiofrequency ablation (RFA) for colorectal liver metastases with systemic therapy vs systemic therapy alone for patients with ≤ 9 liver lesions.³ Systemic therapyconsisted of 5-FU/leucovorin/oxaliplatin, with bevacizumab added to the regimen 3.5 years into the study, per updated standard- of-care. This trial was the first to demonstrate the benefit of aggressive local treatment vs system treatment alone for OMD with a progression-free survival (PFS) benefit (16.8 vs 9.9 months; hazard ratio [HR], 0.63; P = .03) and overall survival (OS) benefit (45.3 vs 40.5 months; HR, 0.74; P = .02) with the addition of local treatment with RFA.

Since the presentations of the SABR-COMET phase 2 RCT and another study by Gomez et al at the American Society for Radiation Oncology (ASTRO) 2018 annual meeting, the paradigm for offering local RT for OMD has rapidly evolved. Both studies found PFS and OS benefits of RT for patients with OMD.^4,5 Additional RCTs have since demonstrated that for properly selected patients with OMD, aggressive local RT improved PFS and OS.^6-9 These small studies have led to larger RCTs to better understand who benefits from local consolidative treatment, particularly RT.^10,11

There is a large degree of heterogeneity in how oncologists define and approach OMD treatment. The 2020 European Society for Radiotherapy and Oncology (ESTRO) and ASTRO consensus guidelines defined the OMD state as 1 to 5 metastatic lesions for which all metastatic sites are safely treatable.¹² The purpose of this study was to evaluate perceptions and practice patterns among radiation oncologists and medical oncologists regarding the use of local RT for OMD across the Veterans Health Administration (VHA).

Methods

A 12-question survey was developed by the VHA Palliative Radiotherapy Task Force using the ESTRO-ASTRO consensus guidelines to define OMD. The survey was emailed to the VHA radiation oncology and medical oncology listservs on August 1, 2023. These listservs consist of physicians in these specialties either directly employed by the VHA or serve in its facilities as contractors. The original response closure date was August 11, 2023, but it was extended to August 18, 2023, to increase responses. No incentives were offered to respondents. Two email reminders were sent to the medical oncology listserv and 3 to the radiation oncology listserv. Descriptive statistics and X² tests were used for data analysis. The impact of specialty and presence of an on-site department of radiation oncology were reviewed. This project was approved by the VHA National Oncology Program and National Radiation Oncology Program.

Results

The survey was sent to 125 radiation oncologists and 515 medical oncologists and 106 were completed for a 16.6% response rate. There were 59 (55.7%) radiation oncologist responses and 47 (44.3%) medical oncologist responses. Most (96.2%) respondents were board-certified, and 84 (79.2%) were affiliated with an academic center. Not every respondent answered every question (Table).

All respondents (n = 105) indicated there is a potential benefit of high-dose RT for appropriately selected cases. Ninety-four oncologists (88.7%) believed that RT for OMD contributes to cure (88.1% of radiation oncologists, 89.4% of medical oncologists; P = .84) for appropriately selected cases. Some respondents who did not believe RT for OMD contributes to cure added comments about other perceived benefits, such as local disease control for palliation, delaying systemic therapy with its associated toxicities, and prolongation of disease-free survival or OS. A higher percentage of respondents with academic affiliations believed high-dose RT contributes to cure, although this difference did not reach statistical significance (Figure 1).

Fifty-five respondents (51.9%; 55.2% radiation oncologists vs 50.0% medical oncologists; P = .60) responded that local RT for OMD treatment should not be limited by primary tumor type. Of respondents who responded that OMD treatment should be limited based on the type of primary tumor, many provided comments that argued there was a benefit for non-small cell lung cancer (NSCLC), prostate adenocarcinoma (PCa), and colorectal cancer.

The definition of how many metastatic lesions qualify as OMD varied. A total of 48.6% of respondents defined OMD as ≤ 3 lesions and 42.9% answered ≤ 5 lesions. A majority of radiation oncologists (55.2%) classified ≤ 5 lesions as OMD, whereas a majority of medical oncologists (66.0%) considered ≤ 3 lesions as OMD (P = .006) (Figure 2).

Thirty-six medical oncologists (76.6%) report having an on-site department of radiation oncology (Figure 3). This subgroup was more likely to consider local RT potentially curative compared with their medical oncology peers without on-site radiation oncology (94.4% vs 72.7%; P = .04).

Case Management

The 3 clinical cases demonstrated the heterogeneity of management approaches for OMD. The first described a man aged 65 years with PCa and 2 asymptomatic pelvic bone metastases. Ninety-three respondents (90.3%) recommended RT at the primary site and 74.8% recommended RT to both the primary site and metastatic foci. Sixty-three respondents (67.7%) recommended a STAMPEDE-compatible dose, and 30 (32.3%) recommended a definitive dose.

The second clinical case was a 60-year-old man with a cT1N2M1 NSCLC, with a solitary metastatic focus to the left iliac wing. Fifty-eight respondents (54.7%) recommended upfront systemic chemotherapy and the option of local therapy to the chest and metastatic focus after initial chemotherapy; 28 respondents (26.4%) recommended upfront chemoradiation to the chest and definitive radiation to the left iliac wing metastasis.

The third clinical case described a male aged 70 years with a history of a treated base of tongue squamous cell carcinoma, with a solitary metastatic focus within the right lung. Respondents could pick multiple treatment options and 85 (81.7%) favored upfront definitive local therapy with surgery or stereotactic body radiotherapy (SBRT), rather than upfront chemotherapy, with future consideration for local treatment. About half of respondents (51.8%) recommended SBRT and 41.2% would let the patient decide between surgery or SBRT. Additionally, 39.6% included in their patient counselling that the treatment may be for curative intent.

Discussion

The use of local treatment to increased PFS, OS, or even cure treatment for OMD has become more accepted since the 2018 ASTRO meeting.^4,5 Palma et al analyzed a controlled primary malignancy of any histology and ≤ 5 metastatic lesions, with all lesions amenable to SBRT.⁴ With a median follow-up of 51 months when comparing the standard-of-care (SOC) arm and the SBRT arm, the 5-year PFS was not reached and the 5-year OS rates were 17.7% and 42.3% (P = .006), respectively. In the SBRT arm, about 1 in 5 patients survived > 5 years without a recurrence or disease progression, vs 0 patients in the control arm. There was a 29% rate of grade 2 or higher toxicity in the SBRT arm, including 3 deaths that were likely due to treatment. Subsequent trials, such as the phase 3 SABR-COMET-3 (1-3 metastases), phase 3 SABR-COMET-10 (4-10 metastases), and phase 1 ARREST (> 10 metastases) trials, have been specifically designed to minimize treatment-related toxicities.^13-15

Gomez et al analyzed patients at 3 sites with a controlled NSCLC primary tumor and ≤ 3 metastases.⁵ At a follow-up of 38.8 months, the PFS was 4.4 months in the SOC arm vs 14.2 months in the RT and/or surgery local treatment arm (P = .02). There was also an OS benefit of 17.0 vs 41.2 months (P = .02), respectively.

Several RCTs soon followed that demonstrated improved PFS and OS with local radiotherapy for OMD; however, total metastatic ablation of the foci is necessary to attain these PFS and OS benefits.^6-9 Still, an oncologic benefit has yet to be proven. The randomized NRGBR002 study phase 2/3 trial for oligometastatic breast cancer included patients with ≤ 4 extracranial metastases and controlled primary disease to metastasis-directed therapy (SBRT and/ or surgical resection) and systemic therapy vs systemic therapy alone.¹⁰ The study did not demonstrate improved PFS or OS at 3 years. However, for most breast cancers, especially with the rapid advancements in systemic therapy that have been achieved, longer follow-up may be necessary to detect a significant difference.

The prospective single-arm phase 2 SABR-5 trial retrospectively demonstrated important lessons about the timing of SBRT and systemic therapy.¹¹ This study included patients with ≤ 5 metastases of any histology, and they received SBRT to all lesions. SABR-5 retrospectively compared patients who received upfront systemic therapy followed by SBRT vs another cohort that first received SBRT and did not receive systemic therapy until there was disease progression. Patients with oligo-progression were excluded, as it demonstrated systemic drug resistance. At a median follow-up time of 34 months, delayed systemic treatment was associated with shorter PFS (23 vs 34 months, respectively; P = .001), but not worse 3-year OS (80% vs 85%, respectively; P = .66). In addition, the delayed systemic treatment arm demonstrated a reduced risk of grade 2 or higher SBRT-related toxicity (odds ratio, 0.35; P < .001).

Similarly, the STOMP phase 2 trial analyzed the role of metastasis-directed therapy (MDT) in delaying initiation of androgen deprivation therapy (ADT) in a randomized phase 2 trial.¹⁶ This study included patients with asymptomatic PCa with a biochemical recurrence after primary treatment, 1 to 3 extracranial metastatic lesions, and serum testosterone levels > 50 ng/mL. Sixty-two patients were randomized 1:1 to either MDT (SBRT or surgery) of all lesions or surveillance. The 5-year ADT-free survival was 34% for MDT vs 8% for surveillance (P = .06).

VHA Radiation Oncology

The VHA has 138 departments of medical oncology, but only 41 departments of radiation oncology. Compared with medical oncologists without an on-site radiation oncology department, those with on-site departments were more likely to believe that local RT was potentially curative (94.4% vs 72.7%, respectively; P = .04). This finding suggests that a cancer center that includes both specialties has closer collaboration, which results in greater inclination to embrace local RT for OMD, as it has demonstrated PFS and OS benefits.

The radiation and medical oncologists surveyed had statistically significant differences in response by specialty regarding the maximal number of lesions still believed to constitute OMD. Most radiation oncologists classified ≤ 5 lesions as OMD, whereas most medical oncologists classified ≤ 3 lesions as OMD. This difference is not unexpected. There is no universally agreed-upon definition of OMD, and criteria differ across studies.

While the SABR-COMET trial did include ≤ 5 metastatic lesions, it was a phase 2 RCT, making subgroup analysis difficult. Ongoing phase 3 trials that are more specific in the number of metastases, comparing 1 to 3 vs 4 to 10 metastases (SABR-COMET-3 and SABR-COMET-10, respectively).^13,14 There is even an ongoing phase 1 trial (ARREST) studying the potential benefits of treating (“restraining”) > 10 metastases, if dosimetrically feasible.¹⁵ Within the VHA, VA STARPORT is investigating MDT for recurrent or de novo hormone-sensitive metastatic PCa.¹⁷ The ongoing HALT phase 2/3 trial focuses on patients with actionable mutations to help determine management of oligo-progression in mutation-positive NSCLC.¹⁸

There was no significant difference by specialty in who responded that offering local RT for OMD treatment should not be limited by histology (55.2% of radiation oncologists and 50.0% of medical oncologists; P = .60). Oncologists could make the argument that some histologies (eg, pancreatic adenocarcinomas) have such poor prognoses that local RT would not meaningfully affect oncologic outcomes, while potentially adding toxicity, whereas others could point to improved systemic therapy regimens and the low toxicity rates with careful hypofractionation regimens. Of note, the 41-patient phase 2 EXTEND trial for pancreatic ductal adenocarcinoma suggested an oncologic benefit to MDT, with far better PFS and no grade ≥ 3 toxicities related to MDT.¹⁹ About half of respondents for each specialty believed the primary histology should affect the decision. Further clarification may emerge from phase 3 trials.

Of note, a 2023 study of 44 radiation and medical oncologists at 2 Harvard Medical School-affiliated hospitals found that for synchronous OMD, 50.0% of medical oncologists and 5.3% (P < .01) of radiation oncologists recommended systemic treatment, suggesting a greater divergence in approach than found in this study.²⁰

Limitations

The response rate of 17.0% raised a potential for selection bias, but this rate is expected for a nonincentivized medical survey. A study by the American Board of Internal Medicine with 11 surveys and 6 weekly email contacts only generated a 23.7% response rate, while another study among physicians demonstrated a 4.5% response rate for email-based contact and 11.8% for mail-based contact.^21,22 We could have asked participants questions regarding demographics and geography to ensure the survey represented a diverse sample of the medical community, although additional questions would likely suppress the response rate. Additional data collection about respondents may elucidate the rationale for differences in their responses, especially between the specialties. In a planned subsequent survey in several years, the question on the number of lesions that qualifies as OMD may be amended to reflect the context and dosimetry for the maximal number of metastases constituting OMD; the joint ESTRO-ASTRO consensus defined OMD as 1 to 5 metastatic lesions, but in which all metastatic sites must be safely treatable.¹² Also, fewer example cases could be included to simplify the survey and boost response rates. A future survey may ask about the timing of SBRT and systemic therapy, and whether SBRT can safely delay systemic therapy.

Conclusions

Survey results demonstrated significant confidence among both radiation oncologists and medical oncologists that local RT for OMD improves outcomes, which is encouraging and a reflection of the recent evidence-based paradigm shift in viewing metastatic disease as a spectrum. However, there is a difference between radiation oncologists and medical oncologists in how they define OMD, and preferred treatment of the sample cases presented revealed nuanced differences by specialty. Close collaboration with radiation oncologists influences the belief of medical oncologists in the beneficial role of RT for OMD. As more phase 3 data for OMD local treatments emerge, additional investigation is needed on how beliefs and practice patterns evolve among radiation and medical oncologists.

The treatment of metastatic solid tumors has been based historically on systemic therapies, with the goal of delaying progression and extend life as long as possible, with tolerable treatment-related adverse events. Some exceptions were made for local treatment with surgery or radiotherapy (RT), often for patients with a single metastasis. A 1939 report describes a patient with renal adenocarcinoma and a solitary lung metastasis who underwent RT to the lung lesion after nephrectomy and subsequently partial lobectomy after the metastatic lesion progressed. The authors argued that if a metastasis appears solitary and accessible, it is plausible to remove it in addition to the primary growth.¹

In 1995 Hellman and Weichselbaum proposed oligometastatic disease (OMD). They reasoned that malignancy exists along a spectrum from localized disease to widely disseminated disease, with OMD existing in between with a still-restricted tumor metastatic capacity. Appropriately selected patients with OMD may be candidates for prolonged disease-free survival or cure with the addition of local therapy to systemic therapy.²

The EORTC 4004 phase 2 randomized control trial (RCT) analyzed radiofrequency ablation (RFA) for colorectal liver metastases with systemic therapy vs systemic therapy alone for patients with ≤ 9 liver lesions.³ Systemic therapyconsisted of 5-FU/leucovorin/oxaliplatin, with bevacizumab added to the regimen 3.5 years into the study, per updated standard- of-care. This trial was the first to demonstrate the benefit of aggressive local treatment vs system treatment alone for OMD with a progression-free survival (PFS) benefit (16.8 vs 9.9 months; hazard ratio [HR], 0.63; P = .03) and overall survival (OS) benefit (45.3 vs 40.5 months; HR, 0.74; P = .02) with the addition of local treatment with RFA.

Since the presentations of the SABR-COMET phase 2 RCT and another study by Gomez et al at the American Society for Radiation Oncology (ASTRO) 2018 annual meeting, the paradigm for offering local RT for OMD has rapidly evolved. Both studies found PFS and OS benefits of RT for patients with OMD.^4,5 Additional RCTs have since demonstrated that for properly selected patients with OMD, aggressive local RT improved PFS and OS.^6-9 These small studies have led to larger RCTs to better understand who benefits from local consolidative treatment, particularly RT.^10,11

There is a large degree of heterogeneity in how oncologists define and approach OMD treatment. The 2020 European Society for Radiotherapy and Oncology (ESTRO) and ASTRO consensus guidelines defined the OMD state as 1 to 5 metastatic lesions for which all metastatic sites are safely treatable.¹² The purpose of this study was to evaluate perceptions and practice patterns among radiation oncologists and medical oncologists regarding the use of local RT for OMD across the Veterans Health Administration (VHA).

Methods

A 12-question survey was developed by the VHA Palliative Radiotherapy Task Force using the ESTRO-ASTRO consensus guidelines to define OMD. The survey was emailed to the VHA radiation oncology and medical oncology listservs on August 1, 2023. These listservs consist of physicians in these specialties either directly employed by the VHA or serve in its facilities as contractors. The original response closure date was August 11, 2023, but it was extended to August 18, 2023, to increase responses. No incentives were offered to respondents. Two email reminders were sent to the medical oncology listserv and 3 to the radiation oncology listserv. Descriptive statistics and X² tests were used for data analysis. The impact of specialty and presence of an on-site department of radiation oncology were reviewed. This project was approved by the VHA National Oncology Program and National Radiation Oncology Program.

Results

The survey was sent to 125 radiation oncologists and 515 medical oncologists and 106 were completed for a 16.6% response rate. There were 59 (55.7%) radiation oncologist responses and 47 (44.3%) medical oncologist responses. Most (96.2%) respondents were board-certified, and 84 (79.2%) were affiliated with an academic center. Not every respondent answered every question (Table).

All respondents (n = 105) indicated there is a potential benefit of high-dose RT for appropriately selected cases. Ninety-four oncologists (88.7%) believed that RT for OMD contributes to cure (88.1% of radiation oncologists, 89.4% of medical oncologists; P = .84) for appropriately selected cases. Some respondents who did not believe RT for OMD contributes to cure added comments about other perceived benefits, such as local disease control for palliation, delaying systemic therapy with its associated toxicities, and prolongation of disease-free survival or OS. A higher percentage of respondents with academic affiliations believed high-dose RT contributes to cure, although this difference did not reach statistical significance (Figure 1).

Fifty-five respondents (51.9%; 55.2% radiation oncologists vs 50.0% medical oncologists; P = .60) responded that local RT for OMD treatment should not be limited by primary tumor type. Of respondents who responded that OMD treatment should be limited based on the type of primary tumor, many provided comments that argued there was a benefit for non-small cell lung cancer (NSCLC), prostate adenocarcinoma (PCa), and colorectal cancer.

The definition of how many metastatic lesions qualify as OMD varied. A total of 48.6% of respondents defined OMD as ≤ 3 lesions and 42.9% answered ≤ 5 lesions. A majority of radiation oncologists (55.2%) classified ≤ 5 lesions as OMD, whereas a majority of medical oncologists (66.0%) considered ≤ 3 lesions as OMD (P = .006) (Figure 2).

Thirty-six medical oncologists (76.6%) report having an on-site department of radiation oncology (Figure 3). This subgroup was more likely to consider local RT potentially curative compared with their medical oncology peers without on-site radiation oncology (94.4% vs 72.7%; P = .04).

Case Management

The 3 clinical cases demonstrated the heterogeneity of management approaches for OMD. The first described a man aged 65 years with PCa and 2 asymptomatic pelvic bone metastases. Ninety-three respondents (90.3%) recommended RT at the primary site and 74.8% recommended RT to both the primary site and metastatic foci. Sixty-three respondents (67.7%) recommended a STAMPEDE-compatible dose, and 30 (32.3%) recommended a definitive dose.

The second clinical case was a 60-year-old man with a cT1N2M1 NSCLC, with a solitary metastatic focus to the left iliac wing. Fifty-eight respondents (54.7%) recommended upfront systemic chemotherapy and the option of local therapy to the chest and metastatic focus after initial chemotherapy; 28 respondents (26.4%) recommended upfront chemoradiation to the chest and definitive radiation to the left iliac wing metastasis.

The third clinical case described a male aged 70 years with a history of a treated base of tongue squamous cell carcinoma, with a solitary metastatic focus within the right lung. Respondents could pick multiple treatment options and 85 (81.7%) favored upfront definitive local therapy with surgery or stereotactic body radiotherapy (SBRT), rather than upfront chemotherapy, with future consideration for local treatment. About half of respondents (51.8%) recommended SBRT and 41.2% would let the patient decide between surgery or SBRT. Additionally, 39.6% included in their patient counselling that the treatment may be for curative intent.

Discussion

The use of local treatment to increased PFS, OS, or even cure treatment for OMD has become more accepted since the 2018 ASTRO meeting.^4,5 Palma et al analyzed a controlled primary malignancy of any histology and ≤ 5 metastatic lesions, with all lesions amenable to SBRT.⁴ With a median follow-up of 51 months when comparing the standard-of-care (SOC) arm and the SBRT arm, the 5-year PFS was not reached and the 5-year OS rates were 17.7% and 42.3% (P = .006), respectively. In the SBRT arm, about 1 in 5 patients survived > 5 years without a recurrence or disease progression, vs 0 patients in the control arm. There was a 29% rate of grade 2 or higher toxicity in the SBRT arm, including 3 deaths that were likely due to treatment. Subsequent trials, such as the phase 3 SABR-COMET-3 (1-3 metastases), phase 3 SABR-COMET-10 (4-10 metastases), and phase 1 ARREST (> 10 metastases) trials, have been specifically designed to minimize treatment-related toxicities.^13-15

Gomez et al analyzed patients at 3 sites with a controlled NSCLC primary tumor and ≤ 3 metastases.⁵ At a follow-up of 38.8 months, the PFS was 4.4 months in the SOC arm vs 14.2 months in the RT and/or surgery local treatment arm (P = .02). There was also an OS benefit of 17.0 vs 41.2 months (P = .02), respectively.

Several RCTs soon followed that demonstrated improved PFS and OS with local radiotherapy for OMD; however, total metastatic ablation of the foci is necessary to attain these PFS and OS benefits.^6-9 Still, an oncologic benefit has yet to be proven. The randomized NRGBR002 study phase 2/3 trial for oligometastatic breast cancer included patients with ≤ 4 extracranial metastases and controlled primary disease to metastasis-directed therapy (SBRT and/ or surgical resection) and systemic therapy vs systemic therapy alone.¹⁰ The study did not demonstrate improved PFS or OS at 3 years. However, for most breast cancers, especially with the rapid advancements in systemic therapy that have been achieved, longer follow-up may be necessary to detect a significant difference.

The prospective single-arm phase 2 SABR-5 trial retrospectively demonstrated important lessons about the timing of SBRT and systemic therapy.¹¹ This study included patients with ≤ 5 metastases of any histology, and they received SBRT to all lesions. SABR-5 retrospectively compared patients who received upfront systemic therapy followed by SBRT vs another cohort that first received SBRT and did not receive systemic therapy until there was disease progression. Patients with oligo-progression were excluded, as it demonstrated systemic drug resistance. At a median follow-up time of 34 months, delayed systemic treatment was associated with shorter PFS (23 vs 34 months, respectively; P = .001), but not worse 3-year OS (80% vs 85%, respectively; P = .66). In addition, the delayed systemic treatment arm demonstrated a reduced risk of grade 2 or higher SBRT-related toxicity (odds ratio, 0.35; P < .001).

Similarly, the STOMP phase 2 trial analyzed the role of metastasis-directed therapy (MDT) in delaying initiation of androgen deprivation therapy (ADT) in a randomized phase 2 trial.¹⁶ This study included patients with asymptomatic PCa with a biochemical recurrence after primary treatment, 1 to 3 extracranial metastatic lesions, and serum testosterone levels > 50 ng/mL. Sixty-two patients were randomized 1:1 to either MDT (SBRT or surgery) of all lesions or surveillance. The 5-year ADT-free survival was 34% for MDT vs 8% for surveillance (P = .06).

VHA Radiation Oncology

The VHA has 138 departments of medical oncology, but only 41 departments of radiation oncology. Compared with medical oncologists without an on-site radiation oncology department, those with on-site departments were more likely to believe that local RT was potentially curative (94.4% vs 72.7%, respectively; P = .04). This finding suggests that a cancer center that includes both specialties has closer collaboration, which results in greater inclination to embrace local RT for OMD, as it has demonstrated PFS and OS benefits.

The radiation and medical oncologists surveyed had statistically significant differences in response by specialty regarding the maximal number of lesions still believed to constitute OMD. Most radiation oncologists classified ≤ 5 lesions as OMD, whereas most medical oncologists classified ≤ 3 lesions as OMD. This difference is not unexpected. There is no universally agreed-upon definition of OMD, and criteria differ across studies.

While the SABR-COMET trial did include ≤ 5 metastatic lesions, it was a phase 2 RCT, making subgroup analysis difficult. Ongoing phase 3 trials that are more specific in the number of metastases, comparing 1 to 3 vs 4 to 10 metastases (SABR-COMET-3 and SABR-COMET-10, respectively).^13,14 There is even an ongoing phase 1 trial (ARREST) studying the potential benefits of treating (“restraining”) > 10 metastases, if dosimetrically feasible.¹⁵ Within the VHA, VA STARPORT is investigating MDT for recurrent or de novo hormone-sensitive metastatic PCa.¹⁷ The ongoing HALT phase 2/3 trial focuses on patients with actionable mutations to help determine management of oligo-progression in mutation-positive NSCLC.¹⁸

There was no significant difference by specialty in who responded that offering local RT for OMD treatment should not be limited by histology (55.2% of radiation oncologists and 50.0% of medical oncologists; P = .60). Oncologists could make the argument that some histologies (eg, pancreatic adenocarcinomas) have such poor prognoses that local RT would not meaningfully affect oncologic outcomes, while potentially adding toxicity, whereas others could point to improved systemic therapy regimens and the low toxicity rates with careful hypofractionation regimens. Of note, the 41-patient phase 2 EXTEND trial for pancreatic ductal adenocarcinoma suggested an oncologic benefit to MDT, with far better PFS and no grade ≥ 3 toxicities related to MDT.¹⁹ About half of respondents for each specialty believed the primary histology should affect the decision. Further clarification may emerge from phase 3 trials.

Of note, a 2023 study of 44 radiation and medical oncologists at 2 Harvard Medical School-affiliated hospitals found that for synchronous OMD, 50.0% of medical oncologists and 5.3% (P < .01) of radiation oncologists recommended systemic treatment, suggesting a greater divergence in approach than found in this study.²⁰

Limitations

The response rate of 17.0% raised a potential for selection bias, but this rate is expected for a nonincentivized medical survey. A study by the American Board of Internal Medicine with 11 surveys and 6 weekly email contacts only generated a 23.7% response rate, while another study among physicians demonstrated a 4.5% response rate for email-based contact and 11.8% for mail-based contact.^21,22 We could have asked participants questions regarding demographics and geography to ensure the survey represented a diverse sample of the medical community, although additional questions would likely suppress the response rate. Additional data collection about respondents may elucidate the rationale for differences in their responses, especially between the specialties. In a planned subsequent survey in several years, the question on the number of lesions that qualifies as OMD may be amended to reflect the context and dosimetry for the maximal number of metastases constituting OMD; the joint ESTRO-ASTRO consensus defined OMD as 1 to 5 metastatic lesions, but in which all metastatic sites must be safely treatable.¹² Also, fewer example cases could be included to simplify the survey and boost response rates. A future survey may ask about the timing of SBRT and systemic therapy, and whether SBRT can safely delay systemic therapy.

Conclusions

Survey results demonstrated significant confidence among both radiation oncologists and medical oncologists that local RT for OMD improves outcomes, which is encouraging and a reflection of the recent evidence-based paradigm shift in viewing metastatic disease as a spectrum. However, there is a difference between radiation oncologists and medical oncologists in how they define OMD, and preferred treatment of the sample cases presented revealed nuanced differences by specialty. Close collaboration with radiation oncologists influences the belief of medical oncologists in the beneficial role of RT for OMD. As more phase 3 data for OMD local treatments emerge, additional investigation is needed on how beliefs and practice patterns evolve among radiation and medical oncologists.

The treatment of metastatic solid tumors has been based historically on systemic therapies, with the goal of delaying progression and extend life as long as possible, with tolerable treatment-related adverse events. Some exceptions were made for local treatment with surgery or radiotherapy (RT), often for patients with a single metastasis. A 1939 report describes a patient with renal adenocarcinoma and a solitary lung metastasis who underwent RT to the lung lesion after nephrectomy and subsequently partial lobectomy after the metastatic lesion progressed. The authors argued that if a metastasis appears solitary and accessible, it is plausible to remove it in addition to the primary growth.¹

In 1995 Hellman and Weichselbaum proposed oligometastatic disease (OMD). They reasoned that malignancy exists along a spectrum from localized disease to widely disseminated disease, with OMD existing in between with a still-restricted tumor metastatic capacity. Appropriately selected patients with OMD may be candidates for prolonged disease-free survival or cure with the addition of local therapy to systemic therapy.²

The EORTC 4004 phase 2 randomized control trial (RCT) analyzed radiofrequency ablation (RFA) for colorectal liver metastases with systemic therapy vs systemic therapy alone for patients with ≤ 9 liver lesions.³ Systemic therapyconsisted of 5-FU/leucovorin/oxaliplatin, with bevacizumab added to the regimen 3.5 years into the study, per updated standard- of-care. This trial was the first to demonstrate the benefit of aggressive local treatment vs system treatment alone for OMD with a progression-free survival (PFS) benefit (16.8 vs 9.9 months; hazard ratio [HR], 0.63; P = .03) and overall survival (OS) benefit (45.3 vs 40.5 months; HR, 0.74; P = .02) with the addition of local treatment with RFA.

Since the presentations of the SABR-COMET phase 2 RCT and another study by Gomez et al at the American Society for Radiation Oncology (ASTRO) 2018 annual meeting, the paradigm for offering local RT for OMD has rapidly evolved. Both studies found PFS and OS benefits of RT for patients with OMD.^4,5 Additional RCTs have since demonstrated that for properly selected patients with OMD, aggressive local RT improved PFS and OS.^6-9 These small studies have led to larger RCTs to better understand who benefits from local consolidative treatment, particularly RT.^10,11

There is a large degree of heterogeneity in how oncologists define and approach OMD treatment. The 2020 European Society for Radiotherapy and Oncology (ESTRO) and ASTRO consensus guidelines defined the OMD state as 1 to 5 metastatic lesions for which all metastatic sites are safely treatable.¹² The purpose of this study was to evaluate perceptions and practice patterns among radiation oncologists and medical oncologists regarding the use of local RT for OMD across the Veterans Health Administration (VHA).

Methods

A 12-question survey was developed by the VHA Palliative Radiotherapy Task Force using the ESTRO-ASTRO consensus guidelines to define OMD. The survey was emailed to the VHA radiation oncology and medical oncology listservs on August 1, 2023. These listservs consist of physicians in these specialties either directly employed by the VHA or serve in its facilities as contractors. The original response closure date was August 11, 2023, but it was extended to August 18, 2023, to increase responses. No incentives were offered to respondents. Two email reminders were sent to the medical oncology listserv and 3 to the radiation oncology listserv. Descriptive statistics and X² tests were used for data analysis. The impact of specialty and presence of an on-site department of radiation oncology were reviewed. This project was approved by the VHA National Oncology Program and National Radiation Oncology Program.

Results

The survey was sent to 125 radiation oncologists and 515 medical oncologists and 106 were completed for a 16.6% response rate. There were 59 (55.7%) radiation oncologist responses and 47 (44.3%) medical oncologist responses. Most (96.2%) respondents were board-certified, and 84 (79.2%) were affiliated with an academic center. Not every respondent answered every question (Table).

All respondents (n = 105) indicated there is a potential benefit of high-dose RT for appropriately selected cases. Ninety-four oncologists (88.7%) believed that RT for OMD contributes to cure (88.1% of radiation oncologists, 89.4% of medical oncologists; P = .84) for appropriately selected cases. Some respondents who did not believe RT for OMD contributes to cure added comments about other perceived benefits, such as local disease control for palliation, delaying systemic therapy with its associated toxicities, and prolongation of disease-free survival or OS. A higher percentage of respondents with academic affiliations believed high-dose RT contributes to cure, although this difference did not reach statistical significance (Figure 1).

Fifty-five respondents (51.9%; 55.2% radiation oncologists vs 50.0% medical oncologists; P = .60) responded that local RT for OMD treatment should not be limited by primary tumor type. Of respondents who responded that OMD treatment should be limited based on the type of primary tumor, many provided comments that argued there was a benefit for non-small cell lung cancer (NSCLC), prostate adenocarcinoma (PCa), and colorectal cancer.

The definition of how many metastatic lesions qualify as OMD varied. A total of 48.6% of respondents defined OMD as ≤ 3 lesions and 42.9% answered ≤ 5 lesions. A majority of radiation oncologists (55.2%) classified ≤ 5 lesions as OMD, whereas a majority of medical oncologists (66.0%) considered ≤ 3 lesions as OMD (P = .006) (Figure 2).

Thirty-six medical oncologists (76.6%) report having an on-site department of radiation oncology (Figure 3). This subgroup was more likely to consider local RT potentially curative compared with their medical oncology peers without on-site radiation oncology (94.4% vs 72.7%; P = .04).

Case Management

The 3 clinical cases demonstrated the heterogeneity of management approaches for OMD. The first described a man aged 65 years with PCa and 2 asymptomatic pelvic bone metastases. Ninety-three respondents (90.3%) recommended RT at the primary site and 74.8% recommended RT to both the primary site and metastatic foci. Sixty-three respondents (67.7%) recommended a STAMPEDE-compatible dose, and 30 (32.3%) recommended a definitive dose.

The second clinical case was a 60-year-old man with a cT1N2M1 NSCLC, with a solitary metastatic focus to the left iliac wing. Fifty-eight respondents (54.7%) recommended upfront systemic chemotherapy and the option of local therapy to the chest and metastatic focus after initial chemotherapy; 28 respondents (26.4%) recommended upfront chemoradiation to the chest and definitive radiation to the left iliac wing metastasis.

The third clinical case described a male aged 70 years with a history of a treated base of tongue squamous cell carcinoma, with a solitary metastatic focus within the right lung. Respondents could pick multiple treatment options and 85 (81.7%) favored upfront definitive local therapy with surgery or stereotactic body radiotherapy (SBRT), rather than upfront chemotherapy, with future consideration for local treatment. About half of respondents (51.8%) recommended SBRT and 41.2% would let the patient decide between surgery or SBRT. Additionally, 39.6% included in their patient counselling that the treatment may be for curative intent.

Discussion

The use of local treatment to increased PFS, OS, or even cure treatment for OMD has become more accepted since the 2018 ASTRO meeting.^4,5 Palma et al analyzed a controlled primary malignancy of any histology and ≤ 5 metastatic lesions, with all lesions amenable to SBRT.⁴ With a median follow-up of 51 months when comparing the standard-of-care (SOC) arm and the SBRT arm, the 5-year PFS was not reached and the 5-year OS rates were 17.7% and 42.3% (P = .006), respectively. In the SBRT arm, about 1 in 5 patients survived > 5 years without a recurrence or disease progression, vs 0 patients in the control arm. There was a 29% rate of grade 2 or higher toxicity in the SBRT arm, including 3 deaths that were likely due to treatment. Subsequent trials, such as the phase 3 SABR-COMET-3 (1-3 metastases), phase 3 SABR-COMET-10 (4-10 metastases), and phase 1 ARREST (> 10 metastases) trials, have been specifically designed to minimize treatment-related toxicities.^13-15

Gomez et al analyzed patients at 3 sites with a controlled NSCLC primary tumor and ≤ 3 metastases.⁵ At a follow-up of 38.8 months, the PFS was 4.4 months in the SOC arm vs 14.2 months in the RT and/or surgery local treatment arm (P = .02). There was also an OS benefit of 17.0 vs 41.2 months (P = .02), respectively.

Several RCTs soon followed that demonstrated improved PFS and OS with local radiotherapy for OMD; however, total metastatic ablation of the foci is necessary to attain these PFS and OS benefits.^6-9 Still, an oncologic benefit has yet to be proven. The randomized NRGBR002 study phase 2/3 trial for oligometastatic breast cancer included patients with ≤ 4 extracranial metastases and controlled primary disease to metastasis-directed therapy (SBRT and/ or surgical resection) and systemic therapy vs systemic therapy alone.¹⁰ The study did not demonstrate improved PFS or OS at 3 years. However, for most breast cancers, especially with the rapid advancements in systemic therapy that have been achieved, longer follow-up may be necessary to detect a significant difference.

The prospective single-arm phase 2 SABR-5 trial retrospectively demonstrated important lessons about the timing of SBRT and systemic therapy.¹¹ This study included patients with ≤ 5 metastases of any histology, and they received SBRT to all lesions. SABR-5 retrospectively compared patients who received upfront systemic therapy followed by SBRT vs another cohort that first received SBRT and did not receive systemic therapy until there was disease progression. Patients with oligo-progression were excluded, as it demonstrated systemic drug resistance. At a median follow-up time of 34 months, delayed systemic treatment was associated with shorter PFS (23 vs 34 months, respectively; P = .001), but not worse 3-year OS (80% vs 85%, respectively; P = .66). In addition, the delayed systemic treatment arm demonstrated a reduced risk of grade 2 or higher SBRT-related toxicity (odds ratio, 0.35; P < .001).

Similarly, the STOMP phase 2 trial analyzed the role of metastasis-directed therapy (MDT) in delaying initiation of androgen deprivation therapy (ADT) in a randomized phase 2 trial.¹⁶ This study included patients with asymptomatic PCa with a biochemical recurrence after primary treatment, 1 to 3 extracranial metastatic lesions, and serum testosterone levels > 50 ng/mL. Sixty-two patients were randomized 1:1 to either MDT (SBRT or surgery) of all lesions or surveillance. The 5-year ADT-free survival was 34% for MDT vs 8% for surveillance (P = .06).

VHA Radiation Oncology

The VHA has 138 departments of medical oncology, but only 41 departments of radiation oncology. Compared with medical oncologists without an on-site radiation oncology department, those with on-site departments were more likely to believe that local RT was potentially curative (94.4% vs 72.7%, respectively; P = .04). This finding suggests that a cancer center that includes both specialties has closer collaboration, which results in greater inclination to embrace local RT for OMD, as it has demonstrated PFS and OS benefits.

The radiation and medical oncologists surveyed had statistically significant differences in response by specialty regarding the maximal number of lesions still believed to constitute OMD. Most radiation oncologists classified ≤ 5 lesions as OMD, whereas most medical oncologists classified ≤ 3 lesions as OMD. This difference is not unexpected. There is no universally agreed-upon definition of OMD, and criteria differ across studies.

While the SABR-COMET trial did include ≤ 5 metastatic lesions, it was a phase 2 RCT, making subgroup analysis difficult. Ongoing phase 3 trials that are more specific in the number of metastases, comparing 1 to 3 vs 4 to 10 metastases (SABR-COMET-3 and SABR-COMET-10, respectively).^13,14 There is even an ongoing phase 1 trial (ARREST) studying the potential benefits of treating (“restraining”) > 10 metastases, if dosimetrically feasible.¹⁵ Within the VHA, VA STARPORT is investigating MDT for recurrent or de novo hormone-sensitive metastatic PCa.¹⁷ The ongoing HALT phase 2/3 trial focuses on patients with actionable mutations to help determine management of oligo-progression in mutation-positive NSCLC.¹⁸

There was no significant difference by specialty in who responded that offering local RT for OMD treatment should not be limited by histology (55.2% of radiation oncologists and 50.0% of medical oncologists; P = .60). Oncologists could make the argument that some histologies (eg, pancreatic adenocarcinomas) have such poor prognoses that local RT would not meaningfully affect oncologic outcomes, while potentially adding toxicity, whereas others could point to improved systemic therapy regimens and the low toxicity rates with careful hypofractionation regimens. Of note, the 41-patient phase 2 EXTEND trial for pancreatic ductal adenocarcinoma suggested an oncologic benefit to MDT, with far better PFS and no grade ≥ 3 toxicities related to MDT.¹⁹ About half of respondents for each specialty believed the primary histology should affect the decision. Further clarification may emerge from phase 3 trials.

Of note, a 2023 study of 44 radiation and medical oncologists at 2 Harvard Medical School-affiliated hospitals found that for synchronous OMD, 50.0% of medical oncologists and 5.3% (P < .01) of radiation oncologists recommended systemic treatment, suggesting a greater divergence in approach than found in this study.²⁰

Limitations

The response rate of 17.0% raised a potential for selection bias, but this rate is expected for a nonincentivized medical survey. A study by the American Board of Internal Medicine with 11 surveys and 6 weekly email contacts only generated a 23.7% response rate, while another study among physicians demonstrated a 4.5% response rate for email-based contact and 11.8% for mail-based contact.^21,22 We could have asked participants questions regarding demographics and geography to ensure the survey represented a diverse sample of the medical community, although additional questions would likely suppress the response rate. Additional data collection about respondents may elucidate the rationale for differences in their responses, especially between the specialties. In a planned subsequent survey in several years, the question on the number of lesions that qualifies as OMD may be amended to reflect the context and dosimetry for the maximal number of metastases constituting OMD; the joint ESTRO-ASTRO consensus defined OMD as 1 to 5 metastatic lesions, but in which all metastatic sites must be safely treatable.¹² Also, fewer example cases could be included to simplify the survey and boost response rates. A future survey may ask about the timing of SBRT and systemic therapy, and whether SBRT can safely delay systemic therapy.

Conclusions

Survey results demonstrated significant confidence among both radiation oncologists and medical oncologists that local RT for OMD improves outcomes, which is encouraging and a reflection of the recent evidence-based paradigm shift in viewing metastatic disease as a spectrum. However, there is a difference between radiation oncologists and medical oncologists in how they define OMD, and preferred treatment of the sample cases presented revealed nuanced differences by specialty. Close collaboration with radiation oncologists influences the belief of medical oncologists in the beneficial role of RT for OMD. As more phase 3 data for OMD local treatments emerge, additional investigation is needed on how beliefs and practice patterns evolve among radiation and medical oncologists.

Cosmetic laser procedures as well as energy-based fat reduction and body-contouring devices are increasingly popular among individuals with skin of color (SOC). Innovations in cosmetic devices and procedures tailored for SOC have allowed for the optimization of outcomes in this patient population. In this article, SOC is defined as darker skin types, including Fitzpatrick skin types (FSTs) IV to VI and ethnic backgrounds such as LatinX, African American, Southeast Asian, Native American, Pacific Islander, Middle Eastern, Asian, and African. Indications for laser treatment include dermatosis papulosa nigrans (DPN), acne scars, skin rejuvenation, and hyperpigmentation. There currently are 6 procedures for nonsurgical fat reduction that are approved by the US Food and Drug Administration (FDA): high-frequency focused ultrasound, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring (Supplementary Table S1).¹

In this review, our initial focus is cosmetic laser ­procedures, encompassing FDA-cleared indications along with the associated risks and benefits in SOC populations. Subsequently, we delve into the realms of energy-based fat reduction and body contouring, offering a comprehensive overview of these noninvasive therapies and addressing considerations for efficacy and safety in these patients.

Dermatosis Papulosa Nigra

In patients with SOC, scissor excision, curettage, or electrodesiccation are the mainstay treatments for removal of DPN (Figure 1). Curettage and electrodesiccation can cause temporary postinflammatory hyperpigmentation (PIH) in these populations, while cryotherapy is not a preferred method in patients with SOC due to the possibility of cryotherapy-induced depigmentation. In a 14-patient split-face study comparing the 532-nm potassium titanyl phosphate (KTP) laser vs electrodesiccation in FSTs IV to VI, the KTP-treated side showed an improvement rate of 96%, while the electrodesiccation side showed an improvement rate of 79%. There was a statistically significant favorable experience for KTP with regard to pain tolerability (P=.002).² Complete resolution of lesions may be seen after 3 to 4 sessions at 4-week intervals. Additionally, the 1064-nm Nd:YAG laser was assessed for treatment of DPN in 2 patients, with 70% to 90% of lesions resolved after a single treatment with no complications.³

Most dermatologists still rely on curettage and electrodesiccation instead of laser therapy to remove DPNs in patients with SOC. The use of the Nd:YAG laser is promising yet expensive for the provider both to purchase and maintain. Electrodesiccation has been used by dermatology practices for decades and can be used without permanent discoloration. To minimize the risk for PIH, we recommend application of a healing ointment such as petroleum jelly or aloe vera gel to the treated lesions as well as lightening agents for PIH and daily use of sunscreen. Overall, providers do not need to purchase an expensive laser device for DPN removal.

Acne Scars

The invention of fractional technology in the early 2000s and its favorable safety profile have changed how dermatologists treat scarring in patients with SOC.^4,5 In fact, nonablative fractional (NAF) resurfacing is a preferred treatment modality for management of acne scars in patients with SOC.⁶ In one study of the 1550-nm erbium-doped fiber laser for treatment of acne scars (3 treatments at intervals of 2-3 weeks) in 10 Japanese patients, clinical improvement was seen in all patients and no severe adverse effects were reported.⁷ In another study, 27 Korean patients with FSTs IV and V were treated with an NAF resurfacing device for acne scars. Excellent results were reported in 30% (8/27) of patients, substantial improvement in 59% (16/27), and moderate improvement in 11% (3/27).⁸ To evaluate outcomes in patients treated with NAF resurfacing, a retrospective review of 961 treatments showed a hyperpigmentation rate of 11.6% in those with FST IV and 33% in FST V.⁹

In one study of the short-pulsed nonablative Nd:YAG laser, 9 patients with FSTs I to V and 2 patients with FSTs IV to V underwent 8 treatments at 2-week intervals. Three blinded observers found a 29% improvement in the Global Acne Scar Severity score, while 89% (8/9) of patients self-reported subjective improvement in their acne scars.¹⁰

The 755-nm picosecond laser and diffractive lens array also have been shown to reduce the appearance of acne scars in patients with SOC, as shown via serial photography in a retrospective study of 56 patients with FSTs IV to VI. Transient hyperpigmentation, erythema, and edema were reported.¹¹

Nonablative laser therapy is preferred for skin rejuvenation in patients with SOC due to a reduced risk for postprocedural hyperpigmentation.¹¹ Ablative resurfacing (eg, CO₂ laser) poses major risks for postprocedural hyperpigmentation, hypopigmentation, and scar formation and therefore should be avoided in these populations.^12,13 A study involving 30 Asian patients (FSTs III-IV) demonstrated that the 1550-nm fractional laser was well tolerated, though higher treatment densities and fluences may lead to temporary adverse effects such as increased redness, swelling, and pain (P<.01).¹⁴ Furthermore, greater density was shown to cause higher levels of redness, hyperpigmentation, and swelling in comparison to higher fluence settings. Of note, patient satisfaction was markedly higher in patients who underwent treatment with higher fluence settings but not in patients with higher densities (P<.05). Postprocedural hyperpigmentation was noted in 6.7% (2/30) of patients studied.¹⁴ In another study, 8 patients with FSTs II to V were treated with either the 1064-nm long-pulsed Nd:YAG laser or the grid fractional monopolar radiofrequency laser.¹⁵ All participants experienced a significant decrease in mean wrinkle count using the Lemperle wrinkle assessment (P<.05). A significant decrease in mean wrinkle assessment score from 3.5 to 3.17 in clinical assessment and a decrease from 3.165 to 2.33 for photographic assessment was noted in patients treated with the grid laser (P<.05). A similar decrease in mean wrinkle assessment score was observed in the Nd:YAG group, with a mean decrease of 3.665 to 2.83 after 2 months for clinical assessment and 3.5 to 2.67 for photographic assessment. Among all patients in the study, 68% (6/8) experienced erythema, 25% (2/8) had a burning sensation, and 25% (2/8) experienced urticaria immediately postprocedure.¹⁵

Nonablative fractional resurfacing is preferred for the management of acne scars in patients with SOC. Adverse effects such as hyperpigmentation typically are transient, and the risk may be minimized with strict photoprotective practices following the procedure. Furthermore, avoidance of topicals containing exfoliants or α-hydroxy acids applied to the treated area following the procedure also may mitigate the risk for postprocedural hyperpigmentation.¹⁶ If hyperpigmentation does occur, use of topical melanogenesis inhibitors such as hydroquinone, kojic acid, or azelaic acid has shown some utility in practice.

Skin Rejuvenation

Nonablative fractional lasers (NAFLs) continue to be popular for treatment of photoaging. One study including 10 Asian patients (FSTs III-V) assessed the 1440-nm diode-based fractional laser for facial rejuvenation.¹⁷ After 4 sessions at 2-week intervals, 80% (8/10) of patients reported decreased skin roughness after both the second and third treatments, while 90% (9/10) had improved texture 1 month after the final procedure. Adverse effects included moderate facial edema and one case of transient hyperpigmentation.¹⁷ Another study reported a significant reduction in pore score (P<.002), with patients noting an overall improvement in skin appearance with minimal erythema, dryness, and flaking following 6 sessions at 2-week intervals using the 1440-nm diode-based fractional laser.¹⁸

The 1550-nm diode fractional laser significantly improved skin pigmentation (P<.001) and texture (P<.001) in 10 patients with FSTs II to IV following 5 sessions at 2- to 3-week intervals, with self-resolving erythema and edema posttreatment (Supplementary Table S2).¹⁹ Overall, NAFLs for the treatment of photoaging are effective with minimal adverse effects (eg, facial edema), which can be reduced with application of cold compression to the face and elevation of the head following treatment as well as the use of additional pillows during overnight sleep.

Laser Treatment for Hyperpigmentation Disorders

Melasma—The FDA recently approved fractional photothermolysis for the treatment of melasma; however, due to the risk for hyperpigmentation given its pathogenesis linked to hyperactive melanocytes, this laser is not considered a first-line therapy for melasma.²⁰ In a split-face, randomized study, 22 patients with FSTs III to V who were diagnosed with either dermal or mixed-type melasma were treated with a low-fluence Q-switched Nd:YAG laser combined with hydroquinone 2% vs hydroquinone 2% alone (Supplementary Table S3).²¹ Each patient was treated weekly for 5 consecutive weeks. The laser-treated side was found to reach an average of 92.5% improvement compared with 19.7% on the hydroquinone-only side. Three of the 22 (13.6%) patients developed mottled hypopigmentation after 5 laser treatments, and 8 (36.4%) developed confetti-type hypopigmentation. Four (18.2%) patients developed rebound hyperpigmentation, and all 22 patients experienced recurrence of melasma by 12 weeks posttreatment.²¹

First-line treatment for melasma involves the application of topical lightening agents such as hydroquinone, azelaic acid, kojic acid, retinoids, or mild topical steroids. Combining laser technology with topical medications can enhance treatment outcomes, particularly yielding positive results for patients with persistent pigmentation concerns. Notably, utilization of 650-microsecond technology with the 1064-nm Nd:YAG laser is considered superior in clinical practice, especially for patients with FSTs IV through VI.

Postinflammatory Hyperpigmentation—A retrospective evaluation of 61 patients with FSTs IV to VI with PIH treated with a 1927-nm NAFL showed a mean improvement of 43.24%, as assessed by 2 dermatologists.²² Additionally, the Nd:YAG 1064-nm 650-microsecond pulse duration laser is an emerging treatment that delivers high and low fluences between 4 J/cm² and 255 J/cm² within a single 650-microsecond pulse duration.²³ The short-pulse duration avoids overheating the skin, mitigating procedural discomfort and the risk for adverse effects commonly seen with the previous generation of low-pulsed lasers. In addition to PIH, this laser has been successfully used to treat pseudofolliculitis barbae.²⁴

Solar Lentigos—In a split-face study treating solar lentigos in Asian patients, 4 treatments with a low-pulsed KTP 532-nm laser were administered with and without a second treatment with a low-pulsed 1064-nm Nd:YAG laser.²⁵ Scoring of a modified pigment severity index and measurement of the melanin index showed that skin treated with the low-pulsed 532-nm laser alone and in combination with the low-pulsed 1064-nm Nd:YAG laser resulted in improvement at 3 months’ follow-up. However, there was no difference between the 2 sides of the face, leading the researchers to conclude that the low-pulsed 532-nm laser appears to be safe and effective for treatment of solar lentigos in Asian patients and does not require the addition of the low-pulsed 1064-nm laser.²⁵  

To avoid hyperpigmentation in patients with SOC, strict photoprotection to the treated areas should be advised. Proper cooling of the laser-treated area is required to minimize PIH, as cooling decreases tissue damage and excessive thermal injury. Test spots should be considered prior to initiation of the full laser treatment. Hydroquinone in a 4% concentration applied daily for 2 weeks preprocedure commonly is employed to reduce the risk for postprocedural hyperpigmentation in clinical practice.^26,27

Skin Tightening and Body Contouring

In general, skin-tightening and body-contouring devices are among the most sought-after procedures. Studies performed in patients with SOC are limited. Herein, we provide background on why these devices are favorable for patients with SOC and our experiences in using them. A summary of these devices can be found in Supplementary Table S4.

Radiofrequency Skin Tightening—Radiofrequency devices are utilized for skin tightening as well as mild fat reduction; they commonly are used on the abdomen, thighs, buttocks, and face.²⁸ People with SOC are more responsive to radiofrequency skin-tightening therapy due to higher baseline collagen content and dermal thickness, more sebaceous activity and skin elasticity, and more melanin content which offers protective thermal buffering.^29,30 As the radiofrequency device emits heat, penetrating deep into the dermis, it generates collagen remodeling and synthesis within 4 to 6 months posttreatment.

Nonsurgical Fat Reduction

Procedures for nonsurgical fat reduction are favorable due to minimal recovery time, manageable cost, and an in-office procedure setting. As noted previously, there are 6 FDA-indicated interventions for nonsurgical fat reduction: ultrasonography, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring.³¹

Ultrasonography—Ultrasound devices designed for body contouring are used for skin tightening and mild fat reduction through the use of acoustic energy.³² These devices can be divided into 2 categories: high frequency and low frequency, with the high-frequency devices being the most popular. High-frequency ultrasound energy produces heat at target sites, which induces necrosis of adipocytes and stimulates collagen remodeling within the tissue matrix.³³ Tissue temperatures above 56°C stimulate adipocyte necrosis while sparing nearby nerves and vessels.²⁸ Because of the short duration of the procedure, the risk for epidermal damage is minimal. Contrary to high-frequency ultrasonography, focus-pulsed ultrasonography employs low-frequency waves to induce the mechanical disruption of adipocytes, which is generally better tolerated due to its nonthermal mechanism. The latter may be advantageous in patients with SOC due to a reduced risk for thermal injury to the epidermis. Multiple treatments often are needed at 3- to 4-week intervals, resulting in gradual improvement observed over 2 to 6 months. One study of microfocused ultrasonography in 25 Asian patients for treatment of face and neck laxity reported that skin laxity was improved or much improved in 84% (21/25) of patients following treatment.³⁴ Adverse effects were reported as mild and transient, resolving within 90 days.³⁴ Ultrasound devices also were shown to improve wrinkles, texture, and overall appearance of the skin in a 71-year-old African American woman 4 months following treatment (Figure 2). These photographs highlight the clinical utility of a microfocused ultrasound skin-tightening treatment in African American patients.

Cryolipolysis—Cryolipolysis is a noninvasive body contouring procedure that employs controlled cooling to induce subcutaneous panniculitis. Through cold-induced apoptosis of adipocytes, this procedure selectively reduces adipose tissue in localized areas such as the flank, abdomen, thighs, buttocks, back, submental area, and upper arms. The temperature used in cryolipolysis is approximately –10°C.³⁵ The lethal temperature for melanocytes is –4 °C, below which melanocyte apoptosis may be induced, resulting in depigmentation. Given the prolonged contact of the skin with a cryolipolysis device for up to 60 minutes during a body-contouring procedure, there is a risk for resultant depigmentation in darker skin types. Controlled studies are needed to fully evaluate the safety and efficacy of cryolipolysis in patients with SOC. One retrospective study of cryolipolysis applied to the abdomen and upper arm of 4122 Asian patients reported a significant (P<.05) reduction in the circumference of the abdomen and the upper-arm areas. No long-term adverse effects were reported.³⁶

Laser Lipolysis—The 1060-nm diode laser for body contouring selectively destroys adipose tissue, resulting in body contouring via thermally induced inflammation. Hyperthermic exposure for 15 minutes selectively elevates adipocyte temperature between 42°C to 47°C, which triggers apoptosis and the eventual clearance of destroyed cells from the interstitial space.³⁷ The selectivity of the 1060-nm wavelength coupled with the device’s contact cooling system preserves the overlying skin and adnexa during the procedure,³⁷ which would minimize epidermal damage that may induce dyspigmentation in patients with SOC. No notable adverse effects or dyspigmentation have been reported using this device.

Injection Lipolysis—Deoxycholic acid is an injectable adipocytolytic for the reduction of submental fat. It nonselectively lyses muscle and other adjacent nonfatty tissue. One study of 50 Indian patients demonstrated a substantial reduction of submental fat in 90% (45/50).³⁸ For each treatment, 5 mL of 30 mg/mL deoxycholic acid was injected. Serial sessions were conducted at 2-month intervals, and most (64% [32/50]) patients required 3 sessions to see a treatment effect. Adverse effects included transient swelling, lumpiness, and tenderness. A phase 2a investigation of the novel injectable small-molecule drug CBL-514 in 43 Asian and White participants found a significant improvement in the reduction in abdominal fat volume (P<.00001) and thickness (P<.0001) relative to baseline at higher doses (unit dose, 2.0 mg/cm² and 1.6 mg/cm²).³⁹ In addition to the adverse effects mentioned previously, pruritus, repeated urticaria, body rash, and fever also were reported.³⁹  

Radiofrequency Lipolysis—Radiofrequency is used for adipolysis through heat-induced apoptosis. To achieve this effect, adipose tissue must sustain a temperature of 42 °C to 45 °C for at least 15 minutes.⁴⁰ In one study, 4 treatments performed at 7-day intervals resulted in a statistically significant reduction in circumference to the treated areas of the inner and outer thighs without any reported adverse effects (P<0.001).⁴¹ Of note, there was 1 cm of distance between the applicator and the skin. The absence of direct contact with the skin is likely to reduce the risk for postprocedural complications in patients with SOC.

Magnetic Resonance Contouring—Magnetic resonance contouring with high-intensity focused electromagnetic technology is an emerging treatment modality for noninvasive body contouring. One distinguishing characteristic from other currently available noninvasive fat-­reduction therapies is that magnetic resonance may improve strength, tone, and muscle thickness.⁴² This modality is FDA approved for contouring of the buttocks and abdomen and employs electromagnetic energy to stimulate approximately 20,000 muscle contractions within a time frame of 30 minutes. Though the mechanisms causing benefits to muscular and adipose tissue have not been elucidated, current findings suggest that the contractions stimulate substantial lipolysis of adipocytes, resulting in the release of large amounts of free fatty acids that cause damage to nearby adipose tissue.⁴³ Multiple treatments are required over time to maintain effect. No major adverse effects have been reported. The likely mechanism of action of magnetic resonance contouring does not appear to pose an increased risk to patients with SOC.

Final Thoughts

One of the major roadblocks in distilling indications along with associated risks and benefits for nonsurgical cosmetic practices for patients with SOC is a void in the primary literature involving these populations. Clinical experience serves to address this deficit in combination with a thorough review of the literature. The 1064-nm Nd:YAG laser has shown clinical utility in the treatment of DPN, melanoma, and acne scars, but it poses financial constraints to the provider in comparison to modalities used for many years. Notably, NAF resurfacing is preferred for the management of acne scars in patients with SOC and continues to gain popularity for the treatment of photoaging. Regarding skin-tightening and body-contouring devices, studies performed in patients with SOC are limited and affected by factors such as small sample sizes, underrepresentation of FSTs IV through VI, short follow-up durations, and a lack of standardized outcome measures. Additionally, few studies assess pigmentary adverse effects or stratify results by skin type, which is critical given the higher risk for PIH in SOC. Ultrasound devices showed clinical utility in improvement of skin laxity, texture, and overall improvement. Patients with SOC respond well to skin-tightening devices due to the increased collagen synthesis. Regarding emerging devices for reduction of adipocytes, deoxycholic acid when injected showed notable improvement in fat reduction but also had adverse effects. As additional studies on cosmetic procedures in SOC emerge, an expansion of treatment options could be offered to this demographic group with confidence, provided proper treatment and follow-up protocols are in place.

Cosmetic laser procedures as well as energy-based fat reduction and body-contouring devices are increasingly popular among individuals with skin of color (SOC). Innovations in cosmetic devices and procedures tailored for SOC have allowed for the optimization of outcomes in this patient population. In this article, SOC is defined as darker skin types, including Fitzpatrick skin types (FSTs) IV to VI and ethnic backgrounds such as LatinX, African American, Southeast Asian, Native American, Pacific Islander, Middle Eastern, Asian, and African. Indications for laser treatment include dermatosis papulosa nigrans (DPN), acne scars, skin rejuvenation, and hyperpigmentation. There currently are 6 procedures for nonsurgical fat reduction that are approved by the US Food and Drug Administration (FDA): high-frequency focused ultrasound, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring (Supplementary Table S1).¹

In this review, our initial focus is cosmetic laser ­procedures, encompassing FDA-cleared indications along with the associated risks and benefits in SOC populations. Subsequently, we delve into the realms of energy-based fat reduction and body contouring, offering a comprehensive overview of these noninvasive therapies and addressing considerations for efficacy and safety in these patients.

Dermatosis Papulosa Nigra

In patients with SOC, scissor excision, curettage, or electrodesiccation are the mainstay treatments for removal of DPN (Figure 1). Curettage and electrodesiccation can cause temporary postinflammatory hyperpigmentation (PIH) in these populations, while cryotherapy is not a preferred method in patients with SOC due to the possibility of cryotherapy-induced depigmentation. In a 14-patient split-face study comparing the 532-nm potassium titanyl phosphate (KTP) laser vs electrodesiccation in FSTs IV to VI, the KTP-treated side showed an improvement rate of 96%, while the electrodesiccation side showed an improvement rate of 79%. There was a statistically significant favorable experience for KTP with regard to pain tolerability (P=.002).² Complete resolution of lesions may be seen after 3 to 4 sessions at 4-week intervals. Additionally, the 1064-nm Nd:YAG laser was assessed for treatment of DPN in 2 patients, with 70% to 90% of lesions resolved after a single treatment with no complications.³

Most dermatologists still rely on curettage and electrodesiccation instead of laser therapy to remove DPNs in patients with SOC. The use of the Nd:YAG laser is promising yet expensive for the provider both to purchase and maintain. Electrodesiccation has been used by dermatology practices for decades and can be used without permanent discoloration. To minimize the risk for PIH, we recommend application of a healing ointment such as petroleum jelly or aloe vera gel to the treated lesions as well as lightening agents for PIH and daily use of sunscreen. Overall, providers do not need to purchase an expensive laser device for DPN removal.

Acne Scars

The invention of fractional technology in the early 2000s and its favorable safety profile have changed how dermatologists treat scarring in patients with SOC.^4,5 In fact, nonablative fractional (NAF) resurfacing is a preferred treatment modality for management of acne scars in patients with SOC.⁶ In one study of the 1550-nm erbium-doped fiber laser for treatment of acne scars (3 treatments at intervals of 2-3 weeks) in 10 Japanese patients, clinical improvement was seen in all patients and no severe adverse effects were reported.⁷ In another study, 27 Korean patients with FSTs IV and V were treated with an NAF resurfacing device for acne scars. Excellent results were reported in 30% (8/27) of patients, substantial improvement in 59% (16/27), and moderate improvement in 11% (3/27).⁸ To evaluate outcomes in patients treated with NAF resurfacing, a retrospective review of 961 treatments showed a hyperpigmentation rate of 11.6% in those with FST IV and 33% in FST V.⁹

In one study of the short-pulsed nonablative Nd:YAG laser, 9 patients with FSTs I to V and 2 patients with FSTs IV to V underwent 8 treatments at 2-week intervals. Three blinded observers found a 29% improvement in the Global Acne Scar Severity score, while 89% (8/9) of patients self-reported subjective improvement in their acne scars.¹⁰

The 755-nm picosecond laser and diffractive lens array also have been shown to reduce the appearance of acne scars in patients with SOC, as shown via serial photography in a retrospective study of 56 patients with FSTs IV to VI. Transient hyperpigmentation, erythema, and edema were reported.¹¹

Nonablative laser therapy is preferred for skin rejuvenation in patients with SOC due to a reduced risk for postprocedural hyperpigmentation.¹¹ Ablative resurfacing (eg, CO₂ laser) poses major risks for postprocedural hyperpigmentation, hypopigmentation, and scar formation and therefore should be avoided in these populations.^12,13 A study involving 30 Asian patients (FSTs III-IV) demonstrated that the 1550-nm fractional laser was well tolerated, though higher treatment densities and fluences may lead to temporary adverse effects such as increased redness, swelling, and pain (P<.01).¹⁴ Furthermore, greater density was shown to cause higher levels of redness, hyperpigmentation, and swelling in comparison to higher fluence settings. Of note, patient satisfaction was markedly higher in patients who underwent treatment with higher fluence settings but not in patients with higher densities (P<.05). Postprocedural hyperpigmentation was noted in 6.7% (2/30) of patients studied.¹⁴ In another study, 8 patients with FSTs II to V were treated with either the 1064-nm long-pulsed Nd:YAG laser or the grid fractional monopolar radiofrequency laser.¹⁵ All participants experienced a significant decrease in mean wrinkle count using the Lemperle wrinkle assessment (P<.05). A significant decrease in mean wrinkle assessment score from 3.5 to 3.17 in clinical assessment and a decrease from 3.165 to 2.33 for photographic assessment was noted in patients treated with the grid laser (P<.05). A similar decrease in mean wrinkle assessment score was observed in the Nd:YAG group, with a mean decrease of 3.665 to 2.83 after 2 months for clinical assessment and 3.5 to 2.67 for photographic assessment. Among all patients in the study, 68% (6/8) experienced erythema, 25% (2/8) had a burning sensation, and 25% (2/8) experienced urticaria immediately postprocedure.¹⁵

Nonablative fractional resurfacing is preferred for the management of acne scars in patients with SOC. Adverse effects such as hyperpigmentation typically are transient, and the risk may be minimized with strict photoprotective practices following the procedure. Furthermore, avoidance of topicals containing exfoliants or α-hydroxy acids applied to the treated area following the procedure also may mitigate the risk for postprocedural hyperpigmentation.¹⁶ If hyperpigmentation does occur, use of topical melanogenesis inhibitors such as hydroquinone, kojic acid, or azelaic acid has shown some utility in practice.

Skin Rejuvenation

Nonablative fractional lasers (NAFLs) continue to be popular for treatment of photoaging. One study including 10 Asian patients (FSTs III-V) assessed the 1440-nm diode-based fractional laser for facial rejuvenation.¹⁷ After 4 sessions at 2-week intervals, 80% (8/10) of patients reported decreased skin roughness after both the second and third treatments, while 90% (9/10) had improved texture 1 month after the final procedure. Adverse effects included moderate facial edema and one case of transient hyperpigmentation.¹⁷ Another study reported a significant reduction in pore score (P<.002), with patients noting an overall improvement in skin appearance with minimal erythema, dryness, and flaking following 6 sessions at 2-week intervals using the 1440-nm diode-based fractional laser.¹⁸

The 1550-nm diode fractional laser significantly improved skin pigmentation (P<.001) and texture (P<.001) in 10 patients with FSTs II to IV following 5 sessions at 2- to 3-week intervals, with self-resolving erythema and edema posttreatment (Supplementary Table S2).¹⁹ Overall, NAFLs for the treatment of photoaging are effective with minimal adverse effects (eg, facial edema), which can be reduced with application of cold compression to the face and elevation of the head following treatment as well as the use of additional pillows during overnight sleep.

Laser Treatment for Hyperpigmentation Disorders

Melasma—The FDA recently approved fractional photothermolysis for the treatment of melasma; however, due to the risk for hyperpigmentation given its pathogenesis linked to hyperactive melanocytes, this laser is not considered a first-line therapy for melasma.²⁰ In a split-face, randomized study, 22 patients with FSTs III to V who were diagnosed with either dermal or mixed-type melasma were treated with a low-fluence Q-switched Nd:YAG laser combined with hydroquinone 2% vs hydroquinone 2% alone (Supplementary Table S3).²¹ Each patient was treated weekly for 5 consecutive weeks. The laser-treated side was found to reach an average of 92.5% improvement compared with 19.7% on the hydroquinone-only side. Three of the 22 (13.6%) patients developed mottled hypopigmentation after 5 laser treatments, and 8 (36.4%) developed confetti-type hypopigmentation. Four (18.2%) patients developed rebound hyperpigmentation, and all 22 patients experienced recurrence of melasma by 12 weeks posttreatment.²¹

First-line treatment for melasma involves the application of topical lightening agents such as hydroquinone, azelaic acid, kojic acid, retinoids, or mild topical steroids. Combining laser technology with topical medications can enhance treatment outcomes, particularly yielding positive results for patients with persistent pigmentation concerns. Notably, utilization of 650-microsecond technology with the 1064-nm Nd:YAG laser is considered superior in clinical practice, especially for patients with FSTs IV through VI.

Postinflammatory Hyperpigmentation—A retrospective evaluation of 61 patients with FSTs IV to VI with PIH treated with a 1927-nm NAFL showed a mean improvement of 43.24%, as assessed by 2 dermatologists.²² Additionally, the Nd:YAG 1064-nm 650-microsecond pulse duration laser is an emerging treatment that delivers high and low fluences between 4 J/cm² and 255 J/cm² within a single 650-microsecond pulse duration.²³ The short-pulse duration avoids overheating the skin, mitigating procedural discomfort and the risk for adverse effects commonly seen with the previous generation of low-pulsed lasers. In addition to PIH, this laser has been successfully used to treat pseudofolliculitis barbae.²⁴

Solar Lentigos—In a split-face study treating solar lentigos in Asian patients, 4 treatments with a low-pulsed KTP 532-nm laser were administered with and without a second treatment with a low-pulsed 1064-nm Nd:YAG laser.²⁵ Scoring of a modified pigment severity index and measurement of the melanin index showed that skin treated with the low-pulsed 532-nm laser alone and in combination with the low-pulsed 1064-nm Nd:YAG laser resulted in improvement at 3 months’ follow-up. However, there was no difference between the 2 sides of the face, leading the researchers to conclude that the low-pulsed 532-nm laser appears to be safe and effective for treatment of solar lentigos in Asian patients and does not require the addition of the low-pulsed 1064-nm laser.²⁵  

To avoid hyperpigmentation in patients with SOC, strict photoprotection to the treated areas should be advised. Proper cooling of the laser-treated area is required to minimize PIH, as cooling decreases tissue damage and excessive thermal injury. Test spots should be considered prior to initiation of the full laser treatment. Hydroquinone in a 4% concentration applied daily for 2 weeks preprocedure commonly is employed to reduce the risk for postprocedural hyperpigmentation in clinical practice.^26,27

Skin Tightening and Body Contouring

In general, skin-tightening and body-contouring devices are among the most sought-after procedures. Studies performed in patients with SOC are limited. Herein, we provide background on why these devices are favorable for patients with SOC and our experiences in using them. A summary of these devices can be found in Supplementary Table S4.

Radiofrequency Skin Tightening—Radiofrequency devices are utilized for skin tightening as well as mild fat reduction; they commonly are used on the abdomen, thighs, buttocks, and face.²⁸ People with SOC are more responsive to radiofrequency skin-tightening therapy due to higher baseline collagen content and dermal thickness, more sebaceous activity and skin elasticity, and more melanin content which offers protective thermal buffering.^29,30 As the radiofrequency device emits heat, penetrating deep into the dermis, it generates collagen remodeling and synthesis within 4 to 6 months posttreatment.

Nonsurgical Fat Reduction

Procedures for nonsurgical fat reduction are favorable due to minimal recovery time, manageable cost, and an in-office procedure setting. As noted previously, there are 6 FDA-indicated interventions for nonsurgical fat reduction: ultrasonography, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring.³¹

Ultrasonography—Ultrasound devices designed for body contouring are used for skin tightening and mild fat reduction through the use of acoustic energy.³² These devices can be divided into 2 categories: high frequency and low frequency, with the high-frequency devices being the most popular. High-frequency ultrasound energy produces heat at target sites, which induces necrosis of adipocytes and stimulates collagen remodeling within the tissue matrix.³³ Tissue temperatures above 56°C stimulate adipocyte necrosis while sparing nearby nerves and vessels.²⁸ Because of the short duration of the procedure, the risk for epidermal damage is minimal. Contrary to high-frequency ultrasonography, focus-pulsed ultrasonography employs low-frequency waves to induce the mechanical disruption of adipocytes, which is generally better tolerated due to its nonthermal mechanism. The latter may be advantageous in patients with SOC due to a reduced risk for thermal injury to the epidermis. Multiple treatments often are needed at 3- to 4-week intervals, resulting in gradual improvement observed over 2 to 6 months. One study of microfocused ultrasonography in 25 Asian patients for treatment of face and neck laxity reported that skin laxity was improved or much improved in 84% (21/25) of patients following treatment.³⁴ Adverse effects were reported as mild and transient, resolving within 90 days.³⁴ Ultrasound devices also were shown to improve wrinkles, texture, and overall appearance of the skin in a 71-year-old African American woman 4 months following treatment (Figure 2). These photographs highlight the clinical utility of a microfocused ultrasound skin-tightening treatment in African American patients.

Cryolipolysis—Cryolipolysis is a noninvasive body contouring procedure that employs controlled cooling to induce subcutaneous panniculitis. Through cold-induced apoptosis of adipocytes, this procedure selectively reduces adipose tissue in localized areas such as the flank, abdomen, thighs, buttocks, back, submental area, and upper arms. The temperature used in cryolipolysis is approximately –10°C.³⁵ The lethal temperature for melanocytes is –4 °C, below which melanocyte apoptosis may be induced, resulting in depigmentation. Given the prolonged contact of the skin with a cryolipolysis device for up to 60 minutes during a body-contouring procedure, there is a risk for resultant depigmentation in darker skin types. Controlled studies are needed to fully evaluate the safety and efficacy of cryolipolysis in patients with SOC. One retrospective study of cryolipolysis applied to the abdomen and upper arm of 4122 Asian patients reported a significant (P<.05) reduction in the circumference of the abdomen and the upper-arm areas. No long-term adverse effects were reported.³⁶

Laser Lipolysis—The 1060-nm diode laser for body contouring selectively destroys adipose tissue, resulting in body contouring via thermally induced inflammation. Hyperthermic exposure for 15 minutes selectively elevates adipocyte temperature between 42°C to 47°C, which triggers apoptosis and the eventual clearance of destroyed cells from the interstitial space.³⁷ The selectivity of the 1060-nm wavelength coupled with the device’s contact cooling system preserves the overlying skin and adnexa during the procedure,³⁷ which would minimize epidermal damage that may induce dyspigmentation in patients with SOC. No notable adverse effects or dyspigmentation have been reported using this device.

Injection Lipolysis—Deoxycholic acid is an injectable adipocytolytic for the reduction of submental fat. It nonselectively lyses muscle and other adjacent nonfatty tissue. One study of 50 Indian patients demonstrated a substantial reduction of submental fat in 90% (45/50).³⁸ For each treatment, 5 mL of 30 mg/mL deoxycholic acid was injected. Serial sessions were conducted at 2-month intervals, and most (64% [32/50]) patients required 3 sessions to see a treatment effect. Adverse effects included transient swelling, lumpiness, and tenderness. A phase 2a investigation of the novel injectable small-molecule drug CBL-514 in 43 Asian and White participants found a significant improvement in the reduction in abdominal fat volume (P<.00001) and thickness (P<.0001) relative to baseline at higher doses (unit dose, 2.0 mg/cm² and 1.6 mg/cm²).³⁹ In addition to the adverse effects mentioned previously, pruritus, repeated urticaria, body rash, and fever also were reported.³⁹  

Radiofrequency Lipolysis—Radiofrequency is used for adipolysis through heat-induced apoptosis. To achieve this effect, adipose tissue must sustain a temperature of 42 °C to 45 °C for at least 15 minutes.⁴⁰ In one study, 4 treatments performed at 7-day intervals resulted in a statistically significant reduction in circumference to the treated areas of the inner and outer thighs without any reported adverse effects (P<0.001).⁴¹ Of note, there was 1 cm of distance between the applicator and the skin. The absence of direct contact with the skin is likely to reduce the risk for postprocedural complications in patients with SOC.

Magnetic Resonance Contouring—Magnetic resonance contouring with high-intensity focused electromagnetic technology is an emerging treatment modality for noninvasive body contouring. One distinguishing characteristic from other currently available noninvasive fat-­reduction therapies is that magnetic resonance may improve strength, tone, and muscle thickness.⁴² This modality is FDA approved for contouring of the buttocks and abdomen and employs electromagnetic energy to stimulate approximately 20,000 muscle contractions within a time frame of 30 minutes. Though the mechanisms causing benefits to muscular and adipose tissue have not been elucidated, current findings suggest that the contractions stimulate substantial lipolysis of adipocytes, resulting in the release of large amounts of free fatty acids that cause damage to nearby adipose tissue.⁴³ Multiple treatments are required over time to maintain effect. No major adverse effects have been reported. The likely mechanism of action of magnetic resonance contouring does not appear to pose an increased risk to patients with SOC.

Final Thoughts

One of the major roadblocks in distilling indications along with associated risks and benefits for nonsurgical cosmetic practices for patients with SOC is a void in the primary literature involving these populations. Clinical experience serves to address this deficit in combination with a thorough review of the literature. The 1064-nm Nd:YAG laser has shown clinical utility in the treatment of DPN, melanoma, and acne scars, but it poses financial constraints to the provider in comparison to modalities used for many years. Notably, NAF resurfacing is preferred for the management of acne scars in patients with SOC and continues to gain popularity for the treatment of photoaging. Regarding skin-tightening and body-contouring devices, studies performed in patients with SOC are limited and affected by factors such as small sample sizes, underrepresentation of FSTs IV through VI, short follow-up durations, and a lack of standardized outcome measures. Additionally, few studies assess pigmentary adverse effects or stratify results by skin type, which is critical given the higher risk for PIH in SOC. Ultrasound devices showed clinical utility in improvement of skin laxity, texture, and overall improvement. Patients with SOC respond well to skin-tightening devices due to the increased collagen synthesis. Regarding emerging devices for reduction of adipocytes, deoxycholic acid when injected showed notable improvement in fat reduction but also had adverse effects. As additional studies on cosmetic procedures in SOC emerge, an expansion of treatment options could be offered to this demographic group with confidence, provided proper treatment and follow-up protocols are in place.

Cosmetic laser procedures as well as energy-based fat reduction and body-contouring devices are increasingly popular among individuals with skin of color (SOC). Innovations in cosmetic devices and procedures tailored for SOC have allowed for the optimization of outcomes in this patient population. In this article, SOC is defined as darker skin types, including Fitzpatrick skin types (FSTs) IV to VI and ethnic backgrounds such as LatinX, African American, Southeast Asian, Native American, Pacific Islander, Middle Eastern, Asian, and African. Indications for laser treatment include dermatosis papulosa nigrans (DPN), acne scars, skin rejuvenation, and hyperpigmentation. There currently are 6 procedures for nonsurgical fat reduction that are approved by the US Food and Drug Administration (FDA): high-frequency focused ultrasound, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring (Supplementary Table S1).¹

In this review, our initial focus is cosmetic laser ­procedures, encompassing FDA-cleared indications along with the associated risks and benefits in SOC populations. Subsequently, we delve into the realms of energy-based fat reduction and body contouring, offering a comprehensive overview of these noninvasive therapies and addressing considerations for efficacy and safety in these patients.

Dermatosis Papulosa Nigra

In patients with SOC, scissor excision, curettage, or electrodesiccation are the mainstay treatments for removal of DPN (Figure 1). Curettage and electrodesiccation can cause temporary postinflammatory hyperpigmentation (PIH) in these populations, while cryotherapy is not a preferred method in patients with SOC due to the possibility of cryotherapy-induced depigmentation. In a 14-patient split-face study comparing the 532-nm potassium titanyl phosphate (KTP) laser vs electrodesiccation in FSTs IV to VI, the KTP-treated side showed an improvement rate of 96%, while the electrodesiccation side showed an improvement rate of 79%. There was a statistically significant favorable experience for KTP with regard to pain tolerability (P=.002).² Complete resolution of lesions may be seen after 3 to 4 sessions at 4-week intervals. Additionally, the 1064-nm Nd:YAG laser was assessed for treatment of DPN in 2 patients, with 70% to 90% of lesions resolved after a single treatment with no complications.³

Most dermatologists still rely on curettage and electrodesiccation instead of laser therapy to remove DPNs in patients with SOC. The use of the Nd:YAG laser is promising yet expensive for the provider both to purchase and maintain. Electrodesiccation has been used by dermatology practices for decades and can be used without permanent discoloration. To minimize the risk for PIH, we recommend application of a healing ointment such as petroleum jelly or aloe vera gel to the treated lesions as well as lightening agents for PIH and daily use of sunscreen. Overall, providers do not need to purchase an expensive laser device for DPN removal.

Acne Scars

The invention of fractional technology in the early 2000s and its favorable safety profile have changed how dermatologists treat scarring in patients with SOC.^4,5 In fact, nonablative fractional (NAF) resurfacing is a preferred treatment modality for management of acne scars in patients with SOC.⁶ In one study of the 1550-nm erbium-doped fiber laser for treatment of acne scars (3 treatments at intervals of 2-3 weeks) in 10 Japanese patients, clinical improvement was seen in all patients and no severe adverse effects were reported.⁷ In another study, 27 Korean patients with FSTs IV and V were treated with an NAF resurfacing device for acne scars. Excellent results were reported in 30% (8/27) of patients, substantial improvement in 59% (16/27), and moderate improvement in 11% (3/27).⁸ To evaluate outcomes in patients treated with NAF resurfacing, a retrospective review of 961 treatments showed a hyperpigmentation rate of 11.6% in those with FST IV and 33% in FST V.⁹

In one study of the short-pulsed nonablative Nd:YAG laser, 9 patients with FSTs I to V and 2 patients with FSTs IV to V underwent 8 treatments at 2-week intervals. Three blinded observers found a 29% improvement in the Global Acne Scar Severity score, while 89% (8/9) of patients self-reported subjective improvement in their acne scars.¹⁰

The 755-nm picosecond laser and diffractive lens array also have been shown to reduce the appearance of acne scars in patients with SOC, as shown via serial photography in a retrospective study of 56 patients with FSTs IV to VI. Transient hyperpigmentation, erythema, and edema were reported.¹¹

Nonablative laser therapy is preferred for skin rejuvenation in patients with SOC due to a reduced risk for postprocedural hyperpigmentation.¹¹ Ablative resurfacing (eg, CO₂ laser) poses major risks for postprocedural hyperpigmentation, hypopigmentation, and scar formation and therefore should be avoided in these populations.^12,13 A study involving 30 Asian patients (FSTs III-IV) demonstrated that the 1550-nm fractional laser was well tolerated, though higher treatment densities and fluences may lead to temporary adverse effects such as increased redness, swelling, and pain (P<.01).¹⁴ Furthermore, greater density was shown to cause higher levels of redness, hyperpigmentation, and swelling in comparison to higher fluence settings. Of note, patient satisfaction was markedly higher in patients who underwent treatment with higher fluence settings but not in patients with higher densities (P<.05). Postprocedural hyperpigmentation was noted in 6.7% (2/30) of patients studied.¹⁴ In another study, 8 patients with FSTs II to V were treated with either the 1064-nm long-pulsed Nd:YAG laser or the grid fractional monopolar radiofrequency laser.¹⁵ All participants experienced a significant decrease in mean wrinkle count using the Lemperle wrinkle assessment (P<.05). A significant decrease in mean wrinkle assessment score from 3.5 to 3.17 in clinical assessment and a decrease from 3.165 to 2.33 for photographic assessment was noted in patients treated with the grid laser (P<.05). A similar decrease in mean wrinkle assessment score was observed in the Nd:YAG group, with a mean decrease of 3.665 to 2.83 after 2 months for clinical assessment and 3.5 to 2.67 for photographic assessment. Among all patients in the study, 68% (6/8) experienced erythema, 25% (2/8) had a burning sensation, and 25% (2/8) experienced urticaria immediately postprocedure.¹⁵

Nonablative fractional resurfacing is preferred for the management of acne scars in patients with SOC. Adverse effects such as hyperpigmentation typically are transient, and the risk may be minimized with strict photoprotective practices following the procedure. Furthermore, avoidance of topicals containing exfoliants or α-hydroxy acids applied to the treated area following the procedure also may mitigate the risk for postprocedural hyperpigmentation.¹⁶ If hyperpigmentation does occur, use of topical melanogenesis inhibitors such as hydroquinone, kojic acid, or azelaic acid has shown some utility in practice.

Skin Rejuvenation

Nonablative fractional lasers (NAFLs) continue to be popular for treatment of photoaging. One study including 10 Asian patients (FSTs III-V) assessed the 1440-nm diode-based fractional laser for facial rejuvenation.¹⁷ After 4 sessions at 2-week intervals, 80% (8/10) of patients reported decreased skin roughness after both the second and third treatments, while 90% (9/10) had improved texture 1 month after the final procedure. Adverse effects included moderate facial edema and one case of transient hyperpigmentation.¹⁷ Another study reported a significant reduction in pore score (P<.002), with patients noting an overall improvement in skin appearance with minimal erythema, dryness, and flaking following 6 sessions at 2-week intervals using the 1440-nm diode-based fractional laser.¹⁸

The 1550-nm diode fractional laser significantly improved skin pigmentation (P<.001) and texture (P<.001) in 10 patients with FSTs II to IV following 5 sessions at 2- to 3-week intervals, with self-resolving erythema and edema posttreatment (Supplementary Table S2).¹⁹ Overall, NAFLs for the treatment of photoaging are effective with minimal adverse effects (eg, facial edema), which can be reduced with application of cold compression to the face and elevation of the head following treatment as well as the use of additional pillows during overnight sleep.

Laser Treatment for Hyperpigmentation Disorders

Melasma—The FDA recently approved fractional photothermolysis for the treatment of melasma; however, due to the risk for hyperpigmentation given its pathogenesis linked to hyperactive melanocytes, this laser is not considered a first-line therapy for melasma.²⁰ In a split-face, randomized study, 22 patients with FSTs III to V who were diagnosed with either dermal or mixed-type melasma were treated with a low-fluence Q-switched Nd:YAG laser combined with hydroquinone 2% vs hydroquinone 2% alone (Supplementary Table S3).²¹ Each patient was treated weekly for 5 consecutive weeks. The laser-treated side was found to reach an average of 92.5% improvement compared with 19.7% on the hydroquinone-only side. Three of the 22 (13.6%) patients developed mottled hypopigmentation after 5 laser treatments, and 8 (36.4%) developed confetti-type hypopigmentation. Four (18.2%) patients developed rebound hyperpigmentation, and all 22 patients experienced recurrence of melasma by 12 weeks posttreatment.²¹

First-line treatment for melasma involves the application of topical lightening agents such as hydroquinone, azelaic acid, kojic acid, retinoids, or mild topical steroids. Combining laser technology with topical medications can enhance treatment outcomes, particularly yielding positive results for patients with persistent pigmentation concerns. Notably, utilization of 650-microsecond technology with the 1064-nm Nd:YAG laser is considered superior in clinical practice, especially for patients with FSTs IV through VI.

Postinflammatory Hyperpigmentation—A retrospective evaluation of 61 patients with FSTs IV to VI with PIH treated with a 1927-nm NAFL showed a mean improvement of 43.24%, as assessed by 2 dermatologists.²² Additionally, the Nd:YAG 1064-nm 650-microsecond pulse duration laser is an emerging treatment that delivers high and low fluences between 4 J/cm² and 255 J/cm² within a single 650-microsecond pulse duration.²³ The short-pulse duration avoids overheating the skin, mitigating procedural discomfort and the risk for adverse effects commonly seen with the previous generation of low-pulsed lasers. In addition to PIH, this laser has been successfully used to treat pseudofolliculitis barbae.²⁴

Solar Lentigos—In a split-face study treating solar lentigos in Asian patients, 4 treatments with a low-pulsed KTP 532-nm laser were administered with and without a second treatment with a low-pulsed 1064-nm Nd:YAG laser.²⁵ Scoring of a modified pigment severity index and measurement of the melanin index showed that skin treated with the low-pulsed 532-nm laser alone and in combination with the low-pulsed 1064-nm Nd:YAG laser resulted in improvement at 3 months’ follow-up. However, there was no difference between the 2 sides of the face, leading the researchers to conclude that the low-pulsed 532-nm laser appears to be safe and effective for treatment of solar lentigos in Asian patients and does not require the addition of the low-pulsed 1064-nm laser.²⁵  

To avoid hyperpigmentation in patients with SOC, strict photoprotection to the treated areas should be advised. Proper cooling of the laser-treated area is required to minimize PIH, as cooling decreases tissue damage and excessive thermal injury. Test spots should be considered prior to initiation of the full laser treatment. Hydroquinone in a 4% concentration applied daily for 2 weeks preprocedure commonly is employed to reduce the risk for postprocedural hyperpigmentation in clinical practice.^26,27

Skin Tightening and Body Contouring

In general, skin-tightening and body-contouring devices are among the most sought-after procedures. Studies performed in patients with SOC are limited. Herein, we provide background on why these devices are favorable for patients with SOC and our experiences in using them. A summary of these devices can be found in Supplementary Table S4.

Radiofrequency Skin Tightening—Radiofrequency devices are utilized for skin tightening as well as mild fat reduction; they commonly are used on the abdomen, thighs, buttocks, and face.²⁸ People with SOC are more responsive to radiofrequency skin-tightening therapy due to higher baseline collagen content and dermal thickness, more sebaceous activity and skin elasticity, and more melanin content which offers protective thermal buffering.^29,30 As the radiofrequency device emits heat, penetrating deep into the dermis, it generates collagen remodeling and synthesis within 4 to 6 months posttreatment.

Nonsurgical Fat Reduction

Procedures for nonsurgical fat reduction are favorable due to minimal recovery time, manageable cost, and an in-office procedure setting. As noted previously, there are 6 FDA-indicated interventions for nonsurgical fat reduction: ultrasonography, cryolipolysis, laser lipolysis, injection lipolysis, radiofrequency lipolysis, and magnetic resonance contouring.³¹

Ultrasonography—Ultrasound devices designed for body contouring are used for skin tightening and mild fat reduction through the use of acoustic energy.³² These devices can be divided into 2 categories: high frequency and low frequency, with the high-frequency devices being the most popular. High-frequency ultrasound energy produces heat at target sites, which induces necrosis of adipocytes and stimulates collagen remodeling within the tissue matrix.³³ Tissue temperatures above 56°C stimulate adipocyte necrosis while sparing nearby nerves and vessels.²⁸ Because of the short duration of the procedure, the risk for epidermal damage is minimal. Contrary to high-frequency ultrasonography, focus-pulsed ultrasonography employs low-frequency waves to induce the mechanical disruption of adipocytes, which is generally better tolerated due to its nonthermal mechanism. The latter may be advantageous in patients with SOC due to a reduced risk for thermal injury to the epidermis. Multiple treatments often are needed at 3- to 4-week intervals, resulting in gradual improvement observed over 2 to 6 months. One study of microfocused ultrasonography in 25 Asian patients for treatment of face and neck laxity reported that skin laxity was improved or much improved in 84% (21/25) of patients following treatment.³⁴ Adverse effects were reported as mild and transient, resolving within 90 days.³⁴ Ultrasound devices also were shown to improve wrinkles, texture, and overall appearance of the skin in a 71-year-old African American woman 4 months following treatment (Figure 2). These photographs highlight the clinical utility of a microfocused ultrasound skin-tightening treatment in African American patients.

Cryolipolysis—Cryolipolysis is a noninvasive body contouring procedure that employs controlled cooling to induce subcutaneous panniculitis. Through cold-induced apoptosis of adipocytes, this procedure selectively reduces adipose tissue in localized areas such as the flank, abdomen, thighs, buttocks, back, submental area, and upper arms. The temperature used in cryolipolysis is approximately –10°C.³⁵ The lethal temperature for melanocytes is –4 °C, below which melanocyte apoptosis may be induced, resulting in depigmentation. Given the prolonged contact of the skin with a cryolipolysis device for up to 60 minutes during a body-contouring procedure, there is a risk for resultant depigmentation in darker skin types. Controlled studies are needed to fully evaluate the safety and efficacy of cryolipolysis in patients with SOC. One retrospective study of cryolipolysis applied to the abdomen and upper arm of 4122 Asian patients reported a significant (P<.05) reduction in the circumference of the abdomen and the upper-arm areas. No long-term adverse effects were reported.³⁶

Laser Lipolysis—The 1060-nm diode laser for body contouring selectively destroys adipose tissue, resulting in body contouring via thermally induced inflammation. Hyperthermic exposure for 15 minutes selectively elevates adipocyte temperature between 42°C to 47°C, which triggers apoptosis and the eventual clearance of destroyed cells from the interstitial space.³⁷ The selectivity of the 1060-nm wavelength coupled with the device’s contact cooling system preserves the overlying skin and adnexa during the procedure,³⁷ which would minimize epidermal damage that may induce dyspigmentation in patients with SOC. No notable adverse effects or dyspigmentation have been reported using this device.

Injection Lipolysis—Deoxycholic acid is an injectable adipocytolytic for the reduction of submental fat. It nonselectively lyses muscle and other adjacent nonfatty tissue. One study of 50 Indian patients demonstrated a substantial reduction of submental fat in 90% (45/50).³⁸ For each treatment, 5 mL of 30 mg/mL deoxycholic acid was injected. Serial sessions were conducted at 2-month intervals, and most (64% [32/50]) patients required 3 sessions to see a treatment effect. Adverse effects included transient swelling, lumpiness, and tenderness. A phase 2a investigation of the novel injectable small-molecule drug CBL-514 in 43 Asian and White participants found a significant improvement in the reduction in abdominal fat volume (P<.00001) and thickness (P<.0001) relative to baseline at higher doses (unit dose, 2.0 mg/cm² and 1.6 mg/cm²).³⁹ In addition to the adverse effects mentioned previously, pruritus, repeated urticaria, body rash, and fever also were reported.³⁹  

Radiofrequency Lipolysis—Radiofrequency is used for adipolysis through heat-induced apoptosis. To achieve this effect, adipose tissue must sustain a temperature of 42 °C to 45 °C for at least 15 minutes.⁴⁰ In one study, 4 treatments performed at 7-day intervals resulted in a statistically significant reduction in circumference to the treated areas of the inner and outer thighs without any reported adverse effects (P<0.001).⁴¹ Of note, there was 1 cm of distance between the applicator and the skin. The absence of direct contact with the skin is likely to reduce the risk for postprocedural complications in patients with SOC.

Magnetic Resonance Contouring—Magnetic resonance contouring with high-intensity focused electromagnetic technology is an emerging treatment modality for noninvasive body contouring. One distinguishing characteristic from other currently available noninvasive fat-­reduction therapies is that magnetic resonance may improve strength, tone, and muscle thickness.⁴² This modality is FDA approved for contouring of the buttocks and abdomen and employs electromagnetic energy to stimulate approximately 20,000 muscle contractions within a time frame of 30 minutes. Though the mechanisms causing benefits to muscular and adipose tissue have not been elucidated, current findings suggest that the contractions stimulate substantial lipolysis of adipocytes, resulting in the release of large amounts of free fatty acids that cause damage to nearby adipose tissue.⁴³ Multiple treatments are required over time to maintain effect. No major adverse effects have been reported. The likely mechanism of action of magnetic resonance contouring does not appear to pose an increased risk to patients with SOC.

Final Thoughts

One of the major roadblocks in distilling indications along with associated risks and benefits for nonsurgical cosmetic practices for patients with SOC is a void in the primary literature involving these populations. Clinical experience serves to address this deficit in combination with a thorough review of the literature. The 1064-nm Nd:YAG laser has shown clinical utility in the treatment of DPN, melanoma, and acne scars, but it poses financial constraints to the provider in comparison to modalities used for many years. Notably, NAF resurfacing is preferred for the management of acne scars in patients with SOC and continues to gain popularity for the treatment of photoaging. Regarding skin-tightening and body-contouring devices, studies performed in patients with SOC are limited and affected by factors such as small sample sizes, underrepresentation of FSTs IV through VI, short follow-up durations, and a lack of standardized outcome measures. Additionally, few studies assess pigmentary adverse effects or stratify results by skin type, which is critical given the higher risk for PIH in SOC. Ultrasound devices showed clinical utility in improvement of skin laxity, texture, and overall improvement. Patients with SOC respond well to skin-tightening devices due to the increased collagen synthesis. Regarding emerging devices for reduction of adipocytes, deoxycholic acid when injected showed notable improvement in fat reduction but also had adverse effects. As additional studies on cosmetic procedures in SOC emerge, an expansion of treatment options could be offered to this demographic group with confidence, provided proper treatment and follow-up protocols are in place.

Personal electronic devices have become more common as consumer-driven health and entertainment practices continue to increase in popularity. A wide variety of devices including smartphones, headphones and earbuds, fitness watches, and continuous glucose monitors (CGMs) allow consumers to collect data and personalize their daily activities and health practices. The global market for fitness tracking devices alone was valued at $62.03 billion in 2024 and is projected to grow to $290.85 billion by 2032.¹ Accordingly, the growing demand for continuous data tracking has led to new and prolonged skin contact with these devices, which have become emerging sources of allergic contact dermatitis (ACD). In this article, we provide a summary of the potential allergenicity of personal electronic devices with a focus on wearable devices, including clinical manifestations, reported allergens, and patch testing and management considerations (Table^2-28).

Earbuds and Headphones

Wireless earbuds and headphones are used for listening to media and may contain microphones for voice calls. Earbuds are inserted into the ears while headphones are worn over the ears with a connecting band across the scalp. These devices frequently are worn during physical activity and thus in the setting of moist sweaty environments and mechanical friction on the skin. Depending on the style of the earbuds or headphones, associated ACD may manifest as acute or chronic pruritic eczema involving the inner and/or outer ears and potentially the periauricular areas or scalp.² In a reported case of earbud ACD, the patient first presented to an otolaryngologist before being referred to a dermatologist for further evaluation and patch testing.⁹ Clinicians may be unfamiliar with these devices as a source of ACD or may potentially overlook inner ear canal manifestations, which may delay diagnosis.

Allergens reported in earbuds include (meth)acrylates,^4-6 nickel, gold,⁸ and silicone.⁹ Apple AirPods and Samsung Galaxy Buds disclose the presence of acrylates and nickel.^5,6 Cases also have been reported of ACD to gold earbud microphones⁸ and unknown allergens within silicone tips.^4,9 Acrylates, named the 2012 Allergen of the Year by the American Contact Dermatitis Society,²⁹ are used in a wide variety of consumer products as adhesives and coatings and are among the most frequently suspected headphone allergens.⁴ While fully polymerized acrylates theoretically are nonallergenic, residual acrylic monomers are potent allergens that may be found in in these products due to incomplete curing or polymer breakdown.²⁹ It remains unclear whether earbud allergen concentrations are sufficient to induce sensitization or merely elicit ACD in previously sensitized users.²⁹ Among patients with earbud ACD, the finding of inconsistent patch test reactions/cross-reactions led to the hypothesis that these headphones may contain an unidentified proprietary (meth)acrylate.⁴

Headphones, often utilized by runners and gymgoers for their comfort and fit, also have gained recent attention for their unique allergen profiles. In 2024, a case series described primary sensitization to octylisothiazolinone causing severe headphone-related ACD.³ This preservative, which is in the same family as methylchloroisothiazolinone/methylisothiazolinone, is used as a biocide in the leather or faux leather that encases the foam padding of headphones.³ Another case report highlighted ACD caused by methylisothiazolinone, methylchloroisothiazolinone, and octylisothiazolinone present in various components of a pair of headphones.² These cases are notable, as European legislation limiting the use of methylchloroisothiazolinone/methylisothiazolinone in personal care products does not apply to inclusion of isothiazolinones in other product categories, such as detergents, paints, glues, and personal electronic devices.

Mobile Phones

Mobile phones are a staple in modern society, used for a multitude of tasks including communication, internet browsing, entertainment, and activity tracking. In the early 2000s, mobile phone ACD primarily manifested on the lateral face, ears, and periauricular regions,¹² as well as the thighs from carriage in pants pockets. Early cases of mobile phone ACD were attributed to metals including chromium¹⁶ and nickel.¹⁴ At that time, lengthy and frequent phone calls with the device against the ear were thought to increase exposure to metal allergens.³⁰ More recently, as the utility of these devices has evolved, ACD has been reported to manifest on the fingers and hands associated with contact with cell phone cases, accessories, and screen protectors (Figure). In one report, a 17-year-old boy with chronic eczema of the palms was diagnosed with ACD to the rubber-related chemicals paraphenylenediamine and N-cyclohexyl-N-phenyl-4-phenylenediamine, confirmed via chemical analysis to be present in a phone case the patient used during daily gaming.¹⁷ Similarly, another case of palmar ACD resulted from thiuram rubber accelerators in a phone case.¹⁸ Most recently, a Japanese patient with a history of skin reactions to costume jewelry developed ACD involving the proximal middle finger due to exposure to nickel in a ring-grip phone case.¹¹ While the European Union has enacted regulations regarding maximum nickel leaching in products that come into direct and prolonged contact with the skin, such regulations have not been implemented in Japan or the United States.¹¹ International e-commerce makes these grips widely available, even in regions where strict metal regulations are in place. As screen time increases, it is important to consider all phone-related exposures including components of the case, screen protector, and main device body.

Watches

Smart watches and fitness bands are widely available to consumers and serve a variety of health and lifestyle functions. Features include fitness tracking, notification management, mobile payment, electrocardiography, navigation, and sleep and oxygen sensors. Multiple companies have produced hand- and wrist-based sensors for detailed wellness tracking within these categories. Allergic contact dermatitis to smart watches and wristbands manifests as eczematous lesions on the wrist (dorsal,^21,22 volar,²⁰ or circumferential involvement^23,24).

(Meth)acrylates used to adhere screen protectors, house lithium ion batteries, and bind metal to plastic have been reported to cause ACD in smart watch users.^22,25 In addition, there are at least 2 published reports of ACD to nickel in Apple Watches.^21,31 Apple, having sold more than 229 million watches worldwide, has acknowledged the presence of trace acrylates and nickel in their watches (the latter falling below European Registration, Evaluation, Authorization, and Restriction of Chemicals limits).³² Hosoki et al²⁰ identified ACD resulting from chromium exposure in the clasp of an Apple Watch band, which remains unreported by the manufacturer as a potential allergen.

Continuous Glucose Monitors

Continuous glucose monitoring systems provide users with dynamic information on their glycemic status and are associated with lower glycated hemoglobin and reduced episodes of hypoglycemia in patients with diabetes.³³ Recently, growing interest in personalized health monitoring and performance optimization has expanded CGM use to individuals without diabetes; there are 2 over-the-counter CGM options currently available in the United States.³⁴

Allergic contact dermatitis to CGMs in patients with diabetes is well characterized, manifesting as pruritic acute or chronic dermatitis at the sensor site.²⁷ To date, we are unaware of published cases of ACD associated with use of CGM in individuals without diabetes; however, wearing a CGM during athletic activities and sweating could potentially increase adhesive degradation and/or penetration of allergens in the skin.⁶

Isobornyl acrylate, named the 2020 Allergen of the Year,³⁵ is the most well-known contact allergen in glucose sensors.^36,33 Initially suspected as a component of the CGM skin adhesive, isobornyl acrylate was found to leach from the device body onto the skin in users of one CGM device.³⁶ Other reported allergens in CGM devices include colophony and related rosin derivatives, ethyl cyanoacrylate, and several chemicals that are not available as commercial patch test substances.²⁷ Understanding these potential allergens is important for patch testing considerations as CGM use increases in individuals without diabetes.

Final Thoughts

Allergic contact dermatitis to personal electronic devices including wearables, sensors, and fitness trackers is an emerging problem that should be considered in cases of dermatitis of the wrists, hands, face, ears, or in any area that comes into contact with such devices. Although in-depth studies are lacking, certain wearable devices appear to introduce continuous, low-level allergen exposure that may be below the sensitization threshold but still is capable of eliciting ACD in previously sensitized users.^21,26 Furthermore, increased allergen exposure is facilitated by prolonged skin contact, mechanical friction, and sweat.

Comprehensive patch testing often is necessary to diagnose cases of ACD to personal electronic devices.³³ The thin-layer rapid use epicutaneous (T.R.U.E.) test does not include (meth)acrylates, which repeatedly have come up as culprit allergens.³⁷ Isobornyl acrylate, a key allergen related to CGMs, is absent from standard patch test series.²⁶ Nickel remains a common culprit in these devices despite adherence to European regulations.²¹ Since there is no obligation for manufacturers to declare all possible ingredients, chemical analysis can be useful in identifying potential allergens and directing the patch test strategy, but this is not feasible in general clinical practice outside the research setting.²

Following patch testing, patient education is essential to managing personal electronic device—induced ACD. Informed patients should switch to products that do not contain their triggers—although this may be more easily said than done, since incomplete ingredient disclosure from manufacturers may necessitate a frustrating and expensive trial-and-error approach. As wearable technology proliferates, device composition and potential contact allergen transparency must be prioritized by manufacturers and regulatory bodies. Until then, clinicians should stay on their toes regarding new and emerging clinical presentations and contact allergens in hopes of improving patient outcomes.

Personal electronic devices have become more common as consumer-driven health and entertainment practices continue to increase in popularity. A wide variety of devices including smartphones, headphones and earbuds, fitness watches, and continuous glucose monitors (CGMs) allow consumers to collect data and personalize their daily activities and health practices. The global market for fitness tracking devices alone was valued at $62.03 billion in 2024 and is projected to grow to $290.85 billion by 2032.¹ Accordingly, the growing demand for continuous data tracking has led to new and prolonged skin contact with these devices, which have become emerging sources of allergic contact dermatitis (ACD). In this article, we provide a summary of the potential allergenicity of personal electronic devices with a focus on wearable devices, including clinical manifestations, reported allergens, and patch testing and management considerations (Table^2-28).

Earbuds and Headphones

Wireless earbuds and headphones are used for listening to media and may contain microphones for voice calls. Earbuds are inserted into the ears while headphones are worn over the ears with a connecting band across the scalp. These devices frequently are worn during physical activity and thus in the setting of moist sweaty environments and mechanical friction on the skin. Depending on the style of the earbuds or headphones, associated ACD may manifest as acute or chronic pruritic eczema involving the inner and/or outer ears and potentially the periauricular areas or scalp.² In a reported case of earbud ACD, the patient first presented to an otolaryngologist before being referred to a dermatologist for further evaluation and patch testing.⁹ Clinicians may be unfamiliar with these devices as a source of ACD or may potentially overlook inner ear canal manifestations, which may delay diagnosis.

Allergens reported in earbuds include (meth)acrylates,^4-6 nickel, gold,⁸ and silicone.⁹ Apple AirPods and Samsung Galaxy Buds disclose the presence of acrylates and nickel.^5,6 Cases also have been reported of ACD to gold earbud microphones⁸ and unknown allergens within silicone tips.^4,9 Acrylates, named the 2012 Allergen of the Year by the American Contact Dermatitis Society,²⁹ are used in a wide variety of consumer products as adhesives and coatings and are among the most frequently suspected headphone allergens.⁴ While fully polymerized acrylates theoretically are nonallergenic, residual acrylic monomers are potent allergens that may be found in in these products due to incomplete curing or polymer breakdown.²⁹ It remains unclear whether earbud allergen concentrations are sufficient to induce sensitization or merely elicit ACD in previously sensitized users.²⁹ Among patients with earbud ACD, the finding of inconsistent patch test reactions/cross-reactions led to the hypothesis that these headphones may contain an unidentified proprietary (meth)acrylate.⁴

Headphones, often utilized by runners and gymgoers for their comfort and fit, also have gained recent attention for their unique allergen profiles. In 2024, a case series described primary sensitization to octylisothiazolinone causing severe headphone-related ACD.³ This preservative, which is in the same family as methylchloroisothiazolinone/methylisothiazolinone, is used as a biocide in the leather or faux leather that encases the foam padding of headphones.³ Another case report highlighted ACD caused by methylisothiazolinone, methylchloroisothiazolinone, and octylisothiazolinone present in various components of a pair of headphones.² These cases are notable, as European legislation limiting the use of methylchloroisothiazolinone/methylisothiazolinone in personal care products does not apply to inclusion of isothiazolinones in other product categories, such as detergents, paints, glues, and personal electronic devices.

Mobile Phones

Mobile phones are a staple in modern society, used for a multitude of tasks including communication, internet browsing, entertainment, and activity tracking. In the early 2000s, mobile phone ACD primarily manifested on the lateral face, ears, and periauricular regions,¹² as well as the thighs from carriage in pants pockets. Early cases of mobile phone ACD were attributed to metals including chromium¹⁶ and nickel.¹⁴ At that time, lengthy and frequent phone calls with the device against the ear were thought to increase exposure to metal allergens.³⁰ More recently, as the utility of these devices has evolved, ACD has been reported to manifest on the fingers and hands associated with contact with cell phone cases, accessories, and screen protectors (Figure). In one report, a 17-year-old boy with chronic eczema of the palms was diagnosed with ACD to the rubber-related chemicals paraphenylenediamine and N-cyclohexyl-N-phenyl-4-phenylenediamine, confirmed via chemical analysis to be present in a phone case the patient used during daily gaming.¹⁷ Similarly, another case of palmar ACD resulted from thiuram rubber accelerators in a phone case.¹⁸ Most recently, a Japanese patient with a history of skin reactions to costume jewelry developed ACD involving the proximal middle finger due to exposure to nickel in a ring-grip phone case.¹¹ While the European Union has enacted regulations regarding maximum nickel leaching in products that come into direct and prolonged contact with the skin, such regulations have not been implemented in Japan or the United States.¹¹ International e-commerce makes these grips widely available, even in regions where strict metal regulations are in place. As screen time increases, it is important to consider all phone-related exposures including components of the case, screen protector, and main device body.

Watches

Smart watches and fitness bands are widely available to consumers and serve a variety of health and lifestyle functions. Features include fitness tracking, notification management, mobile payment, electrocardiography, navigation, and sleep and oxygen sensors. Multiple companies have produced hand- and wrist-based sensors for detailed wellness tracking within these categories. Allergic contact dermatitis to smart watches and wristbands manifests as eczematous lesions on the wrist (dorsal,^21,22 volar,²⁰ or circumferential involvement^23,24).

(Meth)acrylates used to adhere screen protectors, house lithium ion batteries, and bind metal to plastic have been reported to cause ACD in smart watch users.^22,25 In addition, there are at least 2 published reports of ACD to nickel in Apple Watches.^21,31 Apple, having sold more than 229 million watches worldwide, has acknowledged the presence of trace acrylates and nickel in their watches (the latter falling below European Registration, Evaluation, Authorization, and Restriction of Chemicals limits).³² Hosoki et al²⁰ identified ACD resulting from chromium exposure in the clasp of an Apple Watch band, which remains unreported by the manufacturer as a potential allergen.

Continuous Glucose Monitors

Continuous glucose monitoring systems provide users with dynamic information on their glycemic status and are associated with lower glycated hemoglobin and reduced episodes of hypoglycemia in patients with diabetes.³³ Recently, growing interest in personalized health monitoring and performance optimization has expanded CGM use to individuals without diabetes; there are 2 over-the-counter CGM options currently available in the United States.³⁴

Allergic contact dermatitis to CGMs in patients with diabetes is well characterized, manifesting as pruritic acute or chronic dermatitis at the sensor site.²⁷ To date, we are unaware of published cases of ACD associated with use of CGM in individuals without diabetes; however, wearing a CGM during athletic activities and sweating could potentially increase adhesive degradation and/or penetration of allergens in the skin.⁶

Isobornyl acrylate, named the 2020 Allergen of the Year,³⁵ is the most well-known contact allergen in glucose sensors.^36,33 Initially suspected as a component of the CGM skin adhesive, isobornyl acrylate was found to leach from the device body onto the skin in users of one CGM device.³⁶ Other reported allergens in CGM devices include colophony and related rosin derivatives, ethyl cyanoacrylate, and several chemicals that are not available as commercial patch test substances.²⁷ Understanding these potential allergens is important for patch testing considerations as CGM use increases in individuals without diabetes.

Final Thoughts

Allergic contact dermatitis to personal electronic devices including wearables, sensors, and fitness trackers is an emerging problem that should be considered in cases of dermatitis of the wrists, hands, face, ears, or in any area that comes into contact with such devices. Although in-depth studies are lacking, certain wearable devices appear to introduce continuous, low-level allergen exposure that may be below the sensitization threshold but still is capable of eliciting ACD in previously sensitized users.^21,26 Furthermore, increased allergen exposure is facilitated by prolonged skin contact, mechanical friction, and sweat.

Comprehensive patch testing often is necessary to diagnose cases of ACD to personal electronic devices.³³ The thin-layer rapid use epicutaneous (T.R.U.E.) test does not include (meth)acrylates, which repeatedly have come up as culprit allergens.³⁷ Isobornyl acrylate, a key allergen related to CGMs, is absent from standard patch test series.²⁶ Nickel remains a common culprit in these devices despite adherence to European regulations.²¹ Since there is no obligation for manufacturers to declare all possible ingredients, chemical analysis can be useful in identifying potential allergens and directing the patch test strategy, but this is not feasible in general clinical practice outside the research setting.²

Following patch testing, patient education is essential to managing personal electronic device—induced ACD. Informed patients should switch to products that do not contain their triggers—although this may be more easily said than done, since incomplete ingredient disclosure from manufacturers may necessitate a frustrating and expensive trial-and-error approach. As wearable technology proliferates, device composition and potential contact allergen transparency must be prioritized by manufacturers and regulatory bodies. Until then, clinicians should stay on their toes regarding new and emerging clinical presentations and contact allergens in hopes of improving patient outcomes.

Personal electronic devices have become more common as consumer-driven health and entertainment practices continue to increase in popularity. A wide variety of devices including smartphones, headphones and earbuds, fitness watches, and continuous glucose monitors (CGMs) allow consumers to collect data and personalize their daily activities and health practices. The global market for fitness tracking devices alone was valued at $62.03 billion in 2024 and is projected to grow to $290.85 billion by 2032.¹ Accordingly, the growing demand for continuous data tracking has led to new and prolonged skin contact with these devices, which have become emerging sources of allergic contact dermatitis (ACD). In this article, we provide a summary of the potential allergenicity of personal electronic devices with a focus on wearable devices, including clinical manifestations, reported allergens, and patch testing and management considerations (Table^2-28).

Earbuds and Headphones

Wireless earbuds and headphones are used for listening to media and may contain microphones for voice calls. Earbuds are inserted into the ears while headphones are worn over the ears with a connecting band across the scalp. These devices frequently are worn during physical activity and thus in the setting of moist sweaty environments and mechanical friction on the skin. Depending on the style of the earbuds or headphones, associated ACD may manifest as acute or chronic pruritic eczema involving the inner and/or outer ears and potentially the periauricular areas or scalp.² In a reported case of earbud ACD, the patient first presented to an otolaryngologist before being referred to a dermatologist for further evaluation and patch testing.⁹ Clinicians may be unfamiliar with these devices as a source of ACD or may potentially overlook inner ear canal manifestations, which may delay diagnosis.

Allergens reported in earbuds include (meth)acrylates,^4-6 nickel, gold,⁸ and silicone.⁹ Apple AirPods and Samsung Galaxy Buds disclose the presence of acrylates and nickel.^5,6 Cases also have been reported of ACD to gold earbud microphones⁸ and unknown allergens within silicone tips.^4,9 Acrylates, named the 2012 Allergen of the Year by the American Contact Dermatitis Society,²⁹ are used in a wide variety of consumer products as adhesives and coatings and are among the most frequently suspected headphone allergens.⁴ While fully polymerized acrylates theoretically are nonallergenic, residual acrylic monomers are potent allergens that may be found in in these products due to incomplete curing or polymer breakdown.²⁹ It remains unclear whether earbud allergen concentrations are sufficient to induce sensitization or merely elicit ACD in previously sensitized users.²⁹ Among patients with earbud ACD, the finding of inconsistent patch test reactions/cross-reactions led to the hypothesis that these headphones may contain an unidentified proprietary (meth)acrylate.⁴

Headphones, often utilized by runners and gymgoers for their comfort and fit, also have gained recent attention for their unique allergen profiles. In 2024, a case series described primary sensitization to octylisothiazolinone causing severe headphone-related ACD.³ This preservative, which is in the same family as methylchloroisothiazolinone/methylisothiazolinone, is used as a biocide in the leather or faux leather that encases the foam padding of headphones.³ Another case report highlighted ACD caused by methylisothiazolinone, methylchloroisothiazolinone, and octylisothiazolinone present in various components of a pair of headphones.² These cases are notable, as European legislation limiting the use of methylchloroisothiazolinone/methylisothiazolinone in personal care products does not apply to inclusion of isothiazolinones in other product categories, such as detergents, paints, glues, and personal electronic devices.

Mobile Phones

Mobile phones are a staple in modern society, used for a multitude of tasks including communication, internet browsing, entertainment, and activity tracking. In the early 2000s, mobile phone ACD primarily manifested on the lateral face, ears, and periauricular regions,¹² as well as the thighs from carriage in pants pockets. Early cases of mobile phone ACD were attributed to metals including chromium¹⁶ and nickel.¹⁴ At that time, lengthy and frequent phone calls with the device against the ear were thought to increase exposure to metal allergens.³⁰ More recently, as the utility of these devices has evolved, ACD has been reported to manifest on the fingers and hands associated with contact with cell phone cases, accessories, and screen protectors (Figure). In one report, a 17-year-old boy with chronic eczema of the palms was diagnosed with ACD to the rubber-related chemicals paraphenylenediamine and N-cyclohexyl-N-phenyl-4-phenylenediamine, confirmed via chemical analysis to be present in a phone case the patient used during daily gaming.¹⁷ Similarly, another case of palmar ACD resulted from thiuram rubber accelerators in a phone case.¹⁸ Most recently, a Japanese patient with a history of skin reactions to costume jewelry developed ACD involving the proximal middle finger due to exposure to nickel in a ring-grip phone case.¹¹ While the European Union has enacted regulations regarding maximum nickel leaching in products that come into direct and prolonged contact with the skin, such regulations have not been implemented in Japan or the United States.¹¹ International e-commerce makes these grips widely available, even in regions where strict metal regulations are in place. As screen time increases, it is important to consider all phone-related exposures including components of the case, screen protector, and main device body.

Watches

Smart watches and fitness bands are widely available to consumers and serve a variety of health and lifestyle functions. Features include fitness tracking, notification management, mobile payment, electrocardiography, navigation, and sleep and oxygen sensors. Multiple companies have produced hand- and wrist-based sensors for detailed wellness tracking within these categories. Allergic contact dermatitis to smart watches and wristbands manifests as eczematous lesions on the wrist (dorsal,^21,22 volar,²⁰ or circumferential involvement^23,24).

(Meth)acrylates used to adhere screen protectors, house lithium ion batteries, and bind metal to plastic have been reported to cause ACD in smart watch users.^22,25 In addition, there are at least 2 published reports of ACD to nickel in Apple Watches.^21,31 Apple, having sold more than 229 million watches worldwide, has acknowledged the presence of trace acrylates and nickel in their watches (the latter falling below European Registration, Evaluation, Authorization, and Restriction of Chemicals limits).³² Hosoki et al²⁰ identified ACD resulting from chromium exposure in the clasp of an Apple Watch band, which remains unreported by the manufacturer as a potential allergen.

Continuous Glucose Monitors

Continuous glucose monitoring systems provide users with dynamic information on their glycemic status and are associated with lower glycated hemoglobin and reduced episodes of hypoglycemia in patients with diabetes.³³ Recently, growing interest in personalized health monitoring and performance optimization has expanded CGM use to individuals without diabetes; there are 2 over-the-counter CGM options currently available in the United States.³⁴

Allergic contact dermatitis to CGMs in patients with diabetes is well characterized, manifesting as pruritic acute or chronic dermatitis at the sensor site.²⁷ To date, we are unaware of published cases of ACD associated with use of CGM in individuals without diabetes; however, wearing a CGM during athletic activities and sweating could potentially increase adhesive degradation and/or penetration of allergens in the skin.⁶

Isobornyl acrylate, named the 2020 Allergen of the Year,³⁵ is the most well-known contact allergen in glucose sensors.^36,33 Initially suspected as a component of the CGM skin adhesive, isobornyl acrylate was found to leach from the device body onto the skin in users of one CGM device.³⁶ Other reported allergens in CGM devices include colophony and related rosin derivatives, ethyl cyanoacrylate, and several chemicals that are not available as commercial patch test substances.²⁷ Understanding these potential allergens is important for patch testing considerations as CGM use increases in individuals without diabetes.

Final Thoughts

Allergic contact dermatitis to personal electronic devices including wearables, sensors, and fitness trackers is an emerging problem that should be considered in cases of dermatitis of the wrists, hands, face, ears, or in any area that comes into contact with such devices. Although in-depth studies are lacking, certain wearable devices appear to introduce continuous, low-level allergen exposure that may be below the sensitization threshold but still is capable of eliciting ACD in previously sensitized users.^21,26 Furthermore, increased allergen exposure is facilitated by prolonged skin contact, mechanical friction, and sweat.

Comprehensive patch testing often is necessary to diagnose cases of ACD to personal electronic devices.³³ The thin-layer rapid use epicutaneous (T.R.U.E.) test does not include (meth)acrylates, which repeatedly have come up as culprit allergens.³⁷ Isobornyl acrylate, a key allergen related to CGMs, is absent from standard patch test series.²⁶ Nickel remains a common culprit in these devices despite adherence to European regulations.²¹ Since there is no obligation for manufacturers to declare all possible ingredients, chemical analysis can be useful in identifying potential allergens and directing the patch test strategy, but this is not feasible in general clinical practice outside the research setting.²

Following patch testing, patient education is essential to managing personal electronic device—induced ACD. Informed patients should switch to products that do not contain their triggers—although this may be more easily said than done, since incomplete ingredient disclosure from manufacturers may necessitate a frustrating and expensive trial-and-error approach. As wearable technology proliferates, device composition and potential contact allergen transparency must be prioritized by manufacturers and regulatory bodies. Until then, clinicians should stay on their toes regarding new and emerging clinical presentations and contact allergens in hopes of improving patient outcomes.

Practice Gap

Many dermatology practices utilize pens and markers to label biopsy specimen containers, but the ink may have variable susceptibility to fading and smearing when exposed to moisture before processing. Specimen containers often are placed in plastic bags for transport. If formalin accidentally spills into the bag during this time, the labels may be exposed to moisture for hours, overnight, or even over a weekend. Effective labeling with formalin-resistant ink is crucial for maintaining the clarity of anatomic location and planning treatment, especially when multiple samples are obtained.

The Technique

We tested 12 pens and markers commonly used when labeling specimen containers to determine their susceptibility to fading due to accidental formalin exposure (Figure). Various inks were allowed to dry on sample specimen labels for 5 minutes before a thin layer of 10% buffered formalin was evenly distributed over the dried ink. Photographs of the labels were taken at baseline as well as 15 minutes, 1 hour, 3 hours, and 24 hours after formalin exposure.

Fading was observed in both the skin marker and gel panes after 15 minutes and peaked after 1 hour. Gel pens were most susceptible to fading on exposure to formalin, and the level of fading varied by ink color, with certain colors disappearing almost entirely (Figure). The solvent-resistant marker had a robust defense to formalin, as did both ballpoint pens.

Practice Implications

Given our findings, dermatology practices should avoid using gel pens to label specimen containers. Solvent-resistant markers performed as expected; however, ballpoint pens appeared to withstand formalin exposure to a similar degree and often are more readily available. Labeling biopsy specimens with an appropriate ink ensures that each sample is clearly identified with the appropriate anatomic location and any other relevant patient information.

Practice Gap

Many dermatology practices utilize pens and markers to label biopsy specimen containers, but the ink may have variable susceptibility to fading and smearing when exposed to moisture before processing. Specimen containers often are placed in plastic bags for transport. If formalin accidentally spills into the bag during this time, the labels may be exposed to moisture for hours, overnight, or even over a weekend. Effective labeling with formalin-resistant ink is crucial for maintaining the clarity of anatomic location and planning treatment, especially when multiple samples are obtained.

The Technique

We tested 12 pens and markers commonly used when labeling specimen containers to determine their susceptibility to fading due to accidental formalin exposure (Figure). Various inks were allowed to dry on sample specimen labels for 5 minutes before a thin layer of 10% buffered formalin was evenly distributed over the dried ink. Photographs of the labels were taken at baseline as well as 15 minutes, 1 hour, 3 hours, and 24 hours after formalin exposure.

Fading was observed in both the skin marker and gel panes after 15 minutes and peaked after 1 hour. Gel pens were most susceptible to fading on exposure to formalin, and the level of fading varied by ink color, with certain colors disappearing almost entirely (Figure). The solvent-resistant marker had a robust defense to formalin, as did both ballpoint pens.

Practice Implications

Given our findings, dermatology practices should avoid using gel pens to label specimen containers. Solvent-resistant markers performed as expected; however, ballpoint pens appeared to withstand formalin exposure to a similar degree and often are more readily available. Labeling biopsy specimens with an appropriate ink ensures that each sample is clearly identified with the appropriate anatomic location and any other relevant patient information.

Practice Gap

Many dermatology practices utilize pens and markers to label biopsy specimen containers, but the ink may have variable susceptibility to fading and smearing when exposed to moisture before processing. Specimen containers often are placed in plastic bags for transport. If formalin accidentally spills into the bag during this time, the labels may be exposed to moisture for hours, overnight, or even over a weekend. Effective labeling with formalin-resistant ink is crucial for maintaining the clarity of anatomic location and planning treatment, especially when multiple samples are obtained.

The Technique

We tested 12 pens and markers commonly used when labeling specimen containers to determine their susceptibility to fading due to accidental formalin exposure (Figure). Various inks were allowed to dry on sample specimen labels for 5 minutes before a thin layer of 10% buffered formalin was evenly distributed over the dried ink. Photographs of the labels were taken at baseline as well as 15 minutes, 1 hour, 3 hours, and 24 hours after formalin exposure.

Fading was observed in both the skin marker and gel panes after 15 minutes and peaked after 1 hour. Gel pens were most susceptible to fading on exposure to formalin, and the level of fading varied by ink color, with certain colors disappearing almost entirely (Figure). The solvent-resistant marker had a robust defense to formalin, as did both ballpoint pens.

Practice Implications

Given our findings, dermatology practices should avoid using gel pens to label specimen containers. Solvent-resistant markers performed as expected; however, ballpoint pens appeared to withstand formalin exposure to a similar degree and often are more readily available. Labeling biopsy specimens with an appropriate ink ensures that each sample is clearly identified with the appropriate anatomic location and any other relevant patient information.

The umbrella term skin of color (SOC) includes individuals identifying as Black/African, Hispanic, Asian, Native American, Middle Eastern, and Mediterranean as well as multiracial groups. While the Fitzpatrick skin typing system is not an accurate proxy for describing skin tone, SOC populations typically correspond to Fitzpatrick skin types IV to VI, and clinical researchers often report the Fitzpatrick skin type of their study populations.¹

Over the past several decades, the underrepresentation of diverse skin tones in educational resources has limited clinical training.² For example, only 10.3% of conditions featured in contemporary dermatology textbooks are shown in darker skin tones.³ This educational resource gap has spurred a transformative movement toward inclusivity in dermatologic education, research, and clinical practice. Notable examples include VisualDx⁴ and Dermatology for Skin of Color.⁵ In addition, Cutis began publishing the Dx Across the Skin Color Spectrum fact sheet series in 2022 to highlight differences in how cutaneous conditions manifest in various skin tones (https://www.mdedge.com/cutis/dx-across-skin-color-spectrum).

These resources play a critical role in advancing dermatologic knowledge, ensuring that dermatologists and other health care professionals are well equipped to diagnose and treat dermatologic conditions in SOC populations with accuracy and cultural humility. These innovations also have enhanced our understanding of how common dermatologic conditions manifest and respond to treatment in SOC populations. Herein, we highlight advances in diagnostic and therapeutic approaches for the most common concerns among SOC populations in the United States, including acne vulgaris, atopic dermatitis (AD), seborrheic dermatitis (SD), melasma, postinflammatory hyperpigmentation, psoriasis, and seborrheic keratosis.

Chief Concerns Common Among SOC Populations in the United States

Acne Vulgaris—In patients with SOC, acne frequently results in pigmentary changes and scarring that can manifest as both hypertrophic and keloidal scars.⁶ Clinical evidence from randomized controlled studies supports the use of topical dapsone gel as a safe and effective frontline treatment for acne in patients with SOC.^7,8 Notably, the US Food and Drug Administration–approved 1726-nm laser with a contact-cooling sapphire window has demonstrated safety and efficacy in the management of acne across Fitzpatrick skin types II to VI.^9-11 To manage atrophic acne scars, cutting-edge laser and radiofrequency devices including erbium-doped yttrium aluminum garnet, fractional CO₂, and picosecond lasers have been effectively employed in SOC populations. When these energy-based treatments are combined with cooling systems, they substantially reduce the risk for thermal damage in darker skin tones.^12,13

Atopic Dermatitis—While epidemiologic data indicate that Black patients experience a higher prevalence (19.3%) of AD than Asian (17.8%), White (16.1%), or Hispanic (7.8%) groups in the United States, this disparity may be influenced by factors such as access to care and environmental stressors, which require further study.^14-16 The pathogenesis of AD involves a complex interaction between skin barrier dysfunction, immune dysregulation, and environmental triggers, with patients with SOC exhibiting distinct endotypes.^14,17 For example, East Asian individuals have elevated T_H17-related cytokines and a blended T_H17/T_H2 AD-psoriasis endotype,^14,18 while Black individuals have greater T_H2 skewing and filaggrin variations and higher serum IgE levels.¹⁷ Diagnostic advancements, including a modified Eczema Area and Severity Index using grayscale rather than erythema-based assessments for patients with SOC as well as a novel SOC dermatology atlas that includes AD have increased equity in disease evaluation.^19,20 Recent clinical trials support the efficacy of topical crisaborole, topical ruxolitinib, and biologics such as dupilumab, tralokinumab, lebrikizumab, and fezakinumab for AD in SOC populations, with dupilumab also improving postinflammatory hyperpigmentation.^20-22

Seborrheic Dermatitis—Seborrheic dermatitis is common in patients with SOC, though its manifestations vary by racial/ethnic background.²³ In Black patients, petaloid SD is more prevalent and can resemble secondary syphilis, making accurate diagnosis essential to rule out potential mimickers.²⁴ Effective treatments remain limited, as current therapies often fail to address both the underlying yeast-driven inflammation and the resulting pigmentary changes that commonly affect SOC populations.²⁵ Roflumilast foam 0.3%, a phosphodiesterase 4 inhibitor, has emerged as a promising option, offering both anti-inflammatory benefits and improvements in pigmentary alterations—making it particularly valuable for treatment of SD in patients with SOC.²⁶

Melasma—Melasma is more prevalent in women with darker skin types, particularly those of African descent and those from East and Southeast Asia or Latin America.^27,28 Standard treatments including hydroquinone, retinoids, azelaic acid, kojic acid, ascorbic acid, arbutin, alpha hydroxy acids, niacinamide, and the Kligman formula (5% hydroquinone, 0.1% tretinoin, and 0.1% dexamethasone) remain therapeutic foundations in patients with SOC.²⁹ Newer alternatives that are effective in SOC populations include topical metformin 30%30; topical isobutylamido thiazolyl resorcinol or thiamidol31; and tranexamic acid cream 5%, which has comparable efficacy to hydroquinone 4% with fewer adverse effects.³² Laser therapies such as the 675-nm and 1064-nm Q-switched neodymium-doped yttrium aluminum garnet lasers, offer effective pigment reduction and are safe in darker skin tones.^33,34

Postinflammatory Hyperpigmentation—Postinflammatory hyperpigmentation, often triggered by acne in SOC populations,²³ manifests as brown, tan, or gray discoloration and is managed using similar topical agents as melasma, with the 1927-nm laser providing an additional treatment option for patients with SOC.^27,35,36

Psoriasis—In patients with SOC, psoriasis often manifests with thicker plaques, increased scaling, and greater body surface area involvement, leading to considerable quality-of-life implications.³⁷ Although prevalence is highest in White populations (3.6%), Asian (2.5%) and Hispanic/Latino (1.9%) patients experience increased disease severity, potentially explaining why psoriasis is among the top chief complaints for these racial/ ethnic groups in the United States.^23,38 Greater diversity in clinical trials has improved our understanding of the efficacy of biologics for psoriasis in SOC populations. The VISIBLE trial—the first SOC-exclusive psoriasis trial—demonstrated a Psoriasis Area and Severity Index 90 response in 57.1% (44/77) of participants receiving guselkumab vs 3.8% (1/26) of participants receiving placebo by week 16 (P<.001).³⁹ Other biologics such as risankizumab, secukinumab, and brodalumab also have shown efficacy in SOC populations.^40-42 Additionally, topical therapies such as calcipotriene-betamethasone dipropionate cream/aerosol foam and halobetasol propionatetazarotene lotion have proven effective, with minimal adverse effects and low discontinuation rates in patients with SOC.^43-46

Seborrheic Keratosis—In SOC, seborrheic keratosis (SK) often appears as a variant known as dermatosis papulosa nigra (DPN), manifesting as small, benign, hyperpigmented papules, particularly on the face and neck.⁴⁷ Dermatosis papulosa nigra is common in Black, Hispanic, and some Asian populations, with variations in color and distribution among different racial/ethnic groups.⁴⁸ For example, in Korean populations, SKs commonly affect males, and in contrast to the dark brown color common in White populations, SKs in Korean patients often appear lighter brown or sometimes pink.⁴⁹ In contrast to the verrucous and stuck-on appearance often seen in White populations, South Asian populations more often have variants including pedunculated SKs, flat SKs, and stucco keratoses.⁵⁰ High-resolution dermoscopy improves differentiation from malignant lesions; however, a sudden SK eruption in any population warrants evaluation for underlying malignancy. Cryotherapy, though effective for removal of SKs, can cause pigmentary changes in SOC populations, making laser therapy and electrosurgery preferable for these patients due to the lower risk for pigmentary sequela. If hyperpigmentation occurs, topical treatments such as hydroquinone, tretinoin, or azelaic acid can help. New laser technologies and hydrogen-peroxide–based therapies offer safer and more effective removal options while minimizing pigmentary risks in SOC populations.^47,50 While DPNs are common in patients with darker skin tones, there are limited data on optimal treatment frequency, insurance coverage, and efficacy. This literature gap hinders our understanding of treatment accessibility and economic impact on our patients.⁵¹

Final Thoughts

Innovations such as standardized scoring systems and customized therapeutic strategies for conditions including acne, pigmentary disorders, and atopic dermatitis have markedly enhanced patient care and outcomes for the most common chief concerns in SOC populations. In addition, population-specific advancements have addressed unique diagnostic and therapeutic developments in Black, Asian/Pacific Islander, and Hispanic groups, from the nuanced presentations of atopic and seborrheic dermatitis in Black patients, to those of psoriasis in Asian/Pacific Islander and Hispanic populations. Finally, updated epidemiologic studies are essential to capture the current and evolving dermatologic concerns pertinent to patients with SOC, ensuring that future clinical and research efforts align with the unique needs of these populations.

The umbrella term skin of color (SOC) includes individuals identifying as Black/African, Hispanic, Asian, Native American, Middle Eastern, and Mediterranean as well as multiracial groups. While the Fitzpatrick skin typing system is not an accurate proxy for describing skin tone, SOC populations typically correspond to Fitzpatrick skin types IV to VI, and clinical researchers often report the Fitzpatrick skin type of their study populations.¹

Over the past several decades, the underrepresentation of diverse skin tones in educational resources has limited clinical training.² For example, only 10.3% of conditions featured in contemporary dermatology textbooks are shown in darker skin tones.³ This educational resource gap has spurred a transformative movement toward inclusivity in dermatologic education, research, and clinical practice. Notable examples include VisualDx⁴ and Dermatology for Skin of Color.⁵ In addition, Cutis began publishing the Dx Across the Skin Color Spectrum fact sheet series in 2022 to highlight differences in how cutaneous conditions manifest in various skin tones (https://www.mdedge.com/cutis/dx-across-skin-color-spectrum).

These resources play a critical role in advancing dermatologic knowledge, ensuring that dermatologists and other health care professionals are well equipped to diagnose and treat dermatologic conditions in SOC populations with accuracy and cultural humility. These innovations also have enhanced our understanding of how common dermatologic conditions manifest and respond to treatment in SOC populations. Herein, we highlight advances in diagnostic and therapeutic approaches for the most common concerns among SOC populations in the United States, including acne vulgaris, atopic dermatitis (AD), seborrheic dermatitis (SD), melasma, postinflammatory hyperpigmentation, psoriasis, and seborrheic keratosis.

Chief Concerns Common Among SOC Populations in the United States

Acne Vulgaris—In patients with SOC, acne frequently results in pigmentary changes and scarring that can manifest as both hypertrophic and keloidal scars.⁶ Clinical evidence from randomized controlled studies supports the use of topical dapsone gel as a safe and effective frontline treatment for acne in patients with SOC.^7,8 Notably, the US Food and Drug Administration–approved 1726-nm laser with a contact-cooling sapphire window has demonstrated safety and efficacy in the management of acne across Fitzpatrick skin types II to VI.^9-11 To manage atrophic acne scars, cutting-edge laser and radiofrequency devices including erbium-doped yttrium aluminum garnet, fractional CO₂, and picosecond lasers have been effectively employed in SOC populations. When these energy-based treatments are combined with cooling systems, they substantially reduce the risk for thermal damage in darker skin tones.^12,13

Atopic Dermatitis—While epidemiologic data indicate that Black patients experience a higher prevalence (19.3%) of AD than Asian (17.8%), White (16.1%), or Hispanic (7.8%) groups in the United States, this disparity may be influenced by factors such as access to care and environmental stressors, which require further study.^14-16 The pathogenesis of AD involves a complex interaction between skin barrier dysfunction, immune dysregulation, and environmental triggers, with patients with SOC exhibiting distinct endotypes.^14,17 For example, East Asian individuals have elevated T_H17-related cytokines and a blended T_H17/T_H2 AD-psoriasis endotype,^14,18 while Black individuals have greater T_H2 skewing and filaggrin variations and higher serum IgE levels.¹⁷ Diagnostic advancements, including a modified Eczema Area and Severity Index using grayscale rather than erythema-based assessments for patients with SOC as well as a novel SOC dermatology atlas that includes AD have increased equity in disease evaluation.^19,20 Recent clinical trials support the efficacy of topical crisaborole, topical ruxolitinib, and biologics such as dupilumab, tralokinumab, lebrikizumab, and fezakinumab for AD in SOC populations, with dupilumab also improving postinflammatory hyperpigmentation.^20-22

Seborrheic Dermatitis—Seborrheic dermatitis is common in patients with SOC, though its manifestations vary by racial/ethnic background.²³ In Black patients, petaloid SD is more prevalent and can resemble secondary syphilis, making accurate diagnosis essential to rule out potential mimickers.²⁴ Effective treatments remain limited, as current therapies often fail to address both the underlying yeast-driven inflammation and the resulting pigmentary changes that commonly affect SOC populations.²⁵ Roflumilast foam 0.3%, a phosphodiesterase 4 inhibitor, has emerged as a promising option, offering both anti-inflammatory benefits and improvements in pigmentary alterations—making it particularly valuable for treatment of SD in patients with SOC.²⁶

Melasma—Melasma is more prevalent in women with darker skin types, particularly those of African descent and those from East and Southeast Asia or Latin America.^27,28 Standard treatments including hydroquinone, retinoids, azelaic acid, kojic acid, ascorbic acid, arbutin, alpha hydroxy acids, niacinamide, and the Kligman formula (5% hydroquinone, 0.1% tretinoin, and 0.1% dexamethasone) remain therapeutic foundations in patients with SOC.²⁹ Newer alternatives that are effective in SOC populations include topical metformin 30%30; topical isobutylamido thiazolyl resorcinol or thiamidol31; and tranexamic acid cream 5%, which has comparable efficacy to hydroquinone 4% with fewer adverse effects.³² Laser therapies such as the 675-nm and 1064-nm Q-switched neodymium-doped yttrium aluminum garnet lasers, offer effective pigment reduction and are safe in darker skin tones.^33,34

Postinflammatory Hyperpigmentation—Postinflammatory hyperpigmentation, often triggered by acne in SOC populations,²³ manifests as brown, tan, or gray discoloration and is managed using similar topical agents as melasma, with the 1927-nm laser providing an additional treatment option for patients with SOC.^27,35,36

Psoriasis—In patients with SOC, psoriasis often manifests with thicker plaques, increased scaling, and greater body surface area involvement, leading to considerable quality-of-life implications.³⁷ Although prevalence is highest in White populations (3.6%), Asian (2.5%) and Hispanic/Latino (1.9%) patients experience increased disease severity, potentially explaining why psoriasis is among the top chief complaints for these racial/ ethnic groups in the United States.^23,38 Greater diversity in clinical trials has improved our understanding of the efficacy of biologics for psoriasis in SOC populations. The VISIBLE trial—the first SOC-exclusive psoriasis trial—demonstrated a Psoriasis Area and Severity Index 90 response in 57.1% (44/77) of participants receiving guselkumab vs 3.8% (1/26) of participants receiving placebo by week 16 (P<.001).³⁹ Other biologics such as risankizumab, secukinumab, and brodalumab also have shown efficacy in SOC populations.^40-42 Additionally, topical therapies such as calcipotriene-betamethasone dipropionate cream/aerosol foam and halobetasol propionatetazarotene lotion have proven effective, with minimal adverse effects and low discontinuation rates in patients with SOC.^43-46

Seborrheic Keratosis—In SOC, seborrheic keratosis (SK) often appears as a variant known as dermatosis papulosa nigra (DPN), manifesting as small, benign, hyperpigmented papules, particularly on the face and neck.⁴⁷ Dermatosis papulosa nigra is common in Black, Hispanic, and some Asian populations, with variations in color and distribution among different racial/ethnic groups.⁴⁸ For example, in Korean populations, SKs commonly affect males, and in contrast to the dark brown color common in White populations, SKs in Korean patients often appear lighter brown or sometimes pink.⁴⁹ In contrast to the verrucous and stuck-on appearance often seen in White populations, South Asian populations more often have variants including pedunculated SKs, flat SKs, and stucco keratoses.⁵⁰ High-resolution dermoscopy improves differentiation from malignant lesions; however, a sudden SK eruption in any population warrants evaluation for underlying malignancy. Cryotherapy, though effective for removal of SKs, can cause pigmentary changes in SOC populations, making laser therapy and electrosurgery preferable for these patients due to the lower risk for pigmentary sequela. If hyperpigmentation occurs, topical treatments such as hydroquinone, tretinoin, or azelaic acid can help. New laser technologies and hydrogen-peroxide–based therapies offer safer and more effective removal options while minimizing pigmentary risks in SOC populations.^47,50 While DPNs are common in patients with darker skin tones, there are limited data on optimal treatment frequency, insurance coverage, and efficacy. This literature gap hinders our understanding of treatment accessibility and economic impact on our patients.⁵¹

Final Thoughts

Innovations such as standardized scoring systems and customized therapeutic strategies for conditions including acne, pigmentary disorders, and atopic dermatitis have markedly enhanced patient care and outcomes for the most common chief concerns in SOC populations. In addition, population-specific advancements have addressed unique diagnostic and therapeutic developments in Black, Asian/Pacific Islander, and Hispanic groups, from the nuanced presentations of atopic and seborrheic dermatitis in Black patients, to those of psoriasis in Asian/Pacific Islander and Hispanic populations. Finally, updated epidemiologic studies are essential to capture the current and evolving dermatologic concerns pertinent to patients with SOC, ensuring that future clinical and research efforts align with the unique needs of these populations.

The umbrella term skin of color (SOC) includes individuals identifying as Black/African, Hispanic, Asian, Native American, Middle Eastern, and Mediterranean as well as multiracial groups. While the Fitzpatrick skin typing system is not an accurate proxy for describing skin tone, SOC populations typically correspond to Fitzpatrick skin types IV to VI, and clinical researchers often report the Fitzpatrick skin type of their study populations.¹

Over the past several decades, the underrepresentation of diverse skin tones in educational resources has limited clinical training.² For example, only 10.3% of conditions featured in contemporary dermatology textbooks are shown in darker skin tones.³ This educational resource gap has spurred a transformative movement toward inclusivity in dermatologic education, research, and clinical practice. Notable examples include VisualDx⁴ and Dermatology for Skin of Color.⁵ In addition, Cutis began publishing the Dx Across the Skin Color Spectrum fact sheet series in 2022 to highlight differences in how cutaneous conditions manifest in various skin tones (https://www.mdedge.com/cutis/dx-across-skin-color-spectrum).

These resources play a critical role in advancing dermatologic knowledge, ensuring that dermatologists and other health care professionals are well equipped to diagnose and treat dermatologic conditions in SOC populations with accuracy and cultural humility. These innovations also have enhanced our understanding of how common dermatologic conditions manifest and respond to treatment in SOC populations. Herein, we highlight advances in diagnostic and therapeutic approaches for the most common concerns among SOC populations in the United States, including acne vulgaris, atopic dermatitis (AD), seborrheic dermatitis (SD), melasma, postinflammatory hyperpigmentation, psoriasis, and seborrheic keratosis.

Chief Concerns Common Among SOC Populations in the United States

Acne Vulgaris—In patients with SOC, acne frequently results in pigmentary changes and scarring that can manifest as both hypertrophic and keloidal scars.⁶ Clinical evidence from randomized controlled studies supports the use of topical dapsone gel as a safe and effective frontline treatment for acne in patients with SOC.^7,8 Notably, the US Food and Drug Administration–approved 1726-nm laser with a contact-cooling sapphire window has demonstrated safety and efficacy in the management of acne across Fitzpatrick skin types II to VI.^9-11 To manage atrophic acne scars, cutting-edge laser and radiofrequency devices including erbium-doped yttrium aluminum garnet, fractional CO₂, and picosecond lasers have been effectively employed in SOC populations. When these energy-based treatments are combined with cooling systems, they substantially reduce the risk for thermal damage in darker skin tones.^12,13

Atopic Dermatitis—While epidemiologic data indicate that Black patients experience a higher prevalence (19.3%) of AD than Asian (17.8%), White (16.1%), or Hispanic (7.8%) groups in the United States, this disparity may be influenced by factors such as access to care and environmental stressors, which require further study.^14-16 The pathogenesis of AD involves a complex interaction between skin barrier dysfunction, immune dysregulation, and environmental triggers, with patients with SOC exhibiting distinct endotypes.^14,17 For example, East Asian individuals have elevated T_H17-related cytokines and a blended T_H17/T_H2 AD-psoriasis endotype,^14,18 while Black individuals have greater T_H2 skewing and filaggrin variations and higher serum IgE levels.¹⁷ Diagnostic advancements, including a modified Eczema Area and Severity Index using grayscale rather than erythema-based assessments for patients with SOC as well as a novel SOC dermatology atlas that includes AD have increased equity in disease evaluation.^19,20 Recent clinical trials support the efficacy of topical crisaborole, topical ruxolitinib, and biologics such as dupilumab, tralokinumab, lebrikizumab, and fezakinumab for AD in SOC populations, with dupilumab also improving postinflammatory hyperpigmentation.^20-22

Seborrheic Dermatitis—Seborrheic dermatitis is common in patients with SOC, though its manifestations vary by racial/ethnic background.²³ In Black patients, petaloid SD is more prevalent and can resemble secondary syphilis, making accurate diagnosis essential to rule out potential mimickers.²⁴ Effective treatments remain limited, as current therapies often fail to address both the underlying yeast-driven inflammation and the resulting pigmentary changes that commonly affect SOC populations.²⁵ Roflumilast foam 0.3%, a phosphodiesterase 4 inhibitor, has emerged as a promising option, offering both anti-inflammatory benefits and improvements in pigmentary alterations—making it particularly valuable for treatment of SD in patients with SOC.²⁶

Melasma—Melasma is more prevalent in women with darker skin types, particularly those of African descent and those from East and Southeast Asia or Latin America.^27,28 Standard treatments including hydroquinone, retinoids, azelaic acid, kojic acid, ascorbic acid, arbutin, alpha hydroxy acids, niacinamide, and the Kligman formula (5% hydroquinone, 0.1% tretinoin, and 0.1% dexamethasone) remain therapeutic foundations in patients with SOC.²⁹ Newer alternatives that are effective in SOC populations include topical metformin 30%30; topical isobutylamido thiazolyl resorcinol or thiamidol31; and tranexamic acid cream 5%, which has comparable efficacy to hydroquinone 4% with fewer adverse effects.³² Laser therapies such as the 675-nm and 1064-nm Q-switched neodymium-doped yttrium aluminum garnet lasers, offer effective pigment reduction and are safe in darker skin tones.^33,34

Postinflammatory Hyperpigmentation—Postinflammatory hyperpigmentation, often triggered by acne in SOC populations,²³ manifests as brown, tan, or gray discoloration and is managed using similar topical agents as melasma, with the 1927-nm laser providing an additional treatment option for patients with SOC.^27,35,36

Psoriasis—In patients with SOC, psoriasis often manifests with thicker plaques, increased scaling, and greater body surface area involvement, leading to considerable quality-of-life implications.³⁷ Although prevalence is highest in White populations (3.6%), Asian (2.5%) and Hispanic/Latino (1.9%) patients experience increased disease severity, potentially explaining why psoriasis is among the top chief complaints for these racial/ ethnic groups in the United States.^23,38 Greater diversity in clinical trials has improved our understanding of the efficacy of biologics for psoriasis in SOC populations. The VISIBLE trial—the first SOC-exclusive psoriasis trial—demonstrated a Psoriasis Area and Severity Index 90 response in 57.1% (44/77) of participants receiving guselkumab vs 3.8% (1/26) of participants receiving placebo by week 16 (P<.001).³⁹ Other biologics such as risankizumab, secukinumab, and brodalumab also have shown efficacy in SOC populations.^40-42 Additionally, topical therapies such as calcipotriene-betamethasone dipropionate cream/aerosol foam and halobetasol propionatetazarotene lotion have proven effective, with minimal adverse effects and low discontinuation rates in patients with SOC.^43-46

Seborrheic Keratosis—In SOC, seborrheic keratosis (SK) often appears as a variant known as dermatosis papulosa nigra (DPN), manifesting as small, benign, hyperpigmented papules, particularly on the face and neck.⁴⁷ Dermatosis papulosa nigra is common in Black, Hispanic, and some Asian populations, with variations in color and distribution among different racial/ethnic groups.⁴⁸ For example, in Korean populations, SKs commonly affect males, and in contrast to the dark brown color common in White populations, SKs in Korean patients often appear lighter brown or sometimes pink.⁴⁹ In contrast to the verrucous and stuck-on appearance often seen in White populations, South Asian populations more often have variants including pedunculated SKs, flat SKs, and stucco keratoses.⁵⁰ High-resolution dermoscopy improves differentiation from malignant lesions; however, a sudden SK eruption in any population warrants evaluation for underlying malignancy. Cryotherapy, though effective for removal of SKs, can cause pigmentary changes in SOC populations, making laser therapy and electrosurgery preferable for these patients due to the lower risk for pigmentary sequela. If hyperpigmentation occurs, topical treatments such as hydroquinone, tretinoin, or azelaic acid can help. New laser technologies and hydrogen-peroxide–based therapies offer safer and more effective removal options while minimizing pigmentary risks in SOC populations.^47,50 While DPNs are common in patients with darker skin tones, there are limited data on optimal treatment frequency, insurance coverage, and efficacy. This literature gap hinders our understanding of treatment accessibility and economic impact on our patients.⁵¹

Final Thoughts

Innovations such as standardized scoring systems and customized therapeutic strategies for conditions including acne, pigmentary disorders, and atopic dermatitis have markedly enhanced patient care and outcomes for the most common chief concerns in SOC populations. In addition, population-specific advancements have addressed unique diagnostic and therapeutic developments in Black, Asian/Pacific Islander, and Hispanic groups, from the nuanced presentations of atopic and seborrheic dermatitis in Black patients, to those of psoriasis in Asian/Pacific Islander and Hispanic populations. Finally, updated epidemiologic studies are essential to capture the current and evolving dermatologic concerns pertinent to patients with SOC, ensuring that future clinical and research efforts align with the unique needs of these populations.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening conditions that involve widespread necrosis of the skin and mucous membranes.¹ Guidelines for SJS and TEN recommend management in hospitals with access to inpatient dermatology to provide immediate interventions that are necessary for achieving optimal patient outcomes.² A delay in admission of 5 days or more after onset of symptoms has been associated with increases in overall mortality, bacteremia, intensive care unit (ICU) admission, and length of stay.³ Patients who are not directly admitted to specialized facilities and require transfer from other hospitals may experience delays in receiving critical interventions, further increasing the risk for mortality and complications. In this study, we analyzed the clinical outcomes of patients with SJS/TEN in relation to their admission pathway.

Methods

A single-center retrospective chart review was performed at Atrium Health Wake Forest Baptist Medical Center (AHWFBMC) in Winston-Salem, North Carolina. Participants were identified using i2b2, an informatics tool compliant with the Health Insurance Portability and Accountability Act for integrating biology and the bedside. Inclusion criteria were having a diagnosis of SJS (International Classification of Diseases, Tenth Revision, code L51.1; International Classification of Diseases, Ninth Revision, code 695.13), TEN (International Classification of Diseases, Tenth Revision, code L51.2; International Classification of Diseases, Ninth Revision, code 695.15) or Lyell syndrome from January 2012 to December 2024. Patients with erythema multiforme or bullous drug eruption were excluded, as these conditions initially were misdiagnosed as SJS or TEN. Patients with only a reported history of prior SJS or TEN also were excluded.

The following clinical outcomes were assessed: demographics, comorbidities, age at disease onset, outside hospital transfer status, complications during admission, inpatient length of stay in days, age of mortality (if applicable), culprit medications, interventions received, Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) upon admission, site of admission (eg, floor bed, ICU, medical ICU, burn unit), and length of disease process prior to hospital admission. Patients then were categorized as either direct or transfer admissions based on the initial point of care and admission process. Direct admissions included patients who presented to the AHWFBMC emergency department and were subsequently admitted. Transfer patients included patients who initially presented to an outside hospital and were transferred to AHWFBMC. Data regarding the wait time for Physician Access Line requests and the time elapsed from the initial transfer call to arrival at the tertiary hospital also were collected—this is a method that outside hospitals can use to contact physicians at the tertiary hospital for a possible transfer. Statistical analysis was performed using unpaired t tests and X² tests as necessary using GraphPad By Dotmatics Prism.

Results

A total of 112 patients were included in the analysis; of these, 71 had a diagnosis with biopsy confirmation of SJS, SJS/TEN overlap, or TEN (Table 1). Forty-one patients were excluded due to having a diagnosis of erythema multiforme or bullous drug eruption or a reported history of prior SJS or TEN without hospitalization. All biopsies were performed at AHWFBMC. Of the 71 confirmed patients with SJS/TEN, 54 (76%) were female with a mean age of 44 years. The majority of patients identified as Black (35 [49%]) or White (27 [38%]), along with Asian (7 [10%]) and other (2 [3%]). The most common comorbidity was cardiovascular disease in 42 (59%) patients, followed by type 2 diabetes in 36 (51%) patients. Among these 71 patients with SJS/TEN, 29 (41%) were directly admitted to the tertiary hospital, while 42 (59%) were transferred from outside hospitals.

Of the 71 confirmed patients with SJS/TEN, sulfonamides were identified as the most common inciting drug in 25 (41%) patients, followed by beta-lactam antibiotics in 16 (23%) patients (Table 2). This is consistent with previous literature of sulfamethoxazole with trimethoprim as the primary causative drug for SJS and TEN in the United States.¹

Clinical Outcomes—Of the 71 patients, there were 23 (32%) cases of SJS, 29 (41%) cases of SJS/TEN overlap, and 19 (27%) cases of TEN (eTable). The initial and maximum affected body surface area (BSA) was higher in transfer admissions, with a mean maximum BSA of 38.55% in the transfer group compared to 19.14% in the direct admissions. The mean SCORTEN (range, 0-5) was 1.6 overall, with a higher mean score of 1.92 in the transfer group compared to 1.07 in the direct admissions.

Transfer patients had a longer mean stay at the tertiary hospital (13.71 d) compared to direct admissions (7.17 d). The mean time from symptom onset until tertiary hospital admission was 8.5 days; transfer and direct admission patients had similar mean time from symptom onset of 9.02 days and 7.86 days, respectively. Although the duration of cutaneous symptoms from onset until tertiary hospital admission was similar (P=.283) between direct admissions (7.86 d) and transfer patients (9.02 d), the transfer group presented with greater disease severity at the time of admission. Transfer patients had a higher mean maximum BSA involvement (38.55% vs 19.14% [P=.005]), elevated SCORTEN (1.92 vs 1.07 [P=.029]), and longer mean hospital stays (13.71 d vs 7.17 d [P<.0001]) compared to direct admissions.

Despite the absence of mortality in both groups, transfer patients showed a higher number of ICU admissions (19 vs 5 [P=.014]) and burn unit admissions (9 vs 2 [P=.096]), bacteremia (16 vs 4 [P=.025]), acute kidney injury (13 vs 10 [P=.755]), acute respiratory failure (12 vs 5 [P=.272]), and transaminitis (8 vs 3 [P=.319]).

Outside Hospital Treatments—All outside hospitals provided supportive care with intravenous fluids and acetaminophen; however, further care provided at outside hospitals varied (Table 3), with transfer patients most frequently being treated with diphenhydramine (69% [29/42]), antimicrobial medications (57% [24/42]), steroids (40%), and epinephrine (10% [4/42]). Some patients may have received more than one of these treatments. Based on outside hospital treatments, the primary care teams’ main clinical concerns were allergic reactions and infection, as 33 (79%) patients received diphenhydramine (29 [89%]) or epinephrine (4 [12%]) and 24 (52%) received antimicrobial medications. Of the 42 transfer patients, 24 (57%) received or continued these medications before transfer; the medications were promptly discontinued upon tertiary hospital admission.

Once the outside hospitals contacted the tertiary hospital for a referral, the mean length of time between the transfer request and Physician Access Line call was 17.13 minutes (Table 4). Following the transfer request, the mean length of time for arrival at the tertiary hospital was 6.22 hours. The mean length of stay at the outside hospital prior to the patient being transferred was 3.84 days.

Comment

This retrospective study examined 71 patients with biopsy-confirmed SJS, SJS/TEN overlap, or TEN to evaluate differences in clinical outcomes between direct and transfer admissions. Transfer patients had a higher mean maximum affected BSA (38.55% vs 19.14% [P=.005]) and elevated SCORTEN (1.92 vs 1.07 [P=.029]); a higher number of transfer patients were admitted to the ICU (19 vs 5 [P=.014]) and burn unit (9 vs 2 [P=.096]), and this group also demonstrated longer hospitalization stays (13.71 vs 7.17 [P<.0001]). There were more complications among transfer patients, including bacteremia (16 vs 4 [P=.025]), which is consistent with findings from the existing literature.³

Once the decision for transfer of the patients included in our study was initiated and accepted, there was a prompt response and transfer of care; the mean length of time for Physician Access Line request was 17.13 minutes, and the mean transfer time to arrive at the tertiary hospital was 6.22 hours; however, patients spent an average of 3.84 days at outside hospitals, reflecting that transfer calls frequently were initiated due to urgent clinical decline of the patient rather than as an early intervention strategy. The management at outside hospitals often included the continuation of antimicrobial medications, which were discontinued upon transfer to AHWFBMC. Causative agents were either previously prescribed for a new medical condition or initiated for the management of suspected infections at outside hospitals. This may reflect the difficulty in correctly diagnosing SJS/TEN and initiating appropriate management at hospital facilities without an inpatient dermatologist.

The presence of inpatient dermatologists can improve the diagnostic accuracy and treatment of various conditions.^4,5 Dermatology consultations added or changed 77% of treatment plans for 271 hospitalized patients.⁴ The impact of this intervention is reflected by the success of early dermatology consultations in reducing the length of hospitalization and use of inappropriate treatments in the care of skin diseases.^6-8

Access to dermatologic care has been an identified need in inpatient hospitals that may limit the ability of hospitals to promptly treat serious conditions such as SJS/TEN.⁹ From an inpatient dermatology study from 2013 through 2019, 98.2% of 782 inpatient dermatologists reside in metropolitan areas, limiting the availability of care for rural patients; this study also found a decreasing number of facilities with inpatient dermatologists.¹⁰

The limitations of our study include a small sample size of 71 patients, which restricted the generalizability of our results. Our study also was based at a single tertiary center, which thereby limited the findings to this geographic area. It also was difficult to match patients by their demographic and comorbid conditions. The retrospective study design depended on the accuracy and completeness of medical records, which can introduce information bias. Future studies should compare the clinical outcomes of SJS/TEN based on burn unit and ICU admissions.

Conclusion

Prompt identification of SJS/TEN and rapid transfer to hospitals with inpatient dermatology are essential to optimize patient outcomes. Developing and validating SJS/TEN diagnosis and transfer protocols across multiple institutions may be helpful.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening conditions that involve widespread necrosis of the skin and mucous membranes.¹ Guidelines for SJS and TEN recommend management in hospitals with access to inpatient dermatology to provide immediate interventions that are necessary for achieving optimal patient outcomes.² A delay in admission of 5 days or more after onset of symptoms has been associated with increases in overall mortality, bacteremia, intensive care unit (ICU) admission, and length of stay.³ Patients who are not directly admitted to specialized facilities and require transfer from other hospitals may experience delays in receiving critical interventions, further increasing the risk for mortality and complications. In this study, we analyzed the clinical outcomes of patients with SJS/TEN in relation to their admission pathway.

Methods

A single-center retrospective chart review was performed at Atrium Health Wake Forest Baptist Medical Center (AHWFBMC) in Winston-Salem, North Carolina. Participants were identified using i2b2, an informatics tool compliant with the Health Insurance Portability and Accountability Act for integrating biology and the bedside. Inclusion criteria were having a diagnosis of SJS (International Classification of Diseases, Tenth Revision, code L51.1; International Classification of Diseases, Ninth Revision, code 695.13), TEN (International Classification of Diseases, Tenth Revision, code L51.2; International Classification of Diseases, Ninth Revision, code 695.15) or Lyell syndrome from January 2012 to December 2024. Patients with erythema multiforme or bullous drug eruption were excluded, as these conditions initially were misdiagnosed as SJS or TEN. Patients with only a reported history of prior SJS or TEN also were excluded.

The following clinical outcomes were assessed: demographics, comorbidities, age at disease onset, outside hospital transfer status, complications during admission, inpatient length of stay in days, age of mortality (if applicable), culprit medications, interventions received, Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) upon admission, site of admission (eg, floor bed, ICU, medical ICU, burn unit), and length of disease process prior to hospital admission. Patients then were categorized as either direct or transfer admissions based on the initial point of care and admission process. Direct admissions included patients who presented to the AHWFBMC emergency department and were subsequently admitted. Transfer patients included patients who initially presented to an outside hospital and were transferred to AHWFBMC. Data regarding the wait time for Physician Access Line requests and the time elapsed from the initial transfer call to arrival at the tertiary hospital also were collected—this is a method that outside hospitals can use to contact physicians at the tertiary hospital for a possible transfer. Statistical analysis was performed using unpaired t tests and X² tests as necessary using GraphPad By Dotmatics Prism.

Results

A total of 112 patients were included in the analysis; of these, 71 had a diagnosis with biopsy confirmation of SJS, SJS/TEN overlap, or TEN (Table 1). Forty-one patients were excluded due to having a diagnosis of erythema multiforme or bullous drug eruption or a reported history of prior SJS or TEN without hospitalization. All biopsies were performed at AHWFBMC. Of the 71 confirmed patients with SJS/TEN, 54 (76%) were female with a mean age of 44 years. The majority of patients identified as Black (35 [49%]) or White (27 [38%]), along with Asian (7 [10%]) and other (2 [3%]). The most common comorbidity was cardiovascular disease in 42 (59%) patients, followed by type 2 diabetes in 36 (51%) patients. Among these 71 patients with SJS/TEN, 29 (41%) were directly admitted to the tertiary hospital, while 42 (59%) were transferred from outside hospitals.

Of the 71 confirmed patients with SJS/TEN, sulfonamides were identified as the most common inciting drug in 25 (41%) patients, followed by beta-lactam antibiotics in 16 (23%) patients (Table 2). This is consistent with previous literature of sulfamethoxazole with trimethoprim as the primary causative drug for SJS and TEN in the United States.¹

Clinical Outcomes—Of the 71 patients, there were 23 (32%) cases of SJS, 29 (41%) cases of SJS/TEN overlap, and 19 (27%) cases of TEN (eTable). The initial and maximum affected body surface area (BSA) was higher in transfer admissions, with a mean maximum BSA of 38.55% in the transfer group compared to 19.14% in the direct admissions. The mean SCORTEN (range, 0-5) was 1.6 overall, with a higher mean score of 1.92 in the transfer group compared to 1.07 in the direct admissions.

Transfer patients had a longer mean stay at the tertiary hospital (13.71 d) compared to direct admissions (7.17 d). The mean time from symptom onset until tertiary hospital admission was 8.5 days; transfer and direct admission patients had similar mean time from symptom onset of 9.02 days and 7.86 days, respectively. Although the duration of cutaneous symptoms from onset until tertiary hospital admission was similar (P=.283) between direct admissions (7.86 d) and transfer patients (9.02 d), the transfer group presented with greater disease severity at the time of admission. Transfer patients had a higher mean maximum BSA involvement (38.55% vs 19.14% [P=.005]), elevated SCORTEN (1.92 vs 1.07 [P=.029]), and longer mean hospital stays (13.71 d vs 7.17 d [P<.0001]) compared to direct admissions.

Despite the absence of mortality in both groups, transfer patients showed a higher number of ICU admissions (19 vs 5 [P=.014]) and burn unit admissions (9 vs 2 [P=.096]), bacteremia (16 vs 4 [P=.025]), acute kidney injury (13 vs 10 [P=.755]), acute respiratory failure (12 vs 5 [P=.272]), and transaminitis (8 vs 3 [P=.319]).

Outside Hospital Treatments—All outside hospitals provided supportive care with intravenous fluids and acetaminophen; however, further care provided at outside hospitals varied (Table 3), with transfer patients most frequently being treated with diphenhydramine (69% [29/42]), antimicrobial medications (57% [24/42]), steroids (40%), and epinephrine (10% [4/42]). Some patients may have received more than one of these treatments. Based on outside hospital treatments, the primary care teams’ main clinical concerns were allergic reactions and infection, as 33 (79%) patients received diphenhydramine (29 [89%]) or epinephrine (4 [12%]) and 24 (52%) received antimicrobial medications. Of the 42 transfer patients, 24 (57%) received or continued these medications before transfer; the medications were promptly discontinued upon tertiary hospital admission.

Once the outside hospitals contacted the tertiary hospital for a referral, the mean length of time between the transfer request and Physician Access Line call was 17.13 minutes (Table 4). Following the transfer request, the mean length of time for arrival at the tertiary hospital was 6.22 hours. The mean length of stay at the outside hospital prior to the patient being transferred was 3.84 days.

Comment

This retrospective study examined 71 patients with biopsy-confirmed SJS, SJS/TEN overlap, or TEN to evaluate differences in clinical outcomes between direct and transfer admissions. Transfer patients had a higher mean maximum affected BSA (38.55% vs 19.14% [P=.005]) and elevated SCORTEN (1.92 vs 1.07 [P=.029]); a higher number of transfer patients were admitted to the ICU (19 vs 5 [P=.014]) and burn unit (9 vs 2 [P=.096]), and this group also demonstrated longer hospitalization stays (13.71 vs 7.17 [P<.0001]). There were more complications among transfer patients, including bacteremia (16 vs 4 [P=.025]), which is consistent with findings from the existing literature.³

Once the decision for transfer of the patients included in our study was initiated and accepted, there was a prompt response and transfer of care; the mean length of time for Physician Access Line request was 17.13 minutes, and the mean transfer time to arrive at the tertiary hospital was 6.22 hours; however, patients spent an average of 3.84 days at outside hospitals, reflecting that transfer calls frequently were initiated due to urgent clinical decline of the patient rather than as an early intervention strategy. The management at outside hospitals often included the continuation of antimicrobial medications, which were discontinued upon transfer to AHWFBMC. Causative agents were either previously prescribed for a new medical condition or initiated for the management of suspected infections at outside hospitals. This may reflect the difficulty in correctly diagnosing SJS/TEN and initiating appropriate management at hospital facilities without an inpatient dermatologist.

The presence of inpatient dermatologists can improve the diagnostic accuracy and treatment of various conditions.^4,5 Dermatology consultations added or changed 77% of treatment plans for 271 hospitalized patients.⁴ The impact of this intervention is reflected by the success of early dermatology consultations in reducing the length of hospitalization and use of inappropriate treatments in the care of skin diseases.^6-8

Access to dermatologic care has been an identified need in inpatient hospitals that may limit the ability of hospitals to promptly treat serious conditions such as SJS/TEN.⁹ From an inpatient dermatology study from 2013 through 2019, 98.2% of 782 inpatient dermatologists reside in metropolitan areas, limiting the availability of care for rural patients; this study also found a decreasing number of facilities with inpatient dermatologists.¹⁰

The limitations of our study include a small sample size of 71 patients, which restricted the generalizability of our results. Our study also was based at a single tertiary center, which thereby limited the findings to this geographic area. It also was difficult to match patients by their demographic and comorbid conditions. The retrospective study design depended on the accuracy and completeness of medical records, which can introduce information bias. Future studies should compare the clinical outcomes of SJS/TEN based on burn unit and ICU admissions.

Conclusion

Prompt identification of SJS/TEN and rapid transfer to hospitals with inpatient dermatology are essential to optimize patient outcomes. Developing and validating SJS/TEN diagnosis and transfer protocols across multiple institutions may be helpful.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening conditions that involve widespread necrosis of the skin and mucous membranes.¹ Guidelines for SJS and TEN recommend management in hospitals with access to inpatient dermatology to provide immediate interventions that are necessary for achieving optimal patient outcomes.² A delay in admission of 5 days or more after onset of symptoms has been associated with increases in overall mortality, bacteremia, intensive care unit (ICU) admission, and length of stay.³ Patients who are not directly admitted to specialized facilities and require transfer from other hospitals may experience delays in receiving critical interventions, further increasing the risk for mortality and complications. In this study, we analyzed the clinical outcomes of patients with SJS/TEN in relation to their admission pathway.

Methods

A single-center retrospective chart review was performed at Atrium Health Wake Forest Baptist Medical Center (AHWFBMC) in Winston-Salem, North Carolina. Participants were identified using i2b2, an informatics tool compliant with the Health Insurance Portability and Accountability Act for integrating biology and the bedside. Inclusion criteria were having a diagnosis of SJS (International Classification of Diseases, Tenth Revision, code L51.1; International Classification of Diseases, Ninth Revision, code 695.13), TEN (International Classification of Diseases, Tenth Revision, code L51.2; International Classification of Diseases, Ninth Revision, code 695.15) or Lyell syndrome from January 2012 to December 2024. Patients with erythema multiforme or bullous drug eruption were excluded, as these conditions initially were misdiagnosed as SJS or TEN. Patients with only a reported history of prior SJS or TEN also were excluded.

The following clinical outcomes were assessed: demographics, comorbidities, age at disease onset, outside hospital transfer status, complications during admission, inpatient length of stay in days, age of mortality (if applicable), culprit medications, interventions received, Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) upon admission, site of admission (eg, floor bed, ICU, medical ICU, burn unit), and length of disease process prior to hospital admission. Patients then were categorized as either direct or transfer admissions based on the initial point of care and admission process. Direct admissions included patients who presented to the AHWFBMC emergency department and were subsequently admitted. Transfer patients included patients who initially presented to an outside hospital and were transferred to AHWFBMC. Data regarding the wait time for Physician Access Line requests and the time elapsed from the initial transfer call to arrival at the tertiary hospital also were collected—this is a method that outside hospitals can use to contact physicians at the tertiary hospital for a possible transfer. Statistical analysis was performed using unpaired t tests and X² tests as necessary using GraphPad By Dotmatics Prism.

Results

A total of 112 patients were included in the analysis; of these, 71 had a diagnosis with biopsy confirmation of SJS, SJS/TEN overlap, or TEN (Table 1). Forty-one patients were excluded due to having a diagnosis of erythema multiforme or bullous drug eruption or a reported history of prior SJS or TEN without hospitalization. All biopsies were performed at AHWFBMC. Of the 71 confirmed patients with SJS/TEN, 54 (76%) were female with a mean age of 44 years. The majority of patients identified as Black (35 [49%]) or White (27 [38%]), along with Asian (7 [10%]) and other (2 [3%]). The most common comorbidity was cardiovascular disease in 42 (59%) patients, followed by type 2 diabetes in 36 (51%) patients. Among these 71 patients with SJS/TEN, 29 (41%) were directly admitted to the tertiary hospital, while 42 (59%) were transferred from outside hospitals.

Of the 71 confirmed patients with SJS/TEN, sulfonamides were identified as the most common inciting drug in 25 (41%) patients, followed by beta-lactam antibiotics in 16 (23%) patients (Table 2). This is consistent with previous literature of sulfamethoxazole with trimethoprim as the primary causative drug for SJS and TEN in the United States.¹

Clinical Outcomes—Of the 71 patients, there were 23 (32%) cases of SJS, 29 (41%) cases of SJS/TEN overlap, and 19 (27%) cases of TEN (eTable). The initial and maximum affected body surface area (BSA) was higher in transfer admissions, with a mean maximum BSA of 38.55% in the transfer group compared to 19.14% in the direct admissions. The mean SCORTEN (range, 0-5) was 1.6 overall, with a higher mean score of 1.92 in the transfer group compared to 1.07 in the direct admissions.

Transfer patients had a longer mean stay at the tertiary hospital (13.71 d) compared to direct admissions (7.17 d). The mean time from symptom onset until tertiary hospital admission was 8.5 days; transfer and direct admission patients had similar mean time from symptom onset of 9.02 days and 7.86 days, respectively. Although the duration of cutaneous symptoms from onset until tertiary hospital admission was similar (P=.283) between direct admissions (7.86 d) and transfer patients (9.02 d), the transfer group presented with greater disease severity at the time of admission. Transfer patients had a higher mean maximum BSA involvement (38.55% vs 19.14% [P=.005]), elevated SCORTEN (1.92 vs 1.07 [P=.029]), and longer mean hospital stays (13.71 d vs 7.17 d [P<.0001]) compared to direct admissions.

Despite the absence of mortality in both groups, transfer patients showed a higher number of ICU admissions (19 vs 5 [P=.014]) and burn unit admissions (9 vs 2 [P=.096]), bacteremia (16 vs 4 [P=.025]), acute kidney injury (13 vs 10 [P=.755]), acute respiratory failure (12 vs 5 [P=.272]), and transaminitis (8 vs 3 [P=.319]).

Outside Hospital Treatments—All outside hospitals provided supportive care with intravenous fluids and acetaminophen; however, further care provided at outside hospitals varied (Table 3), with transfer patients most frequently being treated with diphenhydramine (69% [29/42]), antimicrobial medications (57% [24/42]), steroids (40%), and epinephrine (10% [4/42]). Some patients may have received more than one of these treatments. Based on outside hospital treatments, the primary care teams’ main clinical concerns were allergic reactions and infection, as 33 (79%) patients received diphenhydramine (29 [89%]) or epinephrine (4 [12%]) and 24 (52%) received antimicrobial medications. Of the 42 transfer patients, 24 (57%) received or continued these medications before transfer; the medications were promptly discontinued upon tertiary hospital admission.

Once the outside hospitals contacted the tertiary hospital for a referral, the mean length of time between the transfer request and Physician Access Line call was 17.13 minutes (Table 4). Following the transfer request, the mean length of time for arrival at the tertiary hospital was 6.22 hours. The mean length of stay at the outside hospital prior to the patient being transferred was 3.84 days.

Comment

This retrospective study examined 71 patients with biopsy-confirmed SJS, SJS/TEN overlap, or TEN to evaluate differences in clinical outcomes between direct and transfer admissions. Transfer patients had a higher mean maximum affected BSA (38.55% vs 19.14% [P=.005]) and elevated SCORTEN (1.92 vs 1.07 [P=.029]); a higher number of transfer patients were admitted to the ICU (19 vs 5 [P=.014]) and burn unit (9 vs 2 [P=.096]), and this group also demonstrated longer hospitalization stays (13.71 vs 7.17 [P<.0001]). There were more complications among transfer patients, including bacteremia (16 vs 4 [P=.025]), which is consistent with findings from the existing literature.³

Once the decision for transfer of the patients included in our study was initiated and accepted, there was a prompt response and transfer of care; the mean length of time for Physician Access Line request was 17.13 minutes, and the mean transfer time to arrive at the tertiary hospital was 6.22 hours; however, patients spent an average of 3.84 days at outside hospitals, reflecting that transfer calls frequently were initiated due to urgent clinical decline of the patient rather than as an early intervention strategy. The management at outside hospitals often included the continuation of antimicrobial medications, which were discontinued upon transfer to AHWFBMC. Causative agents were either previously prescribed for a new medical condition or initiated for the management of suspected infections at outside hospitals. This may reflect the difficulty in correctly diagnosing SJS/TEN and initiating appropriate management at hospital facilities without an inpatient dermatologist.

The presence of inpatient dermatologists can improve the diagnostic accuracy and treatment of various conditions.^4,5 Dermatology consultations added or changed 77% of treatment plans for 271 hospitalized patients.⁴ The impact of this intervention is reflected by the success of early dermatology consultations in reducing the length of hospitalization and use of inappropriate treatments in the care of skin diseases.^6-8

Access to dermatologic care has been an identified need in inpatient hospitals that may limit the ability of hospitals to promptly treat serious conditions such as SJS/TEN.⁹ From an inpatient dermatology study from 2013 through 2019, 98.2% of 782 inpatient dermatologists reside in metropolitan areas, limiting the availability of care for rural patients; this study also found a decreasing number of facilities with inpatient dermatologists.¹⁰

The limitations of our study include a small sample size of 71 patients, which restricted the generalizability of our results. Our study also was based at a single tertiary center, which thereby limited the findings to this geographic area. It also was difficult to match patients by their demographic and comorbid conditions. The retrospective study design depended on the accuracy and completeness of medical records, which can introduce information bias. Future studies should compare the clinical outcomes of SJS/TEN based on burn unit and ICU admissions.

Conclusion

Prompt identification of SJS/TEN and rapid transfer to hospitals with inpatient dermatology are essential to optimize patient outcomes. Developing and validating SJS/TEN diagnosis and transfer protocols across multiple institutions may be helpful.

THE COMPARISON:

• A. Erythematotelangiectatic rosacea in a polygonal vascular pattern on the cheeks in a Black woman who also has eyelid hypopigmentation due to vitiligo.
• B. Rhinophymatous rosacea in a Hispanic woman who also has papules and pustules on the chin and upper lip region as well as facial scarring from severe inflammatory acne during her teen years.
• C. Papulopustular rosacea in a Hispanic man.

Rosacea is a chronic inflammatory condition characterized by facial flushing and persistent erythema of the central face, typically affecting the cheeks and nose. It also may manifest with papules, pustules, and telangiectasias. The 4 main subtypes of rosacea are erythematotelangiectatic, papulopustular, phymatous (involving thickening of the skin, often of the nose), and ocular (dry, itchy, or irritated eyes).¹ Patients also may report stinging, burning, dryness, and edema.² The etiology of rosacea is unclear but is believed to involve immune dysfunction, neurovascular dysregulation, certain microorganisms, and genetic predisposition.^1,2

Epidemiology

Rosacea often is associated with fair skin and more frequently is reported in individuals of Northern European descent.^1,2 While it may be less common in darker skin types, rosacea is not rare in patients with skin of color (SOC). A review of US outpatient data from 1993 to 2010 found that 2% of patients with rosacea were Black, 2.3% were Asian or Pacific Islander, and 3.9% were Hispanic or Latino.³ Global estimates suggest that up to 40 million individuals with SOC may be affected by rosacea,⁴ with the reported prevalence as high as 10%.² Although early research linked rosacea primarily to adults older than 30 years, newer data show peak prevalence between ages 25 to 39 years, suggesting that younger adults may be affected more than previously recognized.⁵

Key Clinical Features

In addition to the traditional subtypes, updated guidelines recommend a phenotype- based approach to diagnosing rosacea focusing on observable features such as persistent redness in the central face and thickened skin rather than classifying patients into broad categories. A diagnosis can be made when at least one diagnostic feature is present (eg, fixed facial erythema or phymatous changes) or when 2 or more major features are observed (eg, papules, pustules, flushing, visible blood vessels, or ocular findings).⁶

In individuals with darker skin types, erythema may not be bright red; rather, the skin may appear pink, reddish-brown, violaceous, or dusky brown.⁷ Postinflammatory hyperpigmentation, which is common in darker skin tones, can further mask erythema.² Pressing a microscope slide or magnifying glass against the skin can help assess for blanching, which is indicative of erythema. Telangiectasias also may be more challenging to appreciate in patients with SOC and typically require bright, shadow-free lighting or dermoscopy for detection.²

Skin thickening across the cheeks and nose with overlying acneform papules can be diagnostic clues of rosacea in darker skin types and help distinguish it from acne.² It also is important to distinguish rosacea from systemic lupus erythematosus, which typically manifests as a malar rash that spares the nasolabial folds and is nonpustular. If uncertain, consider serologic testing for antinuclear antibodies, patch testing, or biopsy.⁸

Worth Noting

Treatment of rosacea is focused on managing symptoms and reducing flares. First-line strategies include behavioral modifications and trigger avoidance, such as minimizing sun exposure and avoiding consumption of alcohol and spicy foods.⁹ Gentle skin care practices are essential, including the use of light, fragrance-free, nonirritating cleansers and moisturizers at least once daily. Application of sunscreen with an SPF of at least 30 also is routinely recommended.^9,10 Additionally, patients should be counseled to avoid harsh cleansers, such as exfoliants, astringents, and chemicals that may further diminish the skin barrier.¹⁰

Treatment options approved by the US Food and Drug Administration for rosacea include oral doxycycline, oral minocycline, topical brimonidine, oxymetazoline, ivermectin, metronidazole, azelaic acid, sodium sulfacetamide/sulfur, encapsulated benzoyl peroxide cream, and minocycline.^11-13

Topical treatment options commonly used off-label for rosacea include topical clindamycin, topical retinoids, and azithromycin. Oral tetracyclines should be avoided in children and pregnant women; instead, oral erythromycin and topical metronidazole commonly are used.¹⁴

Laser or intense pulsed light therapy may be considered, although results have been mixed, and the long-term benefits are uncertain. Given the higher risk for postinflammatory hyperpigmentation in patients with SOC, these modalities should be used cautiously.¹⁵ Among the available options, the Nd:YAG laser is preferred in darker skin types due to its safety profile.¹⁶ A small case series reported successful CO2 laser treatment for rhinophyma in patients with melanated skin; however, some patients developed localized scarring, suggesting that conservative depth settings should be used to reduce risk for this adverse event.¹⁷

Health Disparity Highlight

Rosacea may be underdiagnosed in individuals with darker skin types,^2,15,18 likely due in part to reduced contrast between erythema and background skin tone, which can make features such as flushing and telangiectasias harder to appreciate.^1,10,15

Although tools to assess erythema exist, they rarely are used in everyday clinical practice.¹⁰ In patients with deeply pigmented skin, ensuring adequate examination room lighting and using dermoscopy can help identify any subtle vascular or textural changes localized across the central face. While various imaging techniques are used in clinical trials to monitor treatment response, few have been studied and optimized across a wide range of skin tones.¹⁰ There is a need for dermatologic assessment tools that better capture the degree of erythema, inflammation, and vascular features of rosacea in pigmented skin. Emerging research is focused on developing more equitable imaging technologies.¹⁹

THE COMPARISON:

• A. Erythematotelangiectatic rosacea in a polygonal vascular pattern on the cheeks in a Black woman who also has eyelid hypopigmentation due to vitiligo.
• B. Rhinophymatous rosacea in a Hispanic woman who also has papules and pustules on the chin and upper lip region as well as facial scarring from severe inflammatory acne during her teen years.
• C. Papulopustular rosacea in a Hispanic man.

Rosacea is a chronic inflammatory condition characterized by facial flushing and persistent erythema of the central face, typically affecting the cheeks and nose. It also may manifest with papules, pustules, and telangiectasias. The 4 main subtypes of rosacea are erythematotelangiectatic, papulopustular, phymatous (involving thickening of the skin, often of the nose), and ocular (dry, itchy, or irritated eyes).¹ Patients also may report stinging, burning, dryness, and edema.² The etiology of rosacea is unclear but is believed to involve immune dysfunction, neurovascular dysregulation, certain microorganisms, and genetic predisposition.^1,2

Epidemiology

Rosacea often is associated with fair skin and more frequently is reported in individuals of Northern European descent.^1,2 While it may be less common in darker skin types, rosacea is not rare in patients with skin of color (SOC). A review of US outpatient data from 1993 to 2010 found that 2% of patients with rosacea were Black, 2.3% were Asian or Pacific Islander, and 3.9% were Hispanic or Latino.³ Global estimates suggest that up to 40 million individuals with SOC may be affected by rosacea,⁴ with the reported prevalence as high as 10%.² Although early research linked rosacea primarily to adults older than 30 years, newer data show peak prevalence between ages 25 to 39 years, suggesting that younger adults may be affected more than previously recognized.⁵

Key Clinical Features

In addition to the traditional subtypes, updated guidelines recommend a phenotype- based approach to diagnosing rosacea focusing on observable features such as persistent redness in the central face and thickened skin rather than classifying patients into broad categories. A diagnosis can be made when at least one diagnostic feature is present (eg, fixed facial erythema or phymatous changes) or when 2 or more major features are observed (eg, papules, pustules, flushing, visible blood vessels, or ocular findings).⁶

In individuals with darker skin types, erythema may not be bright red; rather, the skin may appear pink, reddish-brown, violaceous, or dusky brown.⁷ Postinflammatory hyperpigmentation, which is common in darker skin tones, can further mask erythema.² Pressing a microscope slide or magnifying glass against the skin can help assess for blanching, which is indicative of erythema. Telangiectasias also may be more challenging to appreciate in patients with SOC and typically require bright, shadow-free lighting or dermoscopy for detection.²

Skin thickening across the cheeks and nose with overlying acneform papules can be diagnostic clues of rosacea in darker skin types and help distinguish it from acne.² It also is important to distinguish rosacea from systemic lupus erythematosus, which typically manifests as a malar rash that spares the nasolabial folds and is nonpustular. If uncertain, consider serologic testing for antinuclear antibodies, patch testing, or biopsy.⁸

Worth Noting

Treatment of rosacea is focused on managing symptoms and reducing flares. First-line strategies include behavioral modifications and trigger avoidance, such as minimizing sun exposure and avoiding consumption of alcohol and spicy foods.⁹ Gentle skin care practices are essential, including the use of light, fragrance-free, nonirritating cleansers and moisturizers at least once daily. Application of sunscreen with an SPF of at least 30 also is routinely recommended.^9,10 Additionally, patients should be counseled to avoid harsh cleansers, such as exfoliants, astringents, and chemicals that may further diminish the skin barrier.¹⁰

Treatment options approved by the US Food and Drug Administration for rosacea include oral doxycycline, oral minocycline, topical brimonidine, oxymetazoline, ivermectin, metronidazole, azelaic acid, sodium sulfacetamide/sulfur, encapsulated benzoyl peroxide cream, and minocycline.^11-13

Topical treatment options commonly used off-label for rosacea include topical clindamycin, topical retinoids, and azithromycin. Oral tetracyclines should be avoided in children and pregnant women; instead, oral erythromycin and topical metronidazole commonly are used.¹⁴

Laser or intense pulsed light therapy may be considered, although results have been mixed, and the long-term benefits are uncertain. Given the higher risk for postinflammatory hyperpigmentation in patients with SOC, these modalities should be used cautiously.¹⁵ Among the available options, the Nd:YAG laser is preferred in darker skin types due to its safety profile.¹⁶ A small case series reported successful CO2 laser treatment for rhinophyma in patients with melanated skin; however, some patients developed localized scarring, suggesting that conservative depth settings should be used to reduce risk for this adverse event.¹⁷

Health Disparity Highlight

Rosacea may be underdiagnosed in individuals with darker skin types,^2,15,18 likely due in part to reduced contrast between erythema and background skin tone, which can make features such as flushing and telangiectasias harder to appreciate.^1,10,15

Although tools to assess erythema exist, they rarely are used in everyday clinical practice.¹⁰ In patients with deeply pigmented skin, ensuring adequate examination room lighting and using dermoscopy can help identify any subtle vascular or textural changes localized across the central face. While various imaging techniques are used in clinical trials to monitor treatment response, few have been studied and optimized across a wide range of skin tones.¹⁰ There is a need for dermatologic assessment tools that better capture the degree of erythema, inflammation, and vascular features of rosacea in pigmented skin. Emerging research is focused on developing more equitable imaging technologies.¹⁹

THE COMPARISON:

• A. Erythematotelangiectatic rosacea in a polygonal vascular pattern on the cheeks in a Black woman who also has eyelid hypopigmentation due to vitiligo.
• B. Rhinophymatous rosacea in a Hispanic woman who also has papules and pustules on the chin and upper lip region as well as facial scarring from severe inflammatory acne during her teen years.
• C. Papulopustular rosacea in a Hispanic man.

Rosacea is a chronic inflammatory condition characterized by facial flushing and persistent erythema of the central face, typically affecting the cheeks and nose. It also may manifest with papules, pustules, and telangiectasias. The 4 main subtypes of rosacea are erythematotelangiectatic, papulopustular, phymatous (involving thickening of the skin, often of the nose), and ocular (dry, itchy, or irritated eyes).¹ Patients also may report stinging, burning, dryness, and edema.² The etiology of rosacea is unclear but is believed to involve immune dysfunction, neurovascular dysregulation, certain microorganisms, and genetic predisposition.^1,2

Epidemiology

Rosacea often is associated with fair skin and more frequently is reported in individuals of Northern European descent.^1,2 While it may be less common in darker skin types, rosacea is not rare in patients with skin of color (SOC). A review of US outpatient data from 1993 to 2010 found that 2% of patients with rosacea were Black, 2.3% were Asian or Pacific Islander, and 3.9% were Hispanic or Latino.³ Global estimates suggest that up to 40 million individuals with SOC may be affected by rosacea,⁴ with the reported prevalence as high as 10%.² Although early research linked rosacea primarily to adults older than 30 years, newer data show peak prevalence between ages 25 to 39 years, suggesting that younger adults may be affected more than previously recognized.⁵

Key Clinical Features

In addition to the traditional subtypes, updated guidelines recommend a phenotype- based approach to diagnosing rosacea focusing on observable features such as persistent redness in the central face and thickened skin rather than classifying patients into broad categories. A diagnosis can be made when at least one diagnostic feature is present (eg, fixed facial erythema or phymatous changes) or when 2 or more major features are observed (eg, papules, pustules, flushing, visible blood vessels, or ocular findings).⁶

In individuals with darker skin types, erythema may not be bright red; rather, the skin may appear pink, reddish-brown, violaceous, or dusky brown.⁷ Postinflammatory hyperpigmentation, which is common in darker skin tones, can further mask erythema.² Pressing a microscope slide or magnifying glass against the skin can help assess for blanching, which is indicative of erythema. Telangiectasias also may be more challenging to appreciate in patients with SOC and typically require bright, shadow-free lighting or dermoscopy for detection.²

Skin thickening across the cheeks and nose with overlying acneform papules can be diagnostic clues of rosacea in darker skin types and help distinguish it from acne.² It also is important to distinguish rosacea from systemic lupus erythematosus, which typically manifests as a malar rash that spares the nasolabial folds and is nonpustular. If uncertain, consider serologic testing for antinuclear antibodies, patch testing, or biopsy.⁸

Worth Noting

Treatment of rosacea is focused on managing symptoms and reducing flares. First-line strategies include behavioral modifications and trigger avoidance, such as minimizing sun exposure and avoiding consumption of alcohol and spicy foods.⁹ Gentle skin care practices are essential, including the use of light, fragrance-free, nonirritating cleansers and moisturizers at least once daily. Application of sunscreen with an SPF of at least 30 also is routinely recommended.^9,10 Additionally, patients should be counseled to avoid harsh cleansers, such as exfoliants, astringents, and chemicals that may further diminish the skin barrier.¹⁰

Treatment options approved by the US Food and Drug Administration for rosacea include oral doxycycline, oral minocycline, topical brimonidine, oxymetazoline, ivermectin, metronidazole, azelaic acid, sodium sulfacetamide/sulfur, encapsulated benzoyl peroxide cream, and minocycline.^11-13

Topical treatment options commonly used off-label for rosacea include topical clindamycin, topical retinoids, and azithromycin. Oral tetracyclines should be avoided in children and pregnant women; instead, oral erythromycin and topical metronidazole commonly are used.¹⁴

Laser or intense pulsed light therapy may be considered, although results have been mixed, and the long-term benefits are uncertain. Given the higher risk for postinflammatory hyperpigmentation in patients with SOC, these modalities should be used cautiously.¹⁵ Among the available options, the Nd:YAG laser is preferred in darker skin types due to its safety profile.¹⁶ A small case series reported successful CO2 laser treatment for rhinophyma in patients with melanated skin; however, some patients developed localized scarring, suggesting that conservative depth settings should be used to reduce risk for this adverse event.¹⁷

Health Disparity Highlight

Rosacea may be underdiagnosed in individuals with darker skin types,^2,15,18 likely due in part to reduced contrast between erythema and background skin tone, which can make features such as flushing and telangiectasias harder to appreciate.^1,10,15

Although tools to assess erythema exist, they rarely are used in everyday clinical practice.¹⁰ In patients with deeply pigmented skin, ensuring adequate examination room lighting and using dermoscopy can help identify any subtle vascular or textural changes localized across the central face. While various imaging techniques are used in clinical trials to monitor treatment response, few have been studied and optimized across a wide range of skin tones.¹⁰ There is a need for dermatologic assessment tools that better capture the degree of erythema, inflammation, and vascular features of rosacea in pigmented skin. Emerging research is focused on developing more equitable imaging technologies.¹⁹