Take proactive approach with certain systemic therapies

It’s high time for dermatologists to overcome their hesitation in prescribing systemic medications, according to Daniela Kroshinsky, M.D., an associate professor of dermatology at Massachusetts General Hospital in Boston and Harvard Medical School.

“I want dermatologists to feel more empowered in prescribing these medications,” Dr. Kroshinsky tells Dermatology Times following her presentation on systemic therapeutics at this past Summer’s American Academy of Dermatology meeting in Boston, Mass.

Dr. Kroshinsky referenced a 2014 survey of public perception of dermatologists that found only 21% of respondents realized that the specialty treated rashes and other inflammatory conditions of the skin.

Similarly, a 2011 survey by the American Academy of Dermatology (AAD) of 13 non-dermatologic medical association leaders addressing perceptions of dermatologists indicated that these leaders presumed dermatologists had limited access to hospitalized patients and had shifted their focus from medicine to cosmetic procedures (favoring surgical intervention).

“But most concerning was the perception that we were hesitant or unwilling to treat routine rashes,” says Dr. Kroshinsky, director of inpatient dermatology at Massachusetts General Hospital.

However, there is a disconnect between this perception and 2008 workforce data from AAD, which shows that the majority of dermatologists are indeed involved in medical dermatology and nearly half do inpatient consults.

“As a profession, what can we do to more closely align perception with reality?” Dr. Kroshinsky says.

Dr. Kroshinsky cites two categories of systemic medications that dermatologists are called upon to prescribe for dermatologic conditions that are not necessarily dermatologic in origin: hormonal contraceptives for acne and psychopharmalogical drugs (traditionally reserved for psychiatry or neurology) to treat skin conditions like delusions of parasitosis, neurotic excoriations and chronic pruritus.

“Thought leaders in dermatology who treat these conditions believe that we should be managing patients with specific systemic medications, rather than thinking that these drugs are limited to certain other specialties,” Dr. Kroshinsky says. “Therefore, we should be proactive in learning about these medications because new medications are constantly being developed. We need to gain comfort in prescribing them.”

Guidelines and literature have been developed by prominent dermatologists “to help us transition into making those medications more of a first-line therapy,” says Dr. Kroshinsky, director of pediatric dermatology at Massachusetts General Hospital.

Dr. Kroshinsky references a cross-sectional survey of dermatologists for psoriasis treatment patterns that appeared in 2008 in the Journal of the American Academy of Dermatology, which found that 40% of patients with severe psoriasis were still receiving topical therapy alone, rather than transitioning to systemic medications.

A more recent survey of dermatologists in the same journal from 2013 concluded that roughly 50% of respondents did not know the effectiveness or likelihood of side effects for some systemic medications to treat moderate to severe psoriasis.

“This is a call to action that we need to be more aggressive in seeking out data, being comfortable with the data, and then putting it into practice, so our patients can benefit,” Dr. Kroshinsky says.

Dr. Kroshinsky acknowledges that the side effects listed in the package insert for some of the new systemic treatments “can appear very scary. But just like driving a car or being struck by lightning, it is important to understand the true nature of comfort and risk, and how do we balance that risk with the likelihood of benefit. Are we talking about 1% of patients ending up with a side effect, or 1 in 10,000 patients or 1 in 100,000? ”

Dr. Kroshinsky also believes it is paramount that dermatologists update their knowledge of old medications like isotretinoin to treat severe nodular acne.

“Most of the concerns about the association between isotretinoin and psychiatric disease and inflammatory bowel disease (IBD) have turned out to be unfounded,” she says. “Those associations are really not causative but correlative.”

Nonetheless, even among dermatologists who are aware of such data, “there is still a psychological barrier to our moving forwarding in prescribing these systemic medications,” Dr. Kroshinsky says. “Some of this hesitation may be related to medical-legal issues, with public perception over the risk of such drugs.”

A questionnaire-based study on the attitudes, prescription and counseling patterns for isotretinoin among dermatologists that appeared in the Journal of Drugs in Dermatology in 2015 concluded that 47% of respondents did not believe in an association between isotretinoin and IBD, yet they would never or rarely prescribe the drug to patients that might be at risk.

Conversely, the same study found that only 33% of dermatologists who did not believe in a casual association between isotretinoin and psychiatric disturbances would usually or always prescribe the drug.

In cases where there are real risks of side effects, appropriate monitoring is recommended. “We also need to work together to generate data where there are gaps in knowledge,” Dr. Kroshinsky says. “Patients need to be counseled carefully as well.”

For example, even though the black box warning for topical tacrolimus cautions against increased risk in mice, “thousands of patient years using the medication has shown no increased risk,” Dr. Kroshinsky says. “Thus we need to examine concerns more thoroughly so that physicians will feel more comfortable taking ownership of medications that our patients will derive benefit.”