President of the American Academy of Dermatology (AAD), George J. Hruza, MD, MBA, FAAD, Director of the Laser & Dermatologic Surgery in St. Louis, MO and Adjunct Professor of Dermatology at St. Louis University, spoke to Practical Dermatology® about the state of dermatology today. He highlights many of the wins in the treatment of common skin conditions and outlines an advocacy agenda for the specialty’s future.
Have we made progress in treating psoriasis?
George J. Hruza, MD, MBA, FAAD: We know that biologics have proven to be effective and safe for patients with moderate to severe psoriasis. In fact, systemic agents, small molecules, and biologics were more effective than placebo in reaching Psoriasis Area and Severity Index (PASI) 90 according to a study published in Cochrane Reviews. While systemic drugs are highly efficacious in treating psoriasis, a balance of risk versus benefits should be considered along with patient preferences. Further, thanks to the extensive research knowledge, we now know that psoriasis is considered a chronic, multisystem inflammatory disorder, and cautious management of this disease is imperative. Dermatologists’ ultimate goal is to determine the impact of psoriasis treatment on the ability to prevent future disease associated with comorbidity. Thus, dermatologists collaborate with primary care providers and other health care specialists to manage psoriasis associated with co-morbid conditions. This is what providing superior and compassionate care to patients is all about: improving their quality of life.
How are we doing when it comes to acne?
Dr. Hruza: Most dermatologists would agree that the biggest medical advancement for treating acne patients is isotretinoin. A study published in JAMA Dermatology focused on monthly laboratory testing of acne patients receiving standard doses of oral isotretinoin. This protocol is not supported by evidence. Don’t get me wrong: Laboratory monitoring with intent is important. Some patients, depending on how they respond to oral isotretinoin and their medical history, may need monthly evaluations for lipid levels, hepatic function, and complete blood cell count. However, other patients, who are not “high-risk” and who have low laboratory abnormalities, may only require a lipid and hepatic panel testing at baseline and after two months of isotretinoin treatment.
The benefits to scaling back on monitoring include, but are not limited to, cost savings and patient comfort and time commitment. We’re finding that patients who really need to be on this medication are likely to decline simply because they’re afraid of needles and blood tests. As physicians, we also need to consider the time commitment this requirement has for our patients. When you really think about it, honoring monthly doctor appointments can be a huge undertaking for any patient.
What about eczema?
Dr. Hruza: For atopic dermatitis (AD), we’re proud of the progress we’ve seen when treating patients with therapeutic options. Medical treatment breakthroughs have made a significant difference for patients with moderate to severe AD, especially those who are of adolescent ages. Dupilumab is the first immunomodulating injectable biologic approved for moderate to severe atopic dermatitis. This is an invaluable discovery for dermatologists treating patients aged 12 and up. Crisaborole is a new topical phosphodiesterase inhibitor with impressive clearing achieved in moderate atopic dermatitis after a short period of treatment. (For information on the AAD’s current and upcoming clinical guidelines in these areas, visit aad.org/practicecenter/quality/clinical-guidelines.)
Where are we in terms of skin cancer prevention and treatment?
Dr. Hruza: Ultraviolet light exposure is the most preventable risk factor for skin cancer. I remind my patients to stay out of tanning beds, seek shade, wear protective clothing, and use a broad-spectrum, water-resistant sunscreen with SPF 30+ to reduce skin cancer risk every time they are outdoors. Lately, most of us have probably answered a lot of patient questions about sunscreen safety. We know that our patients should continue to use sunscreen in addition to seeking shade and wearing protective clothing. While the FDA is preparing to update regulatory requirements for most sunscreen products sold in the United States, the AAD is providing its comments and expert guidance to help inform the FDA’s decision-making process.
A host of emerging technologies and non-invasive tools are making inroads into the ways in which dermatologists diagnose and potentially treat skin cancer. Advancing and new technologies include Reflectance Confocal Microscopy (RCM) and Optical Coherence Tomography (OCT). RCM and OCT both provide non-invasive visualization of skin lesions in real-time, and both allow longitudinal analysis, but they differ in their depth of penetration, cellular resolution, and field of view. Ultimately, the hope is that RCM and OCT will be married into one machine so that physicians can see the lesion on a cellular level and determine the depth all at the same time.
Hedgehog inhibitors, a class of oral medications, are the first systemic therapies specific for basal cell carcinoma and are revolutionizing the treatment of advanced basal cell carcinoma. We now have a first immunomodulatory systemic therapy for advanced and metastatic cutaneous squamous cell carcinoma that is making a difference for patients who had a very poor prognosis.
What is the most exciting area of research in dermatology today?
Dr. Hruza: In the biologics sphere alone, we have made exceptional strides in researching and developing treatments for hidradenitis suppurativa, chronic urticaria, vitiligo, dermatomyositis, and alopecia areata. Federal medical research funding ensures that we have the resources we need to improve patient care and discover breakthrough treatments that are life changing for our patients. Last year, the American Academy of Dermatology Association (AADA) secured federal funding supporting skin health. Because of the AADA advocacy efforts, skin cancer prevention research within the Center for Disease Control & Prevention (CDC) was increased to $3 million this past year. As part of the Defense Department’s Peer Reviewed Cancer Research Program, $10 million was approved for melanoma-dedicated research.
What are some of your goals for the specialty as AAD president?
Dr. Hruza: My main focus is to help our members to maintain, increase, or recapture the joy of dermatology that they had when they finished residency for the benefit of their patients. I’ve been in practice for three decades and still love going to work every day. Recently, though, I’ve seen how the regulatory burden on physicians has increased dramatically. It is disheartening to see so many dermatologists in my area retiring early simply because they can no longer withstand the innumerable reporting, electronic health records (EHR), and compliance requirements from legislators, regulators, and insurance companies. Ultimately, the obstacles policymakers impose interfere with a critical component of dermatologic care: the doctor-patient relationship.
I know we cannot eliminate all regulatory burdens. However, we can work toward reducing burdens, especially the ones that don’t benefit patients. We must stay committed to efforts that protect patient access to care, specifically, fighting against onerous step-therapy policies, prior authorizations and arbitrary restrictions on dermatology in-office compounding, especially the ability to reduce the pain of local anesthetics for our patients by buffering lidocaine. Closer to home, we must remain adamant about protecting our patients from unsafe expansions of non-physician provider scope of practice, and we must keep fighting for indoor tanning regulations and truth in advertising at the state level.
The Academy has an expanding practice management center that is full of tools to help our members navigate regulatory, EHR, practice management, physician wellness, work-life balance, and practice setting issues. We are also developing a quality innovation center that will help our members improve the quality of care they provide to patients, which is one of the most fulfilling things that we can do in our practices to increase job satisfaction.
The most important thing to do, as a specialty, is to keep improving the practice of dermatology for the sake of our patients. To do so, we need to advocate for policies that reduce the regulatory burden on physicians. No one dermatologist can do this alone, though. Truly effective advocacy is when everyone is an advocate, engaged in the process, and inspired—and all our voices actively coming together to jointly support the profession.