Guidelines of care for the management of acne vulgaris.

BACKGROUND: Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older. OBJECTIVE: The objective of this study was to provide evidence-based recommendations for the management of acne. METHODS: A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations. RESULTS: This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements. LIMITATIONS: Analysis is based on the best available evidence at the time of the systematic review. CONCLUSIONS: These guidelines provide evidence-based recommendations for the management of acne vulgaris.

A propensity score matched cohort study identifying an association of acne, but not oral antibiotic or isotretinoin use, with risk of incident inflammatory bowel disease.

BACKGROUND: Concerns remain regarding whether oral antibiotic or isotretinoin use for acne is associated with increased risk of inflammatory bowel disease (IBD); little is known about whether acne itself is associated with IBD. OBJECTIVE: To determine whether isotretinoin exposure, oral tetracycline-class antibiotic exposure, and/or acne itself are associated with IBD. METHODS: A propensity score matched cohort study was performed using TriNetX between 2001 and 2022 to compare the 1-year incidence of IBD between those without acne compared to those with acne managed without systemic medications, acne managed with oral tetracycline-class antibiotics, and acne managed with isotretinoin. RESULTS: There was a statistically significant association between acne and risk of incident IBD (odds ratio: 1.42; 95% confidence interval: 1.23-1.65). There was no statistically significant association between oral tetracycline-class antibiotic or isotretinoin exposure and IBD. LIMITATIONS: Use of electronic health data; potential for misclassification bias. CONCLUSION: This matched cohort study identifies an association between acne and IBD. These data provide further reassurance regarding the use of isotretinoin in the treatment of acne.

Racial and ethnic differences in barriers to care among US adults with chronic inflammatory skin diseases: A cross-sectional study of the All of Us Research Program.

BACKGROUND: Research on racial and ethnic differences in barriers to care among patients with chronic inflammatory skin diseases (CISDs) is limited. OBJECTIVE: To investigate the prevalence of a broad range of barriers to care among patients with CISDs across different racial and ethnic groups. METHODS: A cross-sectional study was conducted using survey data from participants with CISDs in the All of Us Research Program. Multivariable regression was used to analyze the relationship between race and ethnicity and experiencing barriers to care. RESULTS: Our study included 16,986 patients with CISDs. Compared to White patients, Black and Hispanic patients were significantly more likely to delay care because of cost and a broad range of additional structural barriers, including transportation, work, childcare, adult care, living in a rural area, and the lack of health care workforce diversity. However, associations between race and ethnicity and many barriers to care were substantially attenuated after controlling for insurance, income, and education. LIMITATIONS: The population studied was not a representative sample of US adults, and responses were not specific to dermatologic care. CONCLUSION: Racial and ethnic minority patients with CISDs, especially Black and Hispanic patients, are disproportionately affected by a broad range of barriers to care.

Long-term use of spironolactone for acne in women: A case series of 403 patients.

BACKGROUND: There are limited data regarding the long-term outcomes of spironolactone use for women with acne and its effect on truncal acne. OBJECTIVE: To comprehensively describe outcomes of patients treated with spironolactone in routine clinical practice, including long-term outcomes. METHODS: We performed a retrospective case series of 403 adult women treated for acne with spironolactone at an academic medical center between 2008 and 2019. Rates of objective, as assessed by Comprehensive Acne Severity Scale scores, and subjective acne clearance were evaluated, as well as rates of treatment discontinuation, dosage changes, and drug survival. Logistic regression was used to assess for association between incidence of menstrual adverse effects and combined oral contraceptive use. RESULTS: As evaluated by Comprehensive Acne Severity Scale scores, at the first follow-up, 75.5%, 84.0%, and 80.2% of patients with available data had reduction or complete clearance of acne on the face, chest, and back, respectively. The mean drug survival was 470.7 days. Menstrual adverse effects were less common among those using combined oral contraception (odds ratio, 0.23; 95% confidence interval, 0.11-0.50). LIMITATIONS: This study was conducted at a single academic medical center. CONCLUSIONS: Spironolactone improves clinical outcomes and is well tolerated for many adult women with acne using it for an extended duration.

Age-appropriate cancer screening: A cohort study of adults with psoriasis prescribed biologics, adults in the general population, and adults with hypertension.

BACKGROUND: Psoriasis is associated with increased risk of developing and dying from cancer. OBJECTIVE: To evaluate whether psoriasis patients who are prescribed biologics receive the recommended screening for cervical, breast, and colon cancer. METHODS: We conducted a retrospective cohort study using the Optum deidentified Electronic Health Record data set. Incidence rates for cervical, breast, and colon cancer screening were compared between psoriasis patients who were prescribed biologics and 2 matched comparator cohorts: general patient population and patients being managed for hypertension. Multivariable Cox proportional hazards regression was performed to assess for differences in the rates of cancer screening. RESULTS: Compared with those in the general population without psoriasis, psoriasis patients who were prescribed biologics had higher screening rates for cervical cancer (adjusted hazard ratio [aHR] 1.09; 95% confidence interval [CI] 1.02-1.16) and colon cancer (aHR 1.10; 95% CI 1.02-1.18). Compared with those with hypertension, patients with psoriasis who were prescribed biologics had lower screening rates for breast cancer (aHR 0.88; 95% CI 0.83-0.94) and colon cancer (aHR 0.89; 95% CI 0.83-0.95). CONCLUSIONS AND RELEVANCE: Patients with psoriasis who are prescribed biologic therapies may not be receiving adequate age-appropriate cancer screening, especially for breast and colon cancer.

Frequency and influence of "not relevant" responses on the Dermatology Life Quality Index among adults with atopic dermatitis.

PURPOSE: "Not relevant" responses (NRRs) on the Dermatology Life Quality Index (DLQI) are common among adults with psoriasis and may be associated with underestimation of disease burden. Little is known about "not relevant" responses among adults with atopic dermatitis. We aimed to examine the frequency of NRRs on the DLQI and to determine whether NRRs are associated with underestimation of disease burden among adults with atopic dermatitis. METHODS: Adults with atopic dermatitis were identified and evaluated via online survey. We evaluated the frequency of NRRs on the DLQI, stratified by sociodemographic characteristics. To examine the association between NRRs and other measures of disease burden, Patient-Oriented Eczema Measure (POEM), Patient-Oriented SCORAD (PO-SCORAD), and Short-Form (SF)-12 scores were compared between those who responded "not relevant" versus "not at all". RESULTS: Among 764 adults with atopic dermatitis, most had mild disease. The median (interquartile range [IQR]) POEM, PO-SCORAD, and DLQI scores were 5 (2-10), 24 (14-34), and 2 (1-6), respectively. Most (55.2%) also had at least one NRR, and 17.9% had 4 or more "not relevant" responses, with differences across several sociodemographic characteristics. There were no substantial differences in SF-12, POEM, and PO-SCORAD scores between those who responded "not relevant" versus "not at all". CONCLUSION: NRRs on the DLQI are common among adults with atopic dermatitis and differ across sociodemographic characteristics, suggesting issues with content validity. There is not a clear association between NRRs and other measures of disease severity among adults with mostly mild atopic dermatitis.

Attitudes on Prophylactic Antibiotic Use in Dermatologic Surgery: A Survey Study of American College of Mohs Surgery Members.

BACKGROUND: Antibiotic prescriptions associated with dermatologic surgical visits are increasing and prescribing practices vary among surgeons. OBJECTIVE: To describe dermatologic surgeons' attitudes and practices regarding prophylactic antibiotic use for surgical site infection (SSI), to compare current prescribing practices to those of a 2012 survey, and to determine surgeons' interest in clinical trial data on the utility of prophylactic antibiotics. MATERIALS AND METHODS: This was a cross-sectional online survey of the American College of Mohs Surgery (ACMS) members. Survey items were adapted from a 2012 survey of ACMS members. RESULTS: The survey was initiated by 101 ACMS members. 75.25% (76/101) of surgeons reported routinely prescribing prophylactic antibiotics to reduce SSI risk. The use of prophylactic antibiotics varied with clinical scenario. Most providers (84.21%, 64/76) prescribe postoperative antibiotics, with an average course of 6.56 days. 40.21% (39/97) of respondents were uncertain if prophylaxis prevents SSI, and up to 90.63% (87/96) indicated interest in clinical trial data evaluating the efficacy of oral antibiotics for SSI prevention. CONCLUSION: Dermatologic surgeons continue to report varied attitudes and practices for SSI prophylaxis. Evidence from clinical trials is desired by surgeons to guide clinical practice.

Preferences for Prophylactic Oral Antibiotic Use in Dermatologic Surgery: A Multicenter Discrete Choice Experiment.

BACKGROUND: Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood. OBJECTIVE: To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions. MATERIALS AND METHODS: Multi-center, prospective discrete choice experiment (DCE). RESULTS: Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics. CONCLUSION: Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.

Most common pediatric skin conditions managed in outpatient dermatology clinics in the United States stratified by race and ethnicity.

A better understanding of what skin conditions are most commonly diagnosed in different pediatric racial and ethnic groups in outpatient dermatology clinics could help guide the development of pediatric dermatology educational initiatives for primary care providers and general dermatologists who have limited access to pediatric dermatologists. Using a nationally representative dataset, we evaluated the most common diagnoses in patients younger than 15 years of age (children) and 15-24 years of age (youth) who present to outpatient dermatology clinics, stratified by race and ethnicity. While acne and dermatitis were among the top ten most common diagnoses in all racial and ethnic groups studied, Black children were also commonly diagnosed with dermatophytosis and impetigo, and Black and Hispanic children were often diagnosed with seborrheic dermatitis; pigmentary disorders were among the top three most common diagnoses in Black, Asian, and Hispanic youth. Training more physicians how to evaluate and treat common skin conditions in children and youth of diverse racial and ethnic backgrounds may improve access to care for skin disease in the United States.

Prior authorizations in dermatology and impact on patient care: An updated survey of US dermatology providers and staff by the American Academy of Dermatology.

BACKGROUND: Completing prior authorizations (PAs) can be a lengthy process, which can delay access to appropriate care. A 2017 American Academy of Dermatology survey highlighted that PAs are common across many dermatologic medication classes. However, little is known regarding the impact of PAs on patient care and resource use. METHODS: To better characterize the burden of PAs on dermatology practices and their effects on patient care, a survey was conducted in February 2020 among U.S.-based dermatologists (N=3,000) and the Association of Dermatology Administrators/Managers (ADAM) members (N=718). RESULTS: Respondents reported 24% of patients require PAs. Dermatologists and staff spend a mean of 3.3 hours/day on PAs. Sixty percent of dermatologists reported interrupting patient visits for PAs. Sixty-five percent respondents reported PAs were required for clobetasol, 76% for tretinoin, and 42% for 5-fluorouracil. Respondents noted 45% of PA determinations took beyond one week and 17% took beyond two weeks. Respondents reported 12% of PAs resulted in delaying or abandoning treatment and 17% resulted in less appropriate treatment. CONCLUSIONS: Prior authorization burden remains high and consumes substantial clinical resources, which may negatively impact patient care. Additionally, they result in prolonged treatment delays and are associated with delaying treatment, abandoning treatment, or using lesser treatment.

Simplifying contraception requirements for iPLEDGE: A decision analysis.

BACKGROUND: For persons of childbearing potential prescribed isotretinoin, the iPLEDGE program requires use of 2 simultaneous methods of contraception or commitment to abstinence. OBJECTIVE: To model the relative effectiveness of a variety of contraception strategies for patients taking isotretinoin, including those that are acceptable according to iPLEDGE. METHODS: We performed a decision analysis modeling the estimated rate of pregnancy with various contraception strategies during a typical 6-month course of isotretinoin. RESULTS: Tier 1 contraception options (eg, subdermal hormonal implant, intrauterine devices) each had effectiveness of >99.5% alone. When combined with a secondary form of contraception, tier 2 contraception options (eg, depot medroxyprogesterone injections, combined oral contraceptives) each had effectiveness >99%. LIMITATIONS: Sensitivity analyses were conducted to evaluate the impact of uncertain parameters on the results. CONCLUSION: There may be opportunities to simplify iPLEDGE by recognizing the high effectiveness of tier 1 contraception options and increasing use of secondary forms of contraception among those using tier 2 contraception options as their primary form of contraception. Future studies are needed to understand the most effective strategies in clinical practice to prevent unintended pregnancy for patients taking isotretinoin to improve outcomes and provide patient-centered care.

Evaluating the effect of prior authorizations in patients with complex dermatologic conditions.

BACKGROUND: In dermatology, prior authorizations can delay treatment, decrease patient adherence, and deter providers from advocating for their patients. Patients with complex dermatologic conditions, often requiring off-label treatments, may face particularly significant insurance barriers. OBJECTIVE: Evaluate the effect of prior authorizations in patients with complex dermatologic conditions. METHODS: This prospective cohort study assessed patients treated by a dermatologist during 5 months who specialized in complex dermatology. Patients included were older than 18 years, treated at V.P.W.'s rheumatology-dermatology clinic, and prescribed a medication or ordered a diagnostic procedure that elicited an insurance prior authorization. Data on prior authorization outcome, administrative time, and delay to treatment were collected. RESULTS: Of 51 prior authorizations, 51% were initially denied, with systemic medications more likely denied than topical ones (P < .001). Total administrative time spent on 50 prior authorizations tracked was 62.5 hours (median time per prior authorization 30 minutes [interquartile range 17-105 minutes]). Time to access treatment was tracked for 80% of prior authorizations; median delay was 12 days [interquartile range 5.5-23 days]. LIMITATIONS: Single-center, single-provider patient panel. CONCLUSION: Patients with complex dermatologic conditions face a significant barrier to care because of prior authorizations. The administrative burden for provider practices to address these prior authorizations is substantial and may warrant a streamlined system in collaboration with insurers.

The clinical utility of laboratory monitoring during isotretinoin therapy for acne and changes to monitoring practices over time.

BACKGROUND: As a result of concerns about hypertriglyceridemia, liver enzyme abnormalities, and leukopenia during isotretinoin therapy for acne, patients are often monitored closely with routine laboratory assessments, although the value of this practice has been questioned. METHODS: We conducted a cohort study of patients receiving isotretinoin for acne between January 1, 2008, and June 30, 2017, using the OptumInsights Electronic Health Record Database (Optum, Eden Prairie, MN) to evaluate the frequency of laboratory abnormalities. Poisson regression was used to evaluate for changes to the frequency of routine laboratory monitoring over time. RESULTS: Among 1863 patients treated with isotretinoin, grade 3 or greater triglyceride and liver function testing abnormalities were noted in fewer than 1% and 0.5% of patients screened, respectively. No grade 3 or greater cholesterol or complete blood count abnormalities were observed. There were no meaningful changes in the frequency of laboratory monitoring over time. LIMITATIONS: Limitations include that we are unable to evaluate the clinical notes to understand the exact clinical decision making when clinicians encountered abnormal laboratory values. CONCLUSION: Although laboratory abnormalities are rare and often do not influence management, frequent laboratory monitoring remains a common practice. There are opportunities to improve the quality of care among patients being treated with isotretinoin for acne by reducing the frequency of lipid and liver function monitoring and by eliminating complete blood count monitoring.

Clinical effectiveness and cost-effectiveness of teledermatology: Where are we now, and what are the barriers to adoption?

There has been rapid growth in teledermatology over the past decade, and teledermatology services are increasingly being used to support patient care across a variety of care settings. Teledermatology has the potential to increase access to high-quality dermatologic care while maintaining clinical efficacy and cost-effectiveness. Recent expansions in telemedicine reimbursement from the Centers for Medicare & Medicaid Services (CMS) ensure that teledermatology will play an increasingly prominent role in patient care. Therefore, it is important that dermatologists be well informed of both the promises of teledermatology and the potential practice challenges a continuously evolving mode of care delivery brings. In this article, we will review the evidence on the clinical and cost-effectiveness of teledermatology and we will discuss system-level and practice-level barriers to successful teledermatology implementation as well as potential implications for dermatologists.

Variation in Prescribing and Factors Associated With the Use of Prophylactic Antibiotics for Mohs Surgery: A Single-Institution Retrospective Study.

BACKGROUND: Antibiotic use associated with Mohs surgery is increasing. OBJECTIVE: To understand variation in practice patterns and factors associated with antibiotic use. MATERIALS AND METHODS: The authors conducted a retrospective cohort study of antibiotic use among patients treated with Mohs micrographic surgery between July 1, 2013, and June 30, 2017, at an academic medical center. Multivariate logistic regression was used to evaluate for associations between antibiotic prescribing and the surgeon, site, reconstruction, and patient characteristics. RESULTS: The odds of prescribing antibiotics differed significantly between each surgeon evaluated; 3.35-fold variation in postoperative antibiotic use was observed. Increasing number of surgical sites (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.09-1.41), number of Mohs stages required (OR 1.18; 95% CI 1.08-1.28), and defect area (OR 1.31; 95% CI 1.25-1.37), as well as patient female sex (OR 1.14; 95% CI 1.03-1.27), were associated with increased postoperative antibiotic use, whereas age >80 was associated with decreased use (OR 0.75; 95% CI 0.64-0.87) compared with age <60. CONCLUSION: Antibiotics are more commonly prescribed for repairs that are considered higher risk for infection. However, significant variation exists between surgeons, even within a single institution, suggesting a need for prospective trials and consensus guideline development.

Optimizing the Trial Design for a Comparative Effectiveness Study of Spironolactone versus Oral Antibiotics for Women With Acne: A Delphi Consensus Panel.

For women with acne, their acne often persists into adulthood, with over 50% of women reporting acne between 20–29 years of age and over 35% of women reporting acne between 30–39 years of age.1 While mild acne can usually be managed with topical medications, moderate to severe acne often requires treatment with systemic medications such as oral antibiotics, spironolactone, and isotretinoin.2 Although oral antibiotics are the most common systemic medication prescribed for women with moderate to severe acne, spironolactone may represent a safe and effective therapeutic alternative that can decrease our reliance on oral antibiotics for the treatment of acne.3–5 However, while spironolactone use is increasing, oral antibiotics are still prescribed 3 to 5 times more often than spironolactone.3.