Shaking up traditional thinking about dermatologic therapies

Tucson, Ariz. - Challenging conventional wisdom about treatment modalities might be considered risky business for some dermatologists, but for Norman Levine, M.D., it just comes naturally.

"I just tend to be a skeptical person," he says. "There are many times in my career when I've seen statements made or people doing things, and I have had a different view."

As a dermatologist for 27 years, Dr. Levine, professor of dermatology, University of Arizona College of Medicine, has gathered new insights from clinical experience, reference books, professional meetings and reviews of treatment modalities. He is also an editorial adviser for Dermatology Times.

Dr. Levine's iconoclastic nature has led to some new ways of thinking about what works and what doesn't work in a dermatology practice.

Therapy for rosacea is one example where Dr. Levine challenges conventional wisdom. That wisdom says metronidazole products such as Metrogel (Galderma), Metrocream (Galderma), Metrolotion (Galderma), Rozex gel (Stafford-Miller) and Noritate (Dermik) are effective in the treatment of active rosacea. But Dr. Levine has found metronidazole to work better in maintaining remission of rosacea, although it is only modestly useful in treating active disease. Alternatives to consider using, he says, include azelaic acid, which, although more expensive, is as effective as metronidazole. However, Dr. Levine notes that neither agent will reliably clear inflammatory lesions or have much effect in the erythematotelangiectatic variety of the disease.

Scabies and nail fungus

Another area of conventional thinking he has challenged is scabies therapy. Although ivermectin tablets (Stromectol, Merck) are used by more than 6 million people worldwide for onchocerciasis and other parasitic infections, many dermatologists believe that topical agents are safer and more effective treatments. Dr. Levine, on the other hand, has found the side-effect profile for ivermectin to be very favorable, and reactions transient and mild.

Dr. Levine also presents an alternate view on the treatment of nail fungus infections. While ciclopirox (Penlac) nail lacquer is a popular means of treating onychomycosis and is touted as being effective in such infections, Dr. Levine has found the topical therapy to almost never result in a cure. The medical literature confirms this.

"Are you and your patients satisfied with a 12 percent cure rate?" he asks. "If the answer is 'Yes,' then use this drug. If not, advise your patient to take the money he saves in not purchasing this product and treat the family to dinner."

Reasonable alternatives

Dr. Levine also compares a number of treatments for atopic dermatitis. While tacrolimus (Protopic, Astellas) is a reasonable corticosteroid substitute in treating the condition, the expense of using this medication - upwards of $70 for 30 gm - may be a limiting factor. He concludes that although the drug is fairly effective in treating atopic dermatitis, its price makes it difficult to use in widespread disease. Further, using tacrolimus does not yield a major improvement over the use of mid-potency topical corticosteroids. One study comparing tacrolimus to pimecrolimus (Elidel, Novartis) showed equal efficacy in cases of mild to moderate atopic dermatitis.

In very severe cases of the skin disease, Dr. Levine reports that systemic cyclosporine is able to blunt the Th2 lymphocyte profile with a reasonable short-term safety profile. The drawbacks of this treatment are cost and risk of renal toxicity in a "benign" condition. Nonetheless, Dr. Levine says that cyclosporine is at least as effective as systemic corticosteroids. Further, it is no more risky than long-term corticosteroids, and the toxicities of the drug are more easily monitored.

Enhance what's there

When dermatologists begin to think about new ways to enhance their practice, the benefits for patients are vast, Dr. Levine tells Dermatology Times. For example, dermatologists have the opportunity to do a lot of psychiatric care, and that requires the use of many psychotropic drugs.