549 Measurement properties of four different patient-reported outcomes to assess sleep disturbance in adults with atopic dermatitis DK Lei 1 , M Yousaf 1 , S Janmohamed 1 , P Vakharia 1 , R Chopra 1 , R Chavda 1 , S Gabriel 1 , R Sacotte 1 , K Patel 1 , V Singam 1 , S Immaneni 1 , R Kantor 1 , D Hsu 1 , D Cella 1 and J Silverberg 2,1 1 Dermatology, Feinberg School of Medicine at Northwestern University, Chicago, Illinois, United States and 2 Dermatology, George Washington University School of Medicine, Washington, District of Columbia, United States Sleep is commonly impacted in atopic dermatitis (AD). However, the ideal patient-reported outcome measures to assess sleep in AD patients has not been determined. We sought to determine the measurement properties of the Patient-Reported Outcomes Measurement In- formation System (PROMIS) Itch Questionnaire (PIQ)-Mood and Sleep, Sleep Disturbance (SD), Sleep-Related Impairment (SRI), and Epworth Sleepiness Scale (ESS) in adults with AD. We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n¼491). PIQ Mood and Sleep, PROMIS SD, SRI, and ESS had good convergent validity with intensity and frequency of sleep disturbance, Patient-Oriented Eczema Measure, Eczema Area and Severity Index, total and objective-Scoring AD, Nu- merical Rating Scale of worst-itch and average-itch, and Dermatology Life Quality Index. PIQ Mood and Sleep had significantly better correlations with other severity measures than the other sleep measures (Fisher z-scores, P0.04 for all). PIQ Mood and Sleep had fair ability to distinguish between levels of severity of sleep disturbance, AD or itch, i.e. criterion validity. PROMIS SD, PROMIS SRI and ESS had poor to fair ability to distinguish between different levels of sleep, AD and/or itch severity. All four sleep assessments showed fair responsiveness to change of severity of sleep-disturbance, AD and itch, had good internal consistency, with no floor or ceiling effects, and were feasible for use in clinical practice. In conclusion, PIQ Mood and Sleep, PROMIS SD, PROMIS SRI and ESS showed good construct validity, internal consistency and responsiveness in adult AD. PIQ Mood and Sleep, followed by PROMIS SD, had the best measurement properties in adult AD. 550 Mercaptopurine-induced Sweet syndrome in Crohn’s disease J Wat 1 , M Wat 1,2 and K Honda 1 1 Dermatology, Case Western Reserve University School of Medicine/University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States and 2 Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, United States Azathioprine-induced Sweet syndrome (AISS) usually occurs within a month of initiation of azathioprine. We describe a 19-year-old man with Crohn’s disease, which was well- controlled and chronically managed on 6-mercaptopurine (6-MP) and mesalamine, who presented with painful, hemorrhagic, centrally necrotic pustules on the bilateral dorsal hands and neutropenia. Pathology of a cutaneous lesion revealed a neutrophilic infiltrate, with a negative infectious source. Bone marrow evaluation showed hypocellular marrow consistent with 6-MP toxicity but no evidence of malignancy. Drug-induced Sweet syndrome in thirteen previously described patients co-occurred with fever, painful skin lesions most commonly on the upper extremities, and biopsy-confirmed neutrophilic dermatosis–features all present in this patient. While classically drug-induced Sweet syndrome is temporally associated with drug administration, we propose that this entity can also occur even after months of medi- cation use. We also analyzed previous cases of AISS and azathioprine-hypersensitivity syn- drome (AHSS). Unlike other cases of AISS and AHSS, peripheral neutrophilia was not seen in our index case; on the contrary, neutropenia was present. As seen in at least two other cases of AISS, lesions favored the dorsal hands and face, but lesions in this index case did not involve the trunk. Most cases involved patients with underlying inflammatory bowel disease. Therefore, we propose that azathioprine-induced Sweet syndrome favors the extremities and can still occur even after chronic use of azathioprine or 6-MP and in the absence of neu- trophilia. Recognizing these atypical features in this entity and differentiating it from classical inflammatory bowel disease (IBD)-associated Sweet syndrome is important to prevent mor- tality from azathioprine toxicity or hypersensitivity. 551 Mid-level providers and the dermatology literature: A bibliometric analysis of trends 1973-2018 M Maymone 1 , M Laughter 1 , JD Jones 2 , P Anand 1 , R Dellavalle 1 , J Hugh 1 and C Dunnick 1 1 Department of Dermatology,, University of Colorado Denver School of Medicine, Den- ver, Colorado, United States and 2 Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Denver, Colorado, United States The number of mid-level providers (MLPs) in dermatology has grown tremendously over the last five decades. This increase may be due to the imbalance between the demand for dermatology services and dermatologists. Little research has been done to examine the evolving roles of mid-level providers and the state of scientific publications on this topic. To analyze the trends in publications and key topics related to MLPs in dermatology, PubMed was screened for all articles related to MLPs in dermatology published from 1973 to 2018. The number of publications, citation count, and key topics were assessed. The general concept of the article was graded by 3 independent evaluators and scored as “pro”, “con” or “neutral” toward mid-level providers. The number of publications related to MLPs in dermatology has increased over the past four decades while the proportion of papers with favorable views towards MLPs has declined. The most-cited publications highlight the ongoing workforce shortages in dermatology with an increasing prominence of mid-level providers and evaluate the efficacy between provider types. Limitations of our analysis are that we included a single database, publications written in English only, and a restricted time period from 1973 to the end of 2018. 552 Patient-centered development of a digital implementation tool for integrated knowledge translation with adult atopic dermatitis patients C Bouchard, S Ghazal, N Merati, G Isola, M Ehteshami and C Jack Dermatology, McGill, Montreal, Quebec, Canada Targeted immuno-therapy for adult atopic dermatitis has left an important gap in under- standing both by patients and physicians alike. International guidelines involve complex regimens of skin care, topical therapies, trigger avoidance, and behavioral adaptation first line. Engaging patients is key to communicating these fundamentals; however, resources are often limited at the point of care. Here we describe the development of an implementation tool for integrated KT in order to address this gap. A patient-engagement framework was used in order to identify the adult atopic dermatitis patient ’end-user’ greatest needs. Patient partners were formally engaged and collaboratively an objective was created to survey gaps in open-source online resources. Existing educational information and online communities, as well as patient usage patterns were explored using narrative juxtaposition. A key theme was the wide breadth of unvalidated information found to dominate patient consumption. We then applied the French et al. (2012) four-step systematic framework for developing complex implementation interventions. We found that the theoretical domain of patient-knowledge was most relevant to behavioral change. Relevant barriers identified include limited expertise at point of care, absence of face-to-face KT with clinicians, fear of negative health conse- quences, and self-sought information overload (world wide web, social media). A validated mobile health application was determined to be the most desirable and efficient method for implementing integrated KT. We applied mixed methods to design a mobile health appli- cation with local and national patient partners. The ‘Eczema.app: virtual nurse ’ is a bilingual tool that features patient-driven topics, validated information, and multi-media content. Ev- idence-based education in the mobile application is tailored to the clinical context and can be personalized to the patient. We hypothesize that intervention with the ‘Eczema.app: vir- tual nurse’ will improve patient-reported outcomes. 553 Clinical characteristics of acute graft-versus-host disease in small bowel and multi-visceral transplant recipients CM Brumfiel 1 , PK Dekker 1 , KM Saardi 2 , AH Kroemer 3 , SS Kaufman 3 and HB Pasieka 2,1 1 Georgetown University School of Medicine, Washington, District of Columbia, United States, 2 Dermatology, MedStar Washington Hospital Center, Washington, District of Columbia, United States and 3 MedStar Georgetown Transplant Institute, Washington, District of Columbia, United States Acute graft-versus-host disease (aGVHD) following stem cell transplantation is characterized by rash, liver dysfunction, and diarrhea. Although aGVHD is uncommon following solid organ transplantation, we find higher rates of aGVHD after intestinal (ITx) and multi-visceral transplantation (MVT). In these cases we find a unique presentation as the donor liver (if present) and intestine are spared, leaving skin as the main target. Between 2013 and 2019, we diagnosed 17 cases of aGVHD following ITx (n¼9) and MVT including both intestine and liver (n¼8). Median time to onset of aGVHD was 37 days. Erythema on the trunk, palms, or both was the most common presenting skin finding (15/17 patients). All patients had skin biopsies at the time of diagnosis. Patients presented with grade 1 (7/17), grade 2 (8/17), grade 3 (1/17), and grade 4 (1/17) aGVHD. Peripheral blood chimerism studies obtained in 11 patients revealed donor CD3+ lymphocytes in 5 (45%). Two patients had passenger lymphocyte syndrome, and partial donor stem cell engraftment was diagnosed in a third patient. Native GI tract involvement (usually rectosigmoid), was found in 7/17 patients; other sites included bone marrow, and native liver. In all, 6/17 patients had no evidence of extra- cutaneous aGVHD. Treatment strategies included systemic and topical corticosteroids, anti- thymocyte globulin, extracorporeal photopheresis, and/or JAK inhibitors. Complications of immunosuppression including opportunistic infections (aspergillosis and toxoplasmosis) and post-transplant lymphoproliferative disorder occurred in 7/17 patients. In summary, rash is typically the first, and may be the only, manifestation of aGVHD following luminal organ transplants. Diagnosis may be aided by time of onset of cutaneous manifestations, extra- cutaneous signs, and peripheral blood chimerism. 555 Practice changing landmark study- multi-institutional analysis of image guided superficial radiotherapy (IGSRT) for the treatment of non-melanoma skin cancer (NMSC) L Yu 1 and D Ladd 2 1 Radiation Oncology, Laserderm, Smithtown, New York, United States and 2 Tru-Skin Dermatology, Austin, Texas, United States Practice changing landmark study- multi-institutional analysis of image guided superficial radiotherapy (IGSRT) for the treatment of non-melanoma skin cancer (NMSC). NMSC is generally treated in dermatology offices using surgical techniques. This study presents the largest multi-institutional retrospective modern series of Image Guided Superficial Radio- therapy (IGSRT) for Non-Melanoma Skin Cancer (NMSC). Between July 2013 and December 2019, 2424 NMSC lesions treated with IGSRT at 3 clinics in Texas and 1 clinic in NY were analysed. All lesions received 50, 70 or 100 kiloVoltage(kV) energy IGSRT 2-4 times weekly. KV energy selection was determined by ultrasound depth measurements and/or tumor characteristics. Patients returned 3-6 weeks after completion of therapy for dermoscopy/ clinical evaluation and ultrasound imaging to confirm complete tumor clearance. Patients were then followed every 2-12 months thereafter. Any lesions in the treatment site suspicious for residual or recurrent tumor were biopsied. Exclusion criteria included tumors greater than 4 cm in diameter or non-movable tumors adherent to deeper structures. Follow-up ranged from 0.1-62.8months. At a mean follow up of 15.8 months, 29 patients with 77 lesions expired, all without recurrence. Kaplan-Meier (KM)Tumor control rates at 1, 2 and 5 years were 99.5%, 99.4% and 99.4% respectively. One, 2 and 5 year KM Overall-Survival (OS) for the entire group was 97.6%, 95.8% and 85.8% and unaffected by disease status or treatment. This study represents the largest study of NMSC treated with non-invasive IGSRT. The 99% cure rate is comparable to the best cure rates of other invasive modalities such as Mohs micrographic surgery. This innovative non-surgical technology with its high cure rate in the treatment of NMSC has the potential to transform the practice of dermatology with regard to treatment of NMSC. Patient-Targeted Research | ABSTRACTS www.jidonline.org S75