PracticalDermatology

Acne is one of the most complex, multifaceted, and challenging diseases we treat in dermatology. It takes four to six weeks for most patients to begin to see improvement, there is often poor patient compliance, insurance coverage for medications is increasingly restrictive, and it can be difficult to assess the effectiveness of the treatment regimen. These difficulties often leave both patients and providers frustrated with slow progress and setbacks. However, for every challenge we encounter there are also solutions and many ways to improve acne treatment. By using new methods and tools tremendous strides towards clearer skin and faster results can be made. Ahead are 10 ways to improve acne treatment.

1. Use a Short Questionnaire

Treating acne requires more than just taking a brief history. A short questionnaire is an ideal way to get all the information needed from patients. Key questions include:

• What present and past treatments have you tried?
• What is your skin type (oily, dry, ect)?
• What bothers you about your acne (discoloration, painful cysts, acne scars, blackheads etc)?
• For female patients, do you have regular monthly periods or menstrual flares?
• How much distress is your acne causing you?

2. Address the Expectation Gap and Discourage Spot Treatment

We must assume that patients believe that if they use medications for several months, their acne will be cured. If a patient is a candidate for isotretinoin, his/her expectations can largely be met. Everyone else will need to be educated that other medications take four to six weeks to see improvement with an expectation of 50-75 percent improvement in two to three months. Explaining to patients that the medications work by preventing the formation of new pimples and that every pimple they see now started about a month ago allows them to understand why medications should be applied to the entire acne prone area and not as spot treatment.

3. Give Patients Hope and Let Them Know Acne is Not Their Fault

We cannot forget that acne carries a heavy emotional burden. Many patients believe that having acne is their fault. They read or are told by others that if only they ate better and had better hygiene their skin would clear. Many feel hopeless because of multiple treatment failures or believe their acne may be so severe that nothing will work. Before I explain my treatment plan, I give the patient a very simple but powerful message: “You will get better.” As dermatology providers, we know that it is very rare to have a case of acne that cannot be improved or even cured, but patients don’t know this. I also add that acne is mostly genetic and isn’t affected that much by diet or any other factors. I tell patient they can blame their parents for having acne, which is a message all patients embrace, especially teenagers.

4. Have an Objective Measure of Improvement

Without an objective measurement of acne, we rely on the patient’s and our own opinions of how much the acne has improved, which in turn guides further treatment. This is hardly scientific. The best way to measure acne is with a lesion count. However, a full lesion count of every lesion type on every area is too time consuming to do in a clinical setting. A modified lesion count, while not complete, can be performed quickly and is good enough to measure progress. For example if the patient’s main feature is inflamed cysts on the face, count only those. If lesions are numerous but symmetrical, count only those on one side of the face. If one area of the face is the most severe, count the dominant lesion on that area. Photographs certainly can be helpful but their usefulness is limited by technical difficulties like consistent positioning and lighting. In addition, the work of transferring digital photos from camera to computer to chart can be time prohibitive. However, in this Internet/cloud computing era, there is an iPhone/iPad app for medical photography called Appworx through which photos can be stored in the cloud on a HIPPA-compliant server so no file transfers are required. There are also templates that aid you in getting your patient in the proper position for a good photo. And when you are taking the second photo on a follow-up visit, there is a “ghosting” feature available that puts a translucent image of the last photo on the screen so the current photo can be taken to match the position and angle of the previous photo. This makes taking consistent photo’s much easier. The two photos can then be compared side by side on the iPad for you and the patient. A picture can be worth a thousand words and a side by side photo showing a 50 percent decrease in lesions is often more powerful than telling patient they have a 50 percent decrease in lesions.

5. Establish Confidence

When patients view us as experts, they will be more likely to be compliant. There are several ways to instill their confidence in us as the experts and in the treatment plan. A brief explanation of what causes acne followed by an analysis of their type of acne is a good starting point. Follow this with close inspection of the skin for at least 15 seconds. One complaint I hear over and over is “the doctor never had me take off my makeup and never took a close look at my skin.” This step must not be missed. It’s also important to explain to patients how their medications work. Patients need to know why they are using a certain medication to stay motivated. In addition, when a patient sees you taking a lesion count or photos, it lets them know you are approaching their acne in a thorough and systematic way.

6. Prevent your Treatment Plan from Falling Apart at the Pharmacy

Prior authorizations, age restrictions, high costs, prescription drug deductibles, and coupons, which may or may not work, are the factors that prevent your patients from obtaining their acne medications. Often, the patient doesn’t get all of the medications you prescribed and never contacts you for your help to resolve the problem. There are several things we can do to ensure our patients get the medications we prescribed or an acceptable substitute on their first trip to the pharmacy.

• The backup prescription: On your prescriptions, include the statement: “If medication is not covered or too expensive for the patient please substitute XXXX.” The pharmacist can then substitute the medication without calling you. Be sure to advise the patient on what are doing so they understand they may get a different medication and to remind the pharmacist to look at the substitution instructions if necessary.
• Partner with an independent pharmacy: In many areas, independent pharmacies have evolved that cater to dermatologists. They typically have more expertise in applying discount cards (many have the cards on hand or go online as needed), ways to streamline prior authorizations, compounding services, and are able to problem solve prescriptions better that chain pharmacies, which may not have the time or the expertise to do so. Independent pharmacies are also very useful for navigating the dispensing of Isotretinoin.
• Train staff to deal with pharmacy issues: Make sure your staff understands that pharmacy issues are top priority. Assign one person to make sure drug coupons are kept in stock and train your medical assistant to dispense them at every opportunity. We need to educate the patient as well if we are writing any medications that are brand name or expensive to immediately contact us if they can’t get their medications.

7. Offer Multimedia Patient Education

Wouldn’t it be great if patients know the basics about acne and the treatments you offered before the first visit? This can easily be accomplished by having the patient view a short (two-three minutes) PowerPoint/KeyNote or video presentation. Studies show that patients learn as much or more from a multimedia presentation than having the same information communicated by a trained healthcare professional.1,2 Keep in mind multimedia patient education (MPE) is not intended to replace face-to-face patient education but to enhance it. If you have computers in each room, the MPE can be played right before the visit for maximum effect. If you do not have monitors the patient can view it on a tablet in the room or be advised to view it on your website before the visit.

8. Make Designing an Acne Regimen a Collaborative Effort

For many dermatology problems, the treatment is the same for everyone. This is not the case with acne. We have many tools in our toolbox to customize the best regimen, but any regiment will fail if the patient will not follow it. With the information from the questionnaire at hand, I tell the patient what treatment plan I recommend and then ask, “How does that sound?” to make sure s/he is on board. I also ask, “Do you have any questions?” at the end of every visit. Eliciting the patient’s input twice ensures that his/her questions are answered and his/her concerns and preferences are factored into the plan.

9. Provide Patients with a Written Treatment Plan

We all know that it is normal for patients to forget half of what we tell them at a visit. It is also likely that there were procedures you thought might benefit the patient that you plan to discuss at a follow-up visit. This is why a written treatment plan is so important. Simply create a handout with the medications, procedures, and skincare products you routinely recommend including all key patient education points. Make sure the format is easy to use and can be filled out in under 30 seconds while you are talking to the patient. Handing this plan to the patient is a great way to end the visit.

10. Ask the Right Questions at the First Follow-up Visit

The first follow up is a crucial visit where several key questions need to be answered:

• Did the patient get all of his/her medications? There are many reasons the patient may not have gotten some of their medications. It is not uncommon that one or more medications weren’t covered or were too expensive and not obtained by the patient. You have a chance at follow up to correct these problems, but unless you ask, you may not be aware of any problems.
• Measure compliance. The simple question, “What medications you are using and when?” is an excellent way to measure compliance. We know what medications they are using but asking them to recall their medication regimen gives us a good idea if they are compliant. After using medications regularly for a month the patients should be able to quickly recall their regimen in good detail. Next ask, “Where do you use the topical medications?” If this elicits an answer of “When I have breakouts I put it on the pimples,” the patient is spot treating and needs to be reeducated. “How many days out of this month did you use your topical and/or oral medications?” is also a great question because the patient must quantify their compliance, which allows us to better asses how much improvement they should be having. Lastly, asking about side effects from medication, particularly dryness, is very important. A well trained medical assistant with a checklist covering the above questions (and more) is a great way to help collect all the information you need to have a productive second visit.

A Comprehensive Approach

It is no secret that acne can be frustrating to treat. This frustration in part, stems from the fact that we use an incomplete approach, poorly suited for the complexities of acne. A complex, multidimensional disease requires a more organized and comprehensive approach to achieve great results. Once you adopt a system incorporating some or all of the above techniques, you will find that patients are better educated, have better results, and are more satisfied. n

Steven Leon, MS, PA-C is on staff at Dermatology and Laser Centre in greater Los Angeles. He is cofounder of FixWarts.com.

1. Huber J, Ihrig A, Yass M, Bruckner T, Peters T, Huber CG, et al. Multimedia support for improving preoperative patient education: a randomized controlled trial using the example of radical prostatectomy. Ann Surg Oncol. 2013 Jan;20(1):15-23.

2. Miller DP Jr, Kimberly JR Jr, Case LD, Wofford JL. Using a computer to teach patients about fecal occult blood screening.A randomized trial. J Gen Intern Med. 2005 Nov;20(11):984-988.