The title of this editorial reflects why the lecture, “How do you make this do that?” is a new offering at our Cosmetic Surgery Forum this year. Historically, the dermatology greats were known for their “one-offs” and minor tweaks to products and procedures. The brilliant “Diary of a Practice” pieces by Walter and Dorinda Shelley in Cutis in the 1990s were transformational to me as one of the first “licenses to alter” a style of practice. This ability of our more daring (or innovative) colleagues to reimagine RCT-proven treatments has, for me, always been what separates a good clinician from a great clinician or a true artist.
This is in contradistinction to the dogma of evidence-based medicine (EBM) that proliferates now. There is no doubt that EBM has generally led to safer, more sustainable practices in many medical specialties, and daring treatment decisions can easily lead to both financial and professional ruin with malpractice implications. Nonetheless, on-label limitations lead to fewer innovations and successes in the real world.
According to Robert Rudolph, an astute clinician who trained under both the Shelleys and Albert Kligman, Walter’s genius lay in his confidence to “therapeutically manipulate.” As Dr. Rudolph explained in a personal communication: “He was a spectacular clinical dermatologist, a fine researcher, and a therapeutic manipulator.”
This may now be a lost art, but with the advent of social media and increased access to novel research, highly opinionated and anecdotal interaction should at least be a legitimate part of the intellectual landscape. Indeed, off-label uses of medications have been documented in the literature and during meetings for years, but the astonishing increase in outlets for information seems to have ironically decreased, rather than increased, our ability to know what other practitioners are doing. The newest group of dermatologists (in my opinion) do not have access to this sort of information and practice in a cookbook atmosphere. Most of their information now comes from clinical trials that are highly regulated by the FDA and devoid of nuance once the medications are released to the public. Any interactions occur in highly orchestrated and controlled marketing sessions where off-label questions directed to the podium are unable to be answered for fear of serious consequences.
Fortunately, outlets ranging from continuing medical education (CME), the Dermchat/RxDerm listserv groups, or the “Dermatologist” Facebook group all have a history of positively promoting interactions from which novel therapies can evolve. In fact, this editorial was partially inspired by a communication on RxDerm by Dr. Peter Panagotacos regarding his preferred regimen for frontal fibrosing alopecia:
Stop sunscreens and moisturizers to the upper face and forehead. I prescribe all of these initially—and do not creep up on the treatment one at a time:
a. Topical potent steroid - Clobetasol solution BID
b. Cyclosporine 100 mg BID for 3 months minimum, then reassess
a. Doryx 150 mg daily for 2 months then perhaps switch to Bactrim D/S
b. PLAQUENIL generally after the doxy and Bactrim - about the third month
c. Diflucan 150 to 200 once a week for 2 months then reassess, OR Nizoral 200 daily for two weeks then 400 once a week x 2 months
d. Wash area involved daily with 4% PanOxyl Acne Wash
e. Nizoral Shampoo twice a week
f. EpiDuo QD or Tretinoin gel to area involved hs
C. AGA Treatment
a. Spironolactone 150 QD
b. Dutasteride 0.5 preferably, or Finasteride 5 mg daily, or YAZ
c. Rogaine 5% Foam - no PPG in it
There is no evidence-based-medicine regimen in the world that would encompass such a note in standardized medicine! As such, my own approach has always been to supplement EBM with anecdotal treatments to decide on a final regimen. I encourage each of you to take time to talk to or interact with colleagues about ways that they “color outside the lines.” Consider change, making sure you are safe in your practice and have some basis for any changes. It is critical to have balance and listen to honest feedback. You may be surprised at the wealth of choices available to how you practice, and this may lead to a more fulfilling style of practice for you and your patients.