Michelle M. Levender

Incidence, Risk Factors, and Preventative Management of Skin Cancers in Organ Transplant Recipients: A Review of Single‐ and Multicenter Retrospective Studies from 2006 to 2010

Background Organ transplant recipients (OTRs) taking immunosuppressants are at high risk of skin cancer, which is the most common malignant condition in OTRs, so dermatologic surveillance is important for OTRs. Objectives To characterize the most common skin cancers arising from chronic immunosuppression in OTRs. Methods A PubMed search for retrospective single‐ and multicenter studies reporting skin cancer incidence from 2006 to 2010 was undertaken. Data regarding each studys immunosuppressive regimen, affected skin cancer cohort, and associated risk factors were extracted. Results Thirty‐six articles that met our inclusion criteria reported incidences of nonmelanoma skin cancer (NMSC), Kaposis sarcoma, melanoma, and Merkel cell carcinoma. NMSC was the most commonly reported cancer of all skin cancers after transplantation. Common risk factors were sex, age, sunlight exposure, and immunosuppressive agent‐related (duration, type). Conclusion Sun education programs and frequent screenings in organ transplant clinics have provided the best preventative strategies after transplantation, although the characteristics of the immunosuppressive regimen also play an important role. Thus, the adjuvant strategy of modifying immunosuppression may be effective when confronting severe transplant‐associated skin cancer. Although the decision‐making process for curbing levels of immunosuppression is difficult, further long‐term, randomized controlled studies should assess the effect of using less immunosuppressant medication while preserving graft function.

Quality of Life Measures for Acne Patients

Acne vulgaris affects most adolescents and two-thirds of adults and is associated with substantial psychosocial burden. Health-related quality of life (HRQOL) for patients with acne is an important factor of patient care, and several dermatologic and acne-specific measures have been created to assist in acne research, management, and care. This review describes several skin disease and acne-specific HRQOL measures and their applications in clinical care or research. The ideal HRQOL measure for the management of patients with acne is a concise questionnaire that places minimal burden on respondents and allows physicians to track improvement in HRQOL with successful treatment.

Trends in Sunscreen Recommendation Among US Physicians

IMPORTANCE Sunscreen is an important part of sun protection to prevent skin cancer but may not be recommended as often as guidelines dictate. OBJECTIVE To evaluate trends in sunscreen recommendation among physicians to determine whether they are following suggested patient-education guidelines regarding sun protection, and to assess data regarding physician sunscreen recommendations to determine the association with patient demographics, physician specialty, and physician diagnosis. DESIGN, SETTING, AND PARTICIPANTS The National Ambulatory Medical Care Survey was queried to identify patient visits to nonfederal outpatient physician offices at US ambulatory care practices (January 1, 1989-December 26, 2010) during which sunscreen was recommended. MAIN OUTCOMES AND MEASURES Frequency of sunscreen recommendation. RESULTS According to the National Ambulatory Medical Care Survey, there were an estimated 18.30 billion patient visits nationwide. Physicians mentioned sunscreen at approximately 12.83 million visits (0.07%). Mention of sunscreen was reported by physicians at 0.9% of patient visits associated with a diagnosis of skin disease. Dermatologists recorded the mention of sunscreen the most (86.4% of all visits associated with sunscreen). However, dermatologists reported mentioning sunscreen at only 1.6% of all dermatology visits. Sunscreen was mentioned most frequently to white patients, particularly those in their eighth decade of life, and least frequently to children. Actinic keratosis was the most common diagnosis associated with sunscreen recommendation. CONCLUSIONS AND RELEVANCE Despite encouragement to provide patient education regarding sunscreen use and sun-protective behaviors, the rate at which physicians are mentioning sunscreen at patient visits is quite low, even for patients with a history of skin cancer. The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protective behaviors, which patients should be counseled about at outpatient visits.

Use of topical antibiotics as prophylaxis in clean dermatologic procedures

BACKGROUND Topical antibiotics are not indicated for routine postoperative care in clean dermatologic procedures, but may be widely used. OBJECTIVE We sought to describe topical antibiotic use in clean dermatologic surgical procedures in the United States. METHODS The 1993 to 2007 National Ambulatory Medical Care Survey database was queried for visits in which clean dermatologic surgery was performed. We analyzed provider specialty, use of topical antibiotics, and associated diagnoses. Use of topical antibiotic over time was analyzed by linear regression. RESULTS An estimated 212 million clean dermatologic procedures were performed between 1993 and 2007; topical antibiotics were reported in approximately 10.6 million (5.0%) procedures. Dermatologists were responsible for 63.3% of dermatologic surgery procedures and reported use of topical antibiotic prophylaxis in 8.0 million (6.0%). Dermatologists were more likely to use topical antibiotic prophylaxis than nondermatologists (6.0% vs 3.5%). Use of topical antibiotic prophylaxis decreased over time. LIMITATIONS Data were limited to outpatient procedures. The assumption was made that when topical antibiotics were documented at procedure visits they were being used as prophylaxis. CONCLUSIONS Topical antibiotics continue to be used as prophylaxis in clean dermatologic procedures, despite being ineffective for this purpose and posing a risk to patients. Although topical antibiotic use is decreasing, prophylactic use should be eliminated.

Review: timing of office visits can be a powerful tool to improve adherence in the treatment of dermatologic conditions

Abstract Background: Poor adherence to treatment is a significant problem throughout medicine and particularly in the treatment of dermatologic conditions with topical medications, which present unique barriers to adherence. Purpose: We reviewed the literature to assess whether timing of office visits can be used to improve adherence. Methods: Studies examining adherence and office visits were identified using two search engines. PubMed was searched using the terms “medication adherence” OR “medication compliance” AND “visits.” A Web of Science® cited reference search was performed to identify articles referencing the paper “On White-Coat Effects and the Electronic Monitoring of Compliance” by Alvan R. Feinstein, MD. Results: Fifteen studies were identified, three of which were on dermatologic conditions. Thirteen studies found a positive correlation between adherence and office visits. Three of these studies demonstrated increased adherence with increased visit frequency. One study reported adherence was unaffected by office visits. Limitations: Our review was limited in that none of the studies identified looked at the effect timing of office visits had on adherence in the long term. Conclusions: Strategic scheduling of office visits can be a valuable tool to improve adherence, particularly in the management of dermatologic conditions, and may help spare patients unnecessary exposure to more toxic systemic therapies.

Practice trends in the treatment of actinic keratosis in the United States: 0.5% fluorouracil and combination cryotherapy plus fluorouracil are underused despite evidence of benefit.

Background: Topical fluorouracil and cryotherapy are among the most commonly used treatments for actinic keratosis. Evidence shows that 0.5% fluorouracil has similar efficacy and is better tolerated than 5% fluorouracil. Evidence also shows that combination therapy with cryosurgery and fluorouracil is beneficial. Objective: To examine fluorouracil and cryotherapy use in the treatment of actinic keratosis. Methods: The National Ambulatory Medical Care Survey database was queried for visits for actinic keratosis. Visits were analyzed for patient demographics, provider specialty, and treatment regimens. Fluorouracil and cryotherapy use was analyzed over time. Results: Cryotherapy was the most commonly used treatment for actinic keratosis. Fluorouracil products were prescribed to 1.1 million patients (6.6%) between 2001 and 2008; of these, dermatologists prescribed 0.5% fluorouracil in 51.8% of cases and 5% fluorouracil in 38.9% of cases. Combination fluorouracil and cryotherapy was used for only 1.1% of actinic keratosis visits between 1993 and 2008 and was never used by nondermatologists. Conclusions: Despite evidence suggesting comparable efficacy, greater tolerability, and lower cost of 0.5% fluorouracil relative to 5% fluorouracil, 5% fluorouracil is used by dermatologists almost as often as 0.5% fluorouracil. Among nondermatologists, 5% fluorouracil is used exclusively. Combination therapy of fluorouracil and cryotherapy is underused despite evidence of its benefit.

Patient satisfaction with obstetricians and gynecologists compared with other specialties: analysis of US self-reported survey data

Background: Few studies in the US have evaluated patient satisfaction with physicians across different specialties. We examined patient satisfaction and attitudes toward physicians during outpatient visits in the health care system, including obstetricians and gynecologists and other specialty physicians. Methods: We conducted a cross-sectional and national Web-based survey among anonymous patients who rated their physicians according to satisfaction with treatment on the basis of their experience during their most recent outpatient visits. The survey was user-friendly, validated, and helped patients identify their physicians according to specialty and rate them on a scale of 0 (“not at all satisfied”) to 10 (“extremely satisfied”). The patient satisfaction in obstetricians and gynecologists and other specialists were assessed using logistic regression analysis. Results: A total of 7938 patients who rated physicians belonging to the categories of obstetricians and gynecologists (n = 1903) and other specialties (n = 6035) were included in the study. Other things being equal, the odds of earning a satisfaction rating were almost 55% higher for visits to obstetricians and gynecologists than for other specialties (odds ratio [OR] 1.55 [1.15, 2.09], P < 0.01). Also, other things being equal, compared with other specialists, the odds of patient satisfaction due to the caring and friendly attitude of a physician were three times higher for obstetricians and gynecologists, with a logit coefficient of 1.28 (OR, 3.59 [3.17, 4.07], P < 0.001). Conclusion: Patient satisfaction ratings associated with caring and friendly attitude were higher for obstetricians and gynecologists compared to other specialists. Even though several factors influence patient satisfaction, adoption of factors like reducing waiting times, effective patient–physician communication, and involving patients in the decision-making process might aid physicians in achieving optimal results.

Nonmelanoma skin cancer treatment training varies across different medical specialists

Abstract Background: Physicians from various specialties treat patients with nonmelanoma skin cancer (NMSC). The isolation of specialties from each other may result in different approaches to skin cancer training. Purpose: Our purpose was to determine the type and amount of NMSC surgical training that is received during dermatology, general surgery, internal medicine, otolaryngology, and plastic surgery residencies. Methods: E-mail contact information for residency program directors of all accredited programs in each specialty was compiled through the American Medical Associations online residency database. A total of 920 residency program directors were emailed surveys concerning the training of residents in the treatment of NMSC. Results: Forty-two of 920 surveys were returned. All surveyed specialty groups, except internal medicine, had training in NMSC treatment including simple excision, split thickness skin grafts, and tissue rearrangement. A majority of the dermatology and plastic surgery programs instruct their residents in Mohs micrographic surgery and full thickness skin grafts. Electrodessication and curettage was most often instructed in dermatology, general surgery, and plastic surgery programs. Conclusion: Greater consistency in NMSC treatment training may be beneficial. Because different approaches may be best suited to particular clinical situations, NMSC treatment training should include adequate exposure to all NMSC treatment techniques.

Isotretinoin and oral contraceptive use in female acne patients varies by physician specialty: analysis of data from the National Ambulatory Medical Care Survey

Abstract Objective: To determine whether oral contraceptives (OCPs) are underutilized in the treatment of acne in women of reproductive age, how use of OCPs compares with use of isotretinoin and whether adequate use and documentation of OCPs is occurring with isotretinoin. Material and methods: The National Ambulatory Medical Care Survey (NAMCS) was analyzed over the years 1993–2008 for isotretinoin and OCP use in females aged 12–55 with acne. Results: Isotretinoin was prescribed more often than OCPs at both first visits (4.7% vs. 3.3%) and overall visits (13% vs. 2.6%) for acne. Documentation of OCP or other contraceptive use occurred only 4.1% of the time overall in patients treated with isotretinoin. Specialties varied in both OCP use for acne and contraceptive use with isotretinoin, with ob/gyn specialists most likely to prescribe OCPs and isotretinoin and to report contraceptive use in patients using isotretinoin, and dermatologists least likely to prescribe OCPs. Conclusions: The findings of the current study indicate that OCPs may be underutilized in women with acne. Underreporting of contraceptive use with isotretinoin and variations between specialties in OCP and isotretinoin use indicate a potential for education about the viability of OCPs in acne treatment and the importance of reporting contraceptive use with isotretinoin.

Topical Antibiotic Trends from 1993 to 2007: Use of Topical Antibiotics for Non‐Evidence‐Based Indications

BACKGROUND Systemic antibiotic use has become more conservative with the emergence of drug resistance. Topical antibiotics are employed for a variety of indications, although there are only a few evidence‐based indications. OBJECTIVE To examine topical antibiotics use in the outpatient setting. METHODS Topical antibiotic use was characterized using data from the 1993 to 2007 National Ambulatory Medical Care Survey. Visits were identified at which a topical antibiotic was used and analyzed according to patient demographics, diagnoses, procedures, concomitant medications, and provider specialty. Topical antibiotic use over time was analyzed using linear regression. RESULTS The most frequent diagnoses associated with topical antibiotic use were benign or malignant neoplasm of skin, impetigo, insect bite, and cellulitis. Data revealed a significant downward trend in topical antibiotics associated with dermatologic surgery (p<.001) and a nonsignificant downward trend in use in conjunction with skin biopsies (p=.09). Topical antibiotic use by dermatologists was noted to be decreasing over time, whereas among non dermatologists, it was noted to be increasing, although neither of these trends was statistically significant. CONCLUSION Topical antibiotics continue to be used for non‐evidence‐based indications, despite data that suggest that such use may be detrimental for patients and represents significant costs to the health care system. The authors have indicated no significant interest with commercial supporters.