Mona Shahriari, MD, FAAD: 'The Days of Paternalistic Medicine Are Gone'

Mona Shahriari, MD, FAAD, is an assistant clinical professor of dermatology at Yale University and the associate director of clinical trials at Central Connecticut Dermatology (CCD) Research.

At the 2024 Diversity in Dermatology meeting in San Antonio, Texas, Shahriari spoke at 2 sessions, “Being Sensitive in an Inclusive Environment,” and “Special Considerations of Treating Inflammatory Skin Disease in Women."

Shahriari recently spoke with Dermatology Times to discuss pearls and takeaways from her sessions, including the importance of ensuring culturally competent care in a dermatology environment, unique considerations for women with skin conditions, and more.

Transcript

Mona Shahriari, MD, FAAD: Hi, my name is Mona Shahriari. I'm an assistant clinical professor of dermatology at Yale University and the associate director of clinical trials at CCD Research.

Dermatology Times: What are key highlights and takeaways from your sessions at Diversity in Dermatology?

Shahriari: I was really privileged to be a speaker and faculty member at the Diversity in Dermatology conference in San Antonio in March, and a couple of key highlights from my sessions--I did 2 specific sessions. One was on being culturally sensitive and an inclusive environment. The sessions were a little different than I think what you would normally expect from a CME meeting.

For that specific talk, what we really tried to hone in on was how the lack of culturally competent care is one of the reasons that patients experience healthcare disparities. So really, for us as clinicians, it's important to be aware of our biases, and the assumptions that we make about a patient before we even walk in the room and keep those biases in check so that we're really creating a culturally sensitive and inclusive environment where a patient feels heard, so that they can not only share their struggles with their disease and their therapy, but they have enough trust to comply with any regimens we come up with, follow through with their appointments and the recommendations, so that they can get better control of their skin, but also of their life as a whole.

The other session looked at special considerations of treating women with inflammatory skin disease during the childbearing years. Again, a different kind of a session than what we're usually used to hearing about. But the key takeaways were you want to remember to discuss family planning, potentially contraception as part of any treatment regimen for a woman of childbearing age, because the reality is 50% of all pregnancies are unplanned, and if a woman on a systemic does get pregnant, don't automatically discontinue all therapy. Remember that uncontrolled inflammatory skin disease can have negative consequences for both mom and the unborn baby, too. So shared decision making is going to be a key part of this decision making process, and if you do decide to continue a systemic like a biologic, you want to remember that caring about mom and the unborn baby is one part of the equation. But any utero exposure to a biologic can have some impacts implications for the first few months of life of the newborn baby, so you should keep that in mind. Work with the pediatrician, as well as the OB, to ensure any considerations with respect to changing vaccine schedules are kept in mind for that newborn.

Dermatology Times: How can dermatologists ensure they are providing culturally competent care in a sensitive, inclusive environment?

Shahriari: Honestly, it's hard. I feel like it's one thing that I still struggle with every day. But the first step is we need to recognize this as something that's important to our patients, and be taking the steps toward offering that culturally competent care. One thing I always mention to my residents is you want to respect and accept differences; you're not going to see eye-to-eye with every single patient, and that's okay. You can agree to disagree with respect to certain facts, but that sense of respect needs to be there.

You also want to pay attention to social cues nonverbal cues. For example, I remember having a patient who was wearing an Islamic garb, and I approached them to remove the garb and examine her, and I could tell that she was pulling back from me. When you see that, just take a pause, ask permission before you proceed, and that can really go a long way with the patient. Also, you really want to avoid ethnocentricity. Throw out preconceived notions of what you think about that person, that person's culture, because culture is really complex, and you don't know what aspects of an individual's culture they identify with. You want to keep that exam room a judgment free zone; go in there with an open mind and really be ready to listen to the patients sitting in front of you. You want to proactively ask about culture and cultural expectations to avoid misunderstandings, and this can help build trust, because the patient will feel like, "Yeah, my doctor is actually listening to me."

And finally, you want to take the time to learn about the cultural norms for each person. This might take 1 to 3 visits, and that's okay, because the patient will appreciate that you're trying, and again, that patient-doctor relationship, that trust, will continue to form over time.

Dermatology Times: How does gender influence the presentation and management of inflammatory skin diseases?

Shahriari: It's funny because I came across a quote that said, "For the longest time, women were considered just the same as men, but they had different reproductive structures." The reality is a women are starkly different, and they make up 50% of the population, and when you look at many inflammatory skin diseases, like atopic dermatitis, psoriasis, hidradenitis, these can be more prevalent in women, and they tend to first show up or even flare during the childbearing years. For atopic dermatitis and hidradenitis in particular, this is partly related to the hormonal changes, the high levels of estrogen progesterone, that we as women have that can influence the disease.

When talking to women and men about their experience with these inflammatory diseases, one thing we found was without fault, women also report higher impacts on quality of life than their male counterparts, even though they can have similar objective disease findings on exam. These are really important for us to keep in mind when we're treating women with inflammatory skin disease. But also, we have to know that some of these diseases can impact a woman's ability to have children, and that's a conversation we need to have with them. For atopic dermatitis, for example, that systemic inflammation on its own can impact fertility. For psoriasis and hidradenitis, many women don't want to have a baby, because they're fearful of passing the disease on to their child. They don't know if they're going to flare during or after the pregnancy, or they just feel so embarrassed by their skin disease that they don't even want to be intimate with a partner. It's really important to tell them that we do have treatments that can help you have a baby, if you do choose to have a baby.

The other piece of the puzzle is many times when a woman is trying to conceive or get pregnant, systemics are stopped. This has to do partly with the patient's hesitancy to be on a systemic, but also the prescriber's hesitancy. This is without regard to the negative impacts of uncontrolled inflammation for both the mom and the unborn baby. So really, the bottom line is, given the higher quality of life burden of various inflammatory skin diseases in women, and the fact that they have a higher tendency to have systemics stopped during a time where they may need it more so than ever, we have a lot of work to do in terms of making sure that equitable treatment is being done for both men and women with inflammatory skin disease.

Dermatology Times: What are challenges and barriers women may face when seeking treatment for inflammatory skin diseases?

Shahriari: There are quite a few barriers. One is we have limited data on the safety of systemics in pregnancy and in women that are breastfeeding, because these individuals are excluded from clinical trials. But interestingly, women as a whole were excluded from clinical trials till 1993. A lot of people don't know this. Given that they make up pretty much half the population, a clinical trial is supposed to be representative of the whole population. We can take the results and apply it to real world patients. But if 50% of the population is being excluded, then the trials that we have up until that point weren't ideal in terms of its ability to be applicable to the rest of the population that we see.

The other barrier is lack of access to providers that feel comfortable having those shared decision-making conversations with women that are either pregnant or trying to get pregnant. Because the reality is, many providers are scared to have women on a systemic agent when they're pregnant, and it's easier for them to just stop all therapies, because the first thing we were taught was do no harm, and that's kind of what resonates with them. But most women are probably going to go along with that because they don't want to hurt their baby, so they don't question this decision, and then that could lead to having negative consequences of that uncontrolled inflammation in the mom as well as the unborn baby. Then many women who do go off of these drugs, they may not even tell their provider. But even if their provider is aware, they don't have a plan in place if their disease flares, and they may think there are no options out there for them to treat their disease effectively, so that lack of knowledge is also another barrier that prevents them from getting the treatment that they need.

Dermatology Times: What are unique considerations for treating inflammatory skin diseases in women?

Shahriari: There are negative consequences to uncontrolled inflammation in both mom and the unborn baby, and some diseases like plaque psoriasis can actually improve on their own during pregnancy. But other diseases like atopic dermatitis, hidradenitis, can flare, so we do need to keep this in mind. But just because a patient is pregnant or trying to conceive, you shouldn't automatically discontinue all systemics. Much of this is related to prescriber hesitancy and their inability to really reassure a patient about something that they themselves are not 100% sure about. When you actually look at the data, there are many agents that can be safely used throughout pregnancy, so it's really important to have shared decision-making conversations with the patient about the risks and benefits so that we can make decisions that are based on evidence and the patient's preferences as opposed to decisions based on what we are fearful of as a clinician.

Then a couple of other considerations to keep in mind is when you think of biologics and that IgG protein transfer across the placenta, this doesn't start till about 13 weeks of gestation. This goes against what we've always known, that first trimester exposure is the most important. But when it comes to biologics, actually, it's 13 weeks onwards that the exposure becomes relevant, and so we do want to keep that in mind. If a patient's on a biologic early on in their pregnancy, then we can decide: Do we continue it? Do we discontinue it? But harm has not been done if they're very, very early. When it comes to breastfeeding, we also want to keep in mind that the primary immunoglobulin in breast milk is IgA. Our biologics are primarily IgG, so there really isn't much transfer into the breast milk and then the baby, so breastfeeding is also probably okay. If somebody is going off their medication and they flare post-delivery, you could consider giving them their biologic back.

But the really important takeaway is: You want to continue to have conversations about family planning with all women of childbearing potential who are receiving any therapy, whether it's systemics for inflammatory skin disease, systemics for acne, because 50% of all pregnancies are unplanned, and 80% of patients don't tell their provider when they're trying. It's really important to just have those ongoing conversations so patients are aware that there are options out there. If they flare, they should go off certain medications at certain time points. This way, the patient can feel like they have the right knowledge to make the correct decision.

Dermatology Times: How can dermatologists advocate for gender-inclusive research and treatment guidelines in dermatology?

Shahriari: I think dermatologists and providers in general have really been trying to advocate for including more women in our clinical trials, and we've made some progress on that front. But when you look at some of our studies, depending on the disease state, we do still have an underrepresentation of women. This is partly due to those strict contraceptive guidelines that we have that make it more challenging for some woman to enroll in these trials. And when you really don't know the effect of a drug on a individual, let alone a pregnant individual, I don't blame these individuals, these moms to be, for not wanting to go on a trial, because maybe they do want to get pregnant, maybe they don't want to commit themselves for another year or so of being on a contraceptive. That's something that we're going to have to really discuss with our patients to help them understand the true risks and benefits of being in a clinical trial being on those strict contraceptive regimens. But what we could also do additionally, to get some more info, is having more real world pregnancy registries to monitor individuals post-FDA approval of a drug, if they do get pregnant, what's going to happen, because we can't change that if you got pregnant and you were on a drug. Let's just see how you do, and the more data we have, I think the better we can educate our patients moving forward.

I have to say it was really a delight to give these sessions because it's very different than the usual talks that I give, and preparing it was very unique in terms of I learned a ton as well. But one thing I do want to leave the audience with is just remember that the days of paternalistic medicine are gone. We really owe it to our patients to tell them about the data we have and the data we don't, and we can reach a decision together as to what would be the best treatment for the person sitting in front of us. We can't let our own fears our own bias biases get in the way of delivering good care and providing patients with that true informed consent when deciding to either start a treatment or even when deciding to discontinue a treatment.

[Transcript has been edited for clarity.]