Practice Makes…More Practice

This month I am going to take a break from controversy…it’s too hot, there have been too many meetings, plus life is too short to complain. However, we should review a subject near and dear to all of us, which is optimizing care for patients.

At the recent Summer Meeting of the American Academy of Dermatology in Chicago, I directed a symposium on how to use systemic therapies without fear: “Advanced Systemic Therapeutics.” We had an all-star lineup that brought a lot of pearls and perspectives on how to be aggressive yet sensible with old and new treatments. As we regularly cover in this journal, including in the pages ahead in terms of the treatment approach for atopic dermatitis, there have been significant advances in systemic medications that treat the process of the skin disease, not just what we see. I use the analogy “turning off the faucet instead of mopping up the mess,” using the comparison of steroids alone vs. some of the newer biologic agents and JAK inhibitors. One of the missions of the session was to update attendees on these newer treatments and review their safety and efficacy, as well as best treatment protocols. But, more importantly, we wanted the dermatologists in the audience to not be afraid to actually prescribe these latest available systemic therapies to help their patients…blending some of the art of medicine with the science.

Costs and access aside (obviously, welcome to Fantasy Island right?), there are hindrances to using these—lab monitoring needs, follow-up appointments and patient management, adverse outcomes and side effects to watch for, off-label uses to stay up-to-date with, patient education needs, and potential insurance hoops to jump through—but the benefits for patients and the field of dermatology in general outweigh these burdens. In this era of high copayments and lower reimbursements for treating complicated medical dermatology patients, it behooves us to get these diseases under control and on autopilot as best we can.

The sad truth is that we are at serious risk of losing our ground as allergists, rheumatologists, and other specialists are already eroding our scope of practice—they show no fear or second guessing about starting biologics and immune-based therapies, and many of them fight harder than we do to get the serious (and expensive) drugs covered. The forecast tells us that to prevent the further marginalization of our specialty we need to overcome the trepidation that is spreading across dermatology to prescribe new biologics and other systemic therapies and remind ourselves about quality of life issues for patients with diseases like psoriasis and atopic dermatitis…the ones who don’t sleep, or want to take off their shirts and go swimming, or simply have given in to their diseases and outcomes.

It is good practice to be cautious and critical in assessing the benefits vs. the risks and side effects vs. anticipated responses of any treatments we consider for patients. But when patients or physicians have misperceptions about potential adverse effects, often based on what someone heard instead of what is proven, we have to be open to new options and be prepared for questions on options. Even though we have to be mindful of costs of treatment, the costs and consequences of not offering our patients the best available treatments can be far greater. This notion needs to start at the residency level and with our younger colleagues, because if we are not careful with the way they are sheltered from developing ethical interactions with industry to learn about new vehicles and treatments, or able to attend meetings and escape the bubble, we could have a generation of dermatologists that only prescribes triamcinolone ointment and ketoconazole cream while other specialties and even non-physicians take over treating real skin problems.

So costs aside…what is preventing you from prescribing new systemic therapeutics in your practice? Or, if you’ve started prescribing these treatments, share a success story. We want to hear from you—email editor@bmctoday.com.

—Neal Bhatia, MD
Chief Medical Editor