The Most Beautiful People: Evolving Standards of Beauty mild liver enzyme elevations are common postinfection. Clinically apparent liver injury from terbinafine treatment occurs in 1 per 50 000 to 120 000 cases.6 Asymptomatic elevations in serum aminotransferases are found in less than 1% of patients, which typically self-resolve without discon- tinuing therapy. We recommend baseline transaminase monitoring. How- ever, routine laboratory monitoring during systemic therapy (12 weeks or less) for onychomycosis in healthy children may be unnecessary owing to low incidence of clinically signifi- cant adverse effects, costs of laboratory tests, workup of spu- rious laboratory abnormalities, and patient discomfort. This study is limited by its generalizability, small sample size, and retrospective nature. Larger, prospective studies evaluating the safety profile in pediatric patients are needed to detect the rare but serious adverse effects that could occur during therapy and work toward FDA label changes for a pediatric onychomyco- sis indication. Deepa Patel, BS Leslie A. Castelo-Soccio, MD, PhD Adam I. Rubin, MD Jenna L. Streicher, MD Author Affiliations: University of Louisville, School of Medicine, Louisville, Kentucky (Patel); Department of Pediatrics, Section of Dermatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Castelo-Soccio, Rubin, Streicher); Perelman School of Medicine, University of Pennsylvania, Philadelphia, (Castelo-Soccio, Rubin, Streicher); Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Rubin). Corresponding Author: Jenna L. Streicher, MD, Section of Dermatology, Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Wood Center, third Floor, Philadelphia, PA 19104 (streicherj@email.chop .edu). Accepted for Publication: September 16, 2017. Published Online: November 29, 2017. doi:10.1001/jamadermatol.2017.4483 Author Contributions: Ms Patel and Dr Streicher had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Patel, Streicher. Critical revision of the manuscript for important intellectual content: Castelo- Soccio, Rubin, Streicher. Statistical analysis: Patel. Administrative, technical, or material support: Castelo-Soccio, Rubin. Study supervision: Castelo-Soccio, Rubin, Streicher. Conflict of Interest Disclosures: None reported. 1. Philpot CM, Shuttleworth D. Dermatophyte onychomycosis in children. Clin Exp Dermatol. 1989;14(3):203-205. 2. Friedlander SF, Chan YC, Chan YH, Eichenfield LF. Onychomycosis does not always require systemic treatment for cure: a trial using topical therapy. Pediatr Dermatol. 2013;30(3):316-322. 3. Gupta AK, Paquet M. Systemic antifungals to treat onychomycosis in children: a systematic review. Pediatr Dermatol. 2013;30(3):294-302. 4. Terbinafine hydrochloride [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2017. 5. National Cancer Institute. Common Terminology Criteria for Adverse Events v4.03(CTCAE). https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14 _QuickReference_5x7.pdf. Accessed May 15, 2017. 6. National Library of Medicine, National Institute of Diabetes and Digestive and Kidney Disease. Clinical and research information on drug-induced liver injury: drug record: terbinafine. https://livertox.nlm.nih.gov/Terbinafine.htm. Accessed May 15, 2017. The Most Beautiful People: Evolving Standards of Beauty Not merely an aberration of modern culture, societal obses- sion with beauty is deeply engrained in the past, with the ap- preciation of human aesthetics dating back to early Greek civi- lization. Although ideas on beauty var y with personal preferences and cultural standards, in a society at any given time, there is substantial agreement as to what constitutes hu- man beauty.1 This study uses People magazine to compare stan- dards of beauty in 1990 with present day standards. Methods | Published by Time Inc, People has the largest audi- ence of any US magazine, with a readership of 43.6 million adults.2 We compared People magazine’s World’s Most Beau- tiful (WMB) list in the first issue (1990) with that in the 2017 issue, hypothesizing that beauty standards have not changed. From the 1990 (50 celebrities) and 2017 (135 celebrities) is- sues of People magazine’s WMB list, we extracted the follow- ing information: age at the time of the specific issue, sex, race, skin type, hair color, eye color, and visible dermatologic con- ditions. Characteristics with dichotomous and categorical vari- ables were reported as numbers (percentages) and continu- ous variables as means (SDs). Between-group differences were assessed using the Fisher exact text or χ2 tests for categorical variables and t tests for continuous variables. Results were con- sidered to be significant at P<.05 in the 2-sided hypothesis. In- stitutional review board approval was waived by the Boston University Institutional Review Board. Because no patients were involved in this study, informed consent was not required. Table 2. Demographics of Patients With Laboratory Monitoringa Characteristic Overall Normal Laboratory Results or Laboratory Abnormality Prior to Therapy Laboratory Abnormality During Therapy P Value Patients with laboratory monitoring, No. (%) 144 (54) 138 (96) 6 (4) Sex, No. (%) Female 68 (47) 65 (96) 3 (4) .89 Male 76 (53) 73 (96) 3 (4) Age, No. (%), y <12 71 (49) 68 (96) 3 (4) .97 ≥12 73 (51) 70 (96) 3 (4) a Demographics of the study population and patients who underwent laboratory monitoring. χ2 tests were performed to evaluate covariates of sex and age assuming a .05 significance level. Letters jamadermatology.com (Reprinted) JAMA Dermatology December 2017 Volume 153, Number 12 1327 © 2017 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 mailto:streicherj@email.chop.edu mailto:streicherj@email.chop.edu http://jama.jamanetwork.com/article.aspx?doi=10.1001/jamadermatol.2017.4483&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamadermatol.2017.4483 https://www.ncbi.nlm.nih.gov/pubmed/2531638 https://www.ncbi.nlm.nih.gov/pubmed/2531638 https://www.ncbi.nlm.nih.gov/pubmed/23278851 https://www.ncbi.nlm.nih.gov/pubmed/23278851 https://www.ncbi.nlm.nih.gov/pubmed/23278514 https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf https://livertox.nlm.nih.gov/Terbinafine.htm http://www.jamadermatology.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamadermatol.2017.3693 Results | We compared 50 celebrities from the 1990 WMB list with 135 celebrities from the 2017 WMB list. Fitzpatrick skin types I to III represented 88.0% and Fitzpatrick skin types IV to VI represented 12.0% of the WMB list in 1990, whereas in 2017, Fitzpatrick skin types I to III represented 70.4% and Fitz- patrick skin types IV to VI represented 29.6% (P = .01). Mean age increased; mean (SD) age was 33.2 (11.5) years in 1990 vs 38.9 (11.6) years in 2017 (P = .003). The proportion of females also increased (26 [52.0%] in 1990 vs 119 [88.1%] in 2017; P < .001), as did that of nonwhite races (12 [24.0%] in 1990 vs 54 [40.0%] in 2017; P = .04). Those of mixed race were repre- sented by 1 person (2.0%) in 1990 and 14 persons (10.4%) in 2017 (P = .07). Only 5 of 185 (2.7%) had any visible skin con- dition or lesion that marred the even distribution of texture and/or color (Table 1 and Table 2). Discussion | Human beauty is partially determined by a func- tion of physical features, such as facial averageness, symme- try, skin homogeneity, and sexual dimorphism.3 However, the perception of attractiveness is also influenced by more than these static physical characteristics. Ideals of beauty are of- ten particular to the beholder and determined by the norms of a society, culture, or historical period. As evidenced by our data and contrary to our hypothesis, at present, a wider variety of skin colors and inclusion of older age groups are represented among those deemed to be the most beautiful. Humans are a colorful species of primates, with the genetic palette allowing for wide variation in human skin, hair, and eye color.4 In our study, skin types IV to VI were signifi- cantly more represented in 2017 than in 1990. The cosmetic industry has embraced this wide variety of complexions, pro- ducing varying hues of colors to complement rather than mask and hide inherent tone. The increase in mean age of the people featured in the WMB issue of People, with a significant in- crease in percentage of those 35 years and older, is significant in the present aging society.5 According to the American So- ciety for Dermatologic Surgery 2016 consumer report, 60% were considering a cosmetic procedure, and the top 3 reasons were to increase confidence, increase attractiveness, and look as young as they feel.6 The classic notion of beauty is a matter of mathematical conceptions and instantiating definite proportions. How- ever, with the advent of the highly connected world that has Table 1. Characteristics of the Celebrities Featured in People’s 1990 and 2017 World’s Most Beautiful Lists Characteristic No. (%) of Celebrities (N = 185) Age, y 18-24 19 (10.3) 25-34 63 (34.1) 35-44 60 (32.4) 45-54 28 (15.1) ≥55 15 (8.1) Sex Male 40 (21.6) Female 145 (78.4) Race White 119 (64.3) Black 29 (15.7) Asian 8 (4.3) Hispanic 14 (7.6) Mixed 15 (8.1) Fitzpatrick skin type I 39 (21.1) II 67 (36.2) III 33 (17.8) IV 14 (7.6) V 28 (15.1) VI 4 (2.2) Hair color Blonde 37 (20.0) Brown 143 (77.3) Red 5 (2.7) Eye color Blue 50 (27.0) Brown 98 (53.0) Green 19 (10.3) Hazel 18 (9.7) Visible skin condition Yes 5 (2.7) No 180 (97.3) Table 2. Comparison of Characteristics of the Celebrities Featured in People’s 1990 and 2017 World’s Most Beautiful Lists Characteristic No. (%) of Celebrities P Valuea 1990 (n = 50) 2017 (n = 135) Age, y 18-24 8 (16.0) 11 (8.1) .004 25-34 25 (50.0) 38 (28.1) 35-44 12 (24.0) 48 (35.6) 45-54 2 (4.0) 26 (19.3) ≥55 3 (6.0) 12 (8.9) Sex Male 24 (48.0) 16 (11.9) <.001 Female 26 (52.0) 119 (88.1) Race White 38 (76.0) 81 (60.0) .04 Other 12 (24.0) 54 (40.0) Fitzpatrick skin type I-III 44 (88.0) 95 (70.4) .01 IV-VI 6 (12.0) 40 (29.6) Hair color Blonde 6 (12.0) 31 (23.0) .21 Brown 43 (86.0) 100 (74.1) Red 1 (2.0) 4 (3.0) Eye color Blue 14 (28.0) 36 (26.7) .17 Brown 24 (48.0) 74 (54.8) Green 9 (18.0) 10 (7.4) Hazel 3 (6.0) 15 (11.1) a P values were generated using χ2 or Fisher exact tests where appropriate. Letters 1328 JAMA Dermatology December 2017 Volume 153, Number 12 (Reprinted) jamadermatology.com © 2017 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 http://www.jamadermatology.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamadermatol.2017.3693 exposed individuals to many forms of beauty, we still strive to understand what beauty entails. The mass media platform has for years introduced certain criteria for what constitutes beauty. Through an examination of the WMB issue of People, we found that these beauty standards are evolving as people learn how to integrate the effects of media with exposure to new cultures and different norms. Mayra B. C. Maymone, MD, DSc Hind H. Neamah, MD, MPH Eric A. Secemsky, MD, MSc Roopal V. Kundu, MD Dana Saade, MD Neelam A. Vashi, MD Author Affiliations: Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts (Maymone, Neamah, Saade, Vashi); Department of Medicine, Massachusetts General Hospital, Boston (Secemsky); Harvard Medical School, Boston, Massachusetts (Secemsky); Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Kundu). Corresponding Author: Neelam A. Vashi, MD, Department of Dermatology, Boston University School of Medicine, 609 Albany St, J108, Boston, MA 02118 (nvashi@bu.edu). Accepted for Publication: August 1, 2017. Published Online: October 11, 2017. doi:10.1001/jamadermatol.2017.3693 Author Contributions: Drs Vashi and Neamah had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Maymone, Vashi. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Maymone, Secemsky, Vashi. Critical revision of the manuscript for important intellectual content: Neamah, Secemsky, Kundu, Saade, Vashi. Statistical analysis: Neamah, Secemsky, Vashi. Obtained funding: Vashi. Administrative, technical, or material support: Maymone, Saade, Vashi. Study supervision: Vashi. Conflict of Interest Disclosures: None reported. 1. Hamermesh DS. Beauty Pays: Why Attractive People Are More Successful. Princeton, NJ: Princeton University Press; 2011. 2. Johnso-Greene C. AARP shows largest growth in readership. Folio Magazine. May 18, 2009. http://www.foliomag.com/aarp-shows-largest-readership -growth-people-largest-audience/. Accessed May 21, 2017. 3. Vashi N. Beauty and Body Dysmorphic Disorder: A Clinician’s Guide. New York, NY: Springer International Publishing; 2015. 4. Jablonski NG, Chaplin G. The colours of humanity: the evolution of pigmentation in the human lineage. Philos Trans R Soc Lond B Biol Sci. 2017;372 (1724):1-5. 5. Ortman J, Velkoff V, Hogan H. An aging nation: the older population in the United States: population estimates and projection. US Census Bureau website. May 2014. https://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed May 20, 2017. 6. ASDS Consumer survey on cosmetic procedures 2016. American Society for Dermatologic Surgery (ASDS) website. July 19, 2016. https://www.asds.net /_Media.aspx?id=9576. Accessed May 21, 2017. Addressing Minority Representation in Dermatology: Answering a Call to Action Through Structured Mentorship and Instruction Recent attention has been called to the insufficient represen- tation in dermatology of African American and Hispanic indi- viduals, which comprise the major populations underrepre- sented in medicine (UIM).1,2 There have been 2 recent calls to action to increase UIM populations in dermatology, a task that necessitates action.1,2 Among the numerous approaches previously suggested, mentoring and tutoring have been cited as some of the best to increase diversity.1,2 We present the instructional and men- toring program we used to encourage UIM students in our com- munity to consider dermatology careers in an attempt to show that even brief outreach programs can make a difference. Table. Outline of Lectures, Activities, and Discussions in 4 Lessons Session Content Lesson 1 Introduction Precurriculum survey Discussion What is a dermatologist? Activity Celebrities with dermatological conditions Discussion Resident Q&A Lesson 2 Lecture Layers of the skin Epidermis: layers, functions, Fitzpatrick skin types Dermis: functions, hair growth Subcutaneous fat: functions Lecture Common skin, hair, and nail conditions Acne vulgaris: types, pathogenesis, treatments, postinflammatory hyperpigmentation Vitiligo: pathogenesis Atopic dermatitis: pathogenesis, atopic triad Cutaneous T-cell lymphoma: mycosis fungoides, Sézary syndrome Traction alopecia: pathogenesis, prevention Pseudofolliculitis barbae: pathogenesis, risk factors, prevention Nail signs: pitting, clubbing, spoon shape, Hutchinson sign Activity Classroom response system Lesson 3 Lecture Skin cancer Basal cell carcinoma: risk factors, types, dermoscopy, management Squamous cell carcinoma: risk factors, types Melanoma: risk factors, ABCDEs, types, management Sun protection: how to read sunscreen bottles, UV-A vs UV-B, sun-protective clothing Activity Classroom response system Activity Biopsies and suturing Videos: shave biopsy, punch biopsy, simple interrupted sutures Hands-on practice with biopsy and suture equipment Lesson 4 Lecture Vitamin D Sun-induced synthesis Guidelines for supplementation How to maintain adequate stores Activity Jeopardy Categories: images, hair and nails, skin layers, sun and cancer, miscellaneous Wrap-up Resident Q&A Postcurriculum evaluation Abbreviations: ABCDEs, asymmetry, border, color, diameter, and evolution; Q&A, question and answer. Letters jamadermatology.com (Reprinted) JAMA Dermatology December 2017 Volume 153, Number 12 1329 © 2017 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 mailto:nvashi@bu.edu http://jama.jamanetwork.com/article.aspx?doi=10.1001/jamadermatol.2017.3693&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamadermatol.2017.3693 http://www.foliomag.com/aarp-shows-largest-readership-growth-people-largest-audience/ http://www.foliomag.com/aarp-shows-largest-readership-growth-people-largest-audience/ https://www.ncbi.nlm.nih.gov/pubmed/28533464 https://www.ncbi.nlm.nih.gov/pubmed/28533464 https://www.census.gov/prod/2014pubs/p25-1140.pdf https://www.asds.net/_Media.aspx?id=9576 https://www.asds.net/_Media.aspx?id=9576 http://www.jamadermatology.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamadermatol.2017.3224