Burroughs, Brian

Acanthosis nigricans (AN) is a common dermatologic condition characterized by hyperpigmented, velvety plaques that most frequently affect intertriginous areas. Although often associated with insulin resistance and obesity, AN may also serve as a cutaneous marker of underlying endocrinologic disorders, medication effects, genetic syndromes, or internal malignancy. Recognition of AN provides an important opportunity for early identification of systemic disease and implementation of targeted management strategies. This review summarizes the pathogenesis and etiologic subtypes of AN, highlights key clinical features and differential diagnoses, and outlines an evidence-based diagnostic approach. Management strategies are discussed with emphasis on lifestyle modification, pharmacologic therapies, topical treatments, procedural interventions, and the strength of supporting evidence. Practical considerations relevant to physician assistants are emphasized throughout, including interdisciplinary care and patient education. Early recognition and appropriate management of AN can improve both dermatologic outcomes and overall patient health.

Background Acute otitis externa (AOE) is a common condition encountered in primary care. Evidence-based guidelines recommend topical antimicrobial therapy as first-line treatment for uncomplicated disease regardless of diabetes status. However, clinicians may escalate treatment in patients with diabetes because of concern for necrotizing otitis externa (NOE), a rare but potentially life-threatening complication. This study aimed to evaluate whether diabetes status influences systemic antibiotic use in uncomplicated acute otitis externa and to assess factors associated with treatment decisions. Methods A cross-sectional survey was distributed to primary care clinicians participating in a multi-state primary care practice-based research collaborative, comprising physicians, nurse practitioners, and physician associates within the specialties of family medicine, general pediatrics, and general internal medicine. The survey instrument asked clinicians what they would select as first-line treatment for uncomplicated AOE in patients with and without diabetes mellitus (DM). It also assessed factors influencing management decisions as well as confidence in identifying NOE. The primary outcome was whether the clinician reported they would use systemic antibiotics for treatment of AOE, comparing treatment decisions using relative risk (RR) with 95% confidence intervals (CI) for antibiotic exposure given the presence of DM. Results Out of 257 invitations, 58 respondents completed the survey (22.6%). Systemic antibiotics were selected more frequently when DM was present (19.0%) compared with when DM was absent (5.2%), resulting in a significantly increased likelihood of reported systemic antibiotic use (RR = 3.67; 95% CI, 1.08–12.47; p = 0.043). Clinician confidence in identifying NOE varied, with most respondents reporting only slight or moderate confidence. Conclusions Primary care clinicians reported substantially higher use of systemic antibiotics when managing uncomplicated AOE in patients with DM, representing nearly a fourfold increase in antibiotic exposure despite guideline recommendations favoring topical therapy alone. These findings highlight practice variation which may be driven by concern for necrotizing otitis externa, underscoring opportunities to improve antibiotic stewardship and clinician confidence in risk stratification.