PracticalDermatology

In early March dermatologists and employees of the dermatology pharmaceutical industry were looking ahead to the Annual Meeting of the AAD, albeit with some trepidation. After spreading from China, COVID-19 was racing across Europe; news reports of Italian cities in lockdown had incredulous Americans shaking their heads. A handful of cases had been reported in the US, but containment seemed a viable strategy.

Within weeks, pharmaceutical companies had transitioned employees to remote work status, medical centers and academic institutions halted travel for physicians, and the AAD cancelled its live meeting. As stay-at-home and self-isolation orders took effect nationwide, a majority of dermatology practices were forced to close or limit practice to emergency services. Dermatologists who expected to be learning and interacting in Denver where instead isolated to their homes. One thing was clear: the specialty, the nation, and world were in uncharted territory.

Nearly three months into the crisis in the US, states are lifting restrictions. Practices are opening again, and the world is adjusting to a new normal. Significant questions remain, not the least of which is how the specialty of dermatology and its pharmaceutical industry will advance through the future.

The Story That Wasn’t and the New Face of Interactions

At virtually any other time in history, AbbVie’s acquisition of Allergan would have been a top news story and a source of incessant buzz across the specialty. Pharmaceutical industry news site FiercePharma ranks the $63 Billion deal, which closed last month, as the second largest deal announced in 2019.

Under the combined company, Allergan’s prescription drug products join the AbbVie family, anchored by Humira. Allergan Aesthetics will remain headquartered in Irvine, CA, where it will operate as a new global dedicated business with its own research and development function under the AbbVie umbrella.

The blockbuster deal continues a trend of mergers, acquisitions, and consolidations that started in the dermatology sector more than a decade ago. It also marks the continued investment of Big Pharma in the dermatology specialty. And for good reason: The global dermatology pharmaceutical market had been forecast to reach $34.5 billion by 2023, according to Research and Markets in a July 2019 report. The US dermatology pharmaceutical industry grew by 2.5 percent from 2014 to 2019, according to IBIS World, and prior to the crisis, Data Bridge Market Research had predicted that the US dermatology drug market will reach $27.6 million by 2027.

The COVID-19 pandemic may alter that growth, but the impact remains unclear. Although the crisis has brought reports of some pharmaceutical companies furloughing or laying off their sales forces, most analysts remain relatively optimistic about the strength of the dermatology space moving forward.

Participating in a recent edition of the Derm Insider special series Quarantine Quorum, Samantha Widdicombe, Executive Director at Almirall LLC, acknowledged that ways of doing business have shifted but not halted. “It obviously has not been business as usual. It’s been business in a different way,” she says.

Tom Devine, General Manager, Dermatology Division at Sonoma Pharmaceuticals, noted that while some outsiders assumed work would come to halt, communication with physicians continues at a rapid pace. “It’s been busy,” he told Derm Insider host Neal Bhatia, MD. “Frankly it has been more of a challenge…it has not been business as usual [but I’m] trying to reach out—I’ve gotten a lot of phone calls and inquiries from a lot of your colleagues and clinicians, trying to teach our representatives right now how to communicate with their physicians.”

For an industry characterized by collegial interactions between industry and physicians, many, including Dr. Bhatia, yearn for the chance to meet in person again. “Professional relations has two sides of it, and I think the side that suffers right now is the personal side, the relationships side,” says Mike Vecchiolla, Senior Director, Scientific Affairs at EPI Health. “We may lose the handshake, but do we lose the hug?”

Although he emphasizes that he has missed live interaction, Christopher Billis, Chief Commercial Officer at MC2 Therapeutics, says that digital technologies will continue to have a role in physician/industry communications, especially when efficiency is needed. “Maybe it’s ok that the new norm is to do more of this [digital meeting],” he says. “Maybe more advisory board meetings are going to be held this way. Maybe more one-on-one consulting meetings will be held this way.”

Ms. Widdcombe agrees there is a long-term role for virtual interactions, but she, too, yearns for live meetings. “When you meet face-to-face, you brainstorm more easily,” she adds.

In addition to communication and support of education to help dermatologists navigate the crisis, industry is directly supporting the business of practice. “Many companies have been helpful in extending terms for purchases both before and after the pandemic, which clearly has been a huge help to many,” says Omaha dermatologist Joel Schlessinger, MD, Founder and Course Director of Cosmetic Surgery Forum.

“We were fortunate to have an extension of several months for a laser company’s warranty coverage, which was appreciated.”

Prescribing and the Rise of Teledermatology

While cosmetic services were necessarily halted due to stay-at-home orders and practice closures, prescribing for dermatology drugs has persisted with the advancement of teledermatology.

Results of a late March survey showed that more than a third of physicians had changed their prescribing practices because of COVID-19, with 77 percent of this group increasing medication quantities, 73 percent writing prescriptions without an office visit, and 49 percent reevaluating their patients’ prescriptions. Forty one percent of respondents expressed heightened concern about patient adherence to their medication schedules, according to the survey, interpreted and reported by AbelsonTaylor and fielded by global research company Savanta.

The lifting of certain regulatory restrictions made it possible for dermatologists to launch or expand teledermatology services, although limitations remained, largely due to technology challenges.

Speaking as part of the video series Coping with COVID-19, Carrie Kovarik, MD, Associate Professor of Dermatology at the Hospital of the University of Pennsylvania, noted that the long-existing practice model is having a moment. Successful integration of telemedicine is important with some simple preparations, she stresses.

“It’s important to have tips for patients so that they understand the whole process,” says Dr. Kovarik, noting that patients should determine insurance coverage prior to the virtual consult and should also have a clear understanding of how the consult will be handled (video, photo, or hybrid), and how to access the consult using websites, portals, apps, or other interfaces. Dr. Kovarik and colleagues offered multiple tips to help facilitate productive consults and enhance efficiency as part of the discussion available online at the site of our sister publication Modern Aesthetics® magazine: ModernAesthetics.com/COVID-19.

Although telederm is well suited to common skin complaints, concerns remain about high-risk medical conditions, including melanoma, that may not have been diagnosed in the midst of the crisis. Dr. Kovarik noted that dermpath requests for suspicious lesions have been non-existant some weeks. Teleconsults are intended for focused exams and not for full body exams, she observes, stressing that many suspicious lesions are identified during live full body exams.

“We try to make it as simple as possible,” says Ivy Lee, MD, of teleconsults. In practice in Pasadena, CA, Dr. Lee uses live interactive virtual visits as well as store-and-forward assessments. One interesting aspect of teleconsults is that when patients are in the home setting, it’s easier for them to share details about their skin health and skincare regimens—often having products on hand to show the dermatologist.

“I think as we return to ‘normal’ we need to redefine what that is and where telehealth can play a role and do well and serve our patients better than we have in the past,” Dr. Lee says. “And it will help us appreciate the simple experience of being in the room with our patients.”

Changes across the healthcare system can advance telehealth. “Telehealth needs the removal of state licensure laws to allow for providers to treat across the nation and not be isolated to just the state they live and work in,” says Michael Urban, OTD, MBA, MS, a Senior Lecturer, Director, Doctorate of Occupational Therapy Program in the Allied Health Department in the School of Health Sciences at University of New Haven. He was commenting on data from WalletHub.com that found a nine-time difference in spending on health infrastructure from the highest to the lowest spending states.

“To make sure those in underserved and vulnerable populations have access to these measures, we need to strengthen our internet and cellular networks to offer high speed to all of America to allow for people to then use phones at the minimum to connect with these services. Having worked in home care, I have seen all types of people and they all had, regardless of income, at least one smartphone of some type in their home on some type of plan. Telehealth also needs to be viewed by insurance companies as a face-to-face visit, as many people can use the platform equally the same as compared to a face-to-face visit.”

Ann Marie Marciarille, JD, Professor of Law at the University of Missouri, also commented on the WalletHub data, advocating for insurance reform to support widespread telehealth adoption. “Insurance reform will be required to advance telehealth beyond limited-time waivers to allow an exemption to the face-to-face encounters many jurisdictions require. Medicare should lead the way,” she says. “Robust data management and electronic medical records systems will be needed to prevent abuse, doctor shopping, and fraud on the part of providers.”

The New Red Lipstick

The future of aesthetic medicine has been much debated. While there appears to be wide consensus that the market will rebound, there is less certainty about the timing and shape of that rebound. A RealSelf consumer survey conducted at the end of April found that nearly half (49 percent) of those surveyed have or expect to be financially impacted by the COVID-19 crisis, yet a large majority still plan to move forward with cosmetic procedures soon. Sixty-one percent of respondents said they will return for procedures within six months of their provider reopening. Another nine percent say they plan to move forward with procedures in six months or more, while 27 percent say they are unsure about timing. (Read more about the survey in the May/June edition of Modern Aesthetics® magazine online at ModernAesthetics.com.)

Some observers have noted that cosmetics giant Revlon achieved its initial success during the Great Depression, when the company introduced colored nail enamels and expanded sales of its red lipstick. Despite the challenging economic times, women wanted to look and feel glamourous. They hope the same holds true in the present.

“The lipstick effect is a term that was coined during the Great Depression. Lipstick was one of the most purchased products, because women were looking for a way to feel beautiful in a time where people were struggling to keep their spirits up. Right now, with COVID sweeping the globe, women are at home and wearing less makeup than ever before but all this extra time has given them the ability to experiment with skincare, putting the focus on flawless skin and natural beauty,” observes Marina Peredo, MD, a dermatologist in New York City. “When dermatologist offices start to reopen, I think we will see that the lip filler is going to be this time period’s version of lipstick; everyone is going to be looking for ways to enhance their features without makeup.” She adds that the recent approval and anticipated launch of Restylane Kysse may help physicians meet that demand.

Melanie Palm, MD, who practices in San Diego, has a similar take. “I think post coronavirus there’s really been an emphasis with male and female patients alike: ‘Oh my gosh, this is what I looked like during two months in quarantine.’ And they want to do some things to feel like themselves again and feel pretty or feel handsome.

“I think some of this time away has been really lovely, but I think it’s fortified how much I really care about this specialty and about our field and that we really truly—whether it’s medical or aesthetic treatments—make such a difference in patient’s lives.”

Until We Meet Again

A key aspect of the interaction between industry and physicians is support for medical education. With limitations on large indoor gatherings expected for some time, ongoing travel concerns, and a desire by dermatologists to get back to seeing patients, when and how will live educational meetings return?

Jashin Wu, MD had to shift the inaugural San Diego Dermatology Symposium from its late May date to September 11-13. He is optimistic the meeting will offer a chance for dermatologists to learn and interact in person. “For the short-term, the impact of the COVID-19 pandemic is clear: cancellations, postponements, and virtual conferences. Both the annual and summer meetings of the AAD were cancelled in 2020. It’s possible that the 2021 annual meeting in San Francisco could be cancelled, as well, if there is no viable vaccine available by then,” Dr. Wu says. “But for small meetings of less than 100-300 attendees, it’s possible that live conferences could still be held if social distancing can be done (six feet between seats) and other changes are made, such as no buffet meals.”

Despite a desire to “get back to business,” industry response may be variable, Dr. Wu predicts. “Some companies are cancelling attendance at all meetings in 2020, whereas others are taking a wait-and-see approach,” he says.

“COVID has changed so many aspects of our professional lives, and education is yet one more thing that has suffered due to this awful scourge,” observes Dr. Schlessinger. He says he is unsure of the future of meetings in general.

“I can’t say at this time where we will all end up, as there are too many factors to consider, including plane travel, availability of venues that are safe, and disposable income to travel to destinations for seminars or meetings,” he says. “My hope is that this is obviated if we find a vaccine in the near future, but this is clearly a wish and not a definitive answer.”

Meanwhile, Dr. Schlessinger sees potential benefits in emerging technologies. “For the time being, we continue to adapt and refine the use of Zoom and other video sources for education. These do provide some solace and community, though they are clearly inferior to the benefits of true interactions.

“If and when this ends, it will be great to get back to the old way of seeing reps and salespeople. Until then, we remain appreciative of being alone together!”