Rosacea Core Domain Set for Clinical Trials and Practice: A Consensus Statement

Importance

Inconsistent reporting of outcomes in clinical trials of rosacea is impeding and likely preventing accurate data pooling and meta-analyses. There is a need for standardization of outcomes assessed during intervention trials of rosacea.

Objective

To develop a rosacea core outcome set (COS) based on key domains that are globally relevant and applicable to all demographic groups to be used as a minimum list of outcomes for reporting by rosacea clinical trials, and when appropriate, in clinical practice.

Evidence Review

A systematic literature review of rosacea clinical trials was conducted. Discrete outcomes were extracted and augmented through discussions and focus groups with key stakeholders. The initial list of 192 outcomes was refined to identify 50 unique outcomes that were rated through the Delphi process Round 1 by 88 panelists (63 physicians from 17 countries and 25 patients with rosacea in the US) on 9-point Likert scale. Based on feedback, an additional 11 outcomes were added in Round 2. Outcomes deemed to be critical for inclusion (rated 7-9 by ≥70% of both groups) were discussed in consensus meetings. The outcomes deemed to be most important for inclusion by at least 85% of the participants were incorporated into the final core domain set.

Findings

The Delphi process and consensus-building meetings identified a final core set of 8 domains for rosacea clinical trials: ocular signs and symptoms; skin signs of disease; skin symptoms; overall severity; patient satisfaction; quality of life; degree of improvement; and presence and severity of treatment-related adverse events. Recommendations were also made for application in the clinical setting.

Conclusions and Relevance

This core domain set for rosacea research is now available; its adoption by researchers may improve the usefulness of future trials of rosacea therapies by enabling meta-analyses and other comparisons across studies. This core domain set may also be useful in clinical practice.

Race and ethnicity are inadequate predictors of ambulatory visit length and utilization of preventive services

Health disparities can be experienced by any disadvantaged group who has limited access to healthcare or decreased quality of care. Quality of care can be measured by physician-patient communication measures such as length of visit, health outcomes, patient satisfaction, or by the services one receives such as screening or health education. This study aims to determine the relationship between length of physician-patient encounter, number of preventive services, ethnicity, and race. This study utilizes data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016. Visits with a single diagnosis were selected. Visits with the five most frequent diagnoses were selected by International Classification of Diseases, Ninth or Tenth Revision (ICD-9/ICD-10) classification. The primary outcome is time spent with a physician in minutes and the number of preventive services provided represented by the Preventive Service Index (PSI). Of 255,916 visits, non-white individuals made up 16.2% (95% Confidence Interval 15.9-16.4) while Latinos represented 13.4% (95%CI 13.2-13.6) of individuals. Multivariate analysis revealed minimal differences in visit length in race and ethnic groups regardless of diagnosis. Greater PSI was associated with individuals less than 43 years old (Odds Ratio (OR) 2.0, 95% CI 1.8-2.3, p =< 0.0001), those who reside in metropolitan statistical areas (MSAs) (OR 1.2, 95% CI 1.1-1.4, p = 0.006), non-white individuals (OR 1.2, 95% CI 1.1-1.3, p = 0.004), and those with private insurance (OR 1.3, 95% CI 1.1-1.4, p =< 0.0001). Race and ethnicity do not predict length of time with a physician regardless of diagnosis. Age, race, location within a metropolitan area, and insurance are significant but minimal predictors of receiving preventive services in the rank-order leading five most frequent diagnoses. This large, population-based study highlights improvements in the distribution of healthcare services from previous studies.

Number Bias in Clinicians' Documentation of Actinic Keratosis Removal

BACKGROUND

Actinic keratosis (AK) is a pre-cancerous skin condition caused by sun exposure. Number bias, a phenomenon that occurs when meaning other than numerical value is associated with numbers, may influence the reporting of AK removal. The present study aims to determine if number bias is affecting healthcare providers' documentation of patient-provider encounters.

METHODS

A single-center retrospective chart review of 1415 patients' charts was conducted at the University of Cincinnati Medical Center. To determine if there was a significant difference between even and odd-numbered AK removals reported, an exact binomial test was used. The frequency of removals per encounter was fitted to a zero-truncated negative binomial distribution to predict the number of removals expected. All data were analyzed with RStudio.

RESULTS

There were 741 odd and 549 even encounters. Odd removals were reported at a significantly greater frequency than even p < 0.001. Age may be contributing to the observed number bias (p < 0.001). One, two, and eight were reportedly removed more frequently, while nine, 13, and 14 were reportedly removed less frequently than expected, respectively.

CONCLUSION

Number bias may be affecting clinicians' documentation of AK removal and should be investigated in other clinical settings.

The Persistence of Nystatin Use for Dermatophyte Infections

BACKGROUND

Despite the limited use of nystatin for tinea infections, physicians may continue to use it.

METHODS

We assessed the National Ambulatory Medical Care Survey for all to determine the extent of topical nystatin use in tinea infections.

RESULTS

Topical nystatin was used at 4.3% (2.1%, 6.0%) of all tinea infection visits. It was not used at visits with dermatologists and was most common among family medicine physicians (P=.02).

DISCUSSION

Physicians are continuing to use nystatin for the treatment of tinea infections. Dermatologists have discontinued this treatment regimen, whereas other specialties have an opportunity to further improve their knowledge in this regard. J Drugs Dermatol. 2023;22(12):e49-e50.     doi:10.36849/JDD.5606e.

Management of Pediatric Psoriasis: A U.S. Survey Based on Visits from the National Ambulatory Medical Care Survey (NAMCS)

INTRODUCTION

Approximately one-third of psoriasis cases present in the first two decades of life. Many psoriasis treatments are approved by the U.S. Food and Drug Administration (FDA) for adults, including topical agents, systemic non-biologic agents, and systemic biologic agents. Only a handful of psoriasis treatments are FDA approved for children. Given the constantly evolving landscape of pediatric psoriasis management, our aim is to characterize how children with psoriasis are treated in the U.S.

METHODS

Data from the 2003-2016 and 2018 National Ambulatory Medical Care Survey (NAMCS) were used to evaluate patient demographics and treatment patterns for visits of children with psoriasis. Visits were stratified by those with a diagnosis of psoriasis and those for children with a diagnosis of psoriasis. Separate analyses for visits of children with a diagnosis of psoriasis were performed, including for sex, race, ethnicity, age, specialty of provider seen, and medications prescribed.

RESULTS

Pediatric psoriasis visits accounted for 3.3% of visits with psoriasis from 2003 to 2016 and in 2018; about one-third of those visits were to primary care providers. Children with psoriasis were prescribed a variety of topical and systemic medications, of which the most frequently prescribed treatments were topical tacrolimus, followed by topical clobetasol and topical betamethasone dipropionate or betamethasone valerate. Etanercept was the only biologic prescribed to children. At least 59% of the visits for children with a diagnosis of psoriasis included a topical prescription while at least 5.3% of the visits included a systemic prescription.

CONCLUSION

Use of off-label treatments was common for pediatric psoriasis. Most children with psoriasis were treated with topicals, of which tacrolimus, an unapproved treatment, was the most common. The frequent use of tacrolimus could indicate an avoidance of corticosteroids in children.

Onychomycosis Treatment Prescribed at Only Twenty Percent of Visits: A Cross-Sectional Analysis of the National Ambulatory Medical Care Survey 2007 to 2016

BACKGROUND

Onychomycosis represents the highest proportion of nail disorders seen in clinical practice. Onychomycosis management may differ amongst specialties, with impact on patient outcomes and quality of life (QoL).

OBJECTIVE

We aimed to characterize onychomycosis treatment across specialties, accounting for patient demographics, to assess for potential onychomycosis practice gaps.

MATERIALS/METHODS

We conducted a population based cross-sectional analysis using the National Ambulatory Medical Care Survey (NAMCS) 2007 to 2016 (the most recent years available).

RESULTS

Overall, 71.6% of onychomycosis visits were with general practitioners (GPs), 25.8% with dermatologists, and 2.58% with pediatricians. No onychomycosis treatment was prescribed at 82.0% of dermatology visits and 78.9% of GP visits. Dermatologists (Odds Ratio (OR):2.27 [95% Confidence Interval (CI):[2.14-2.41]; P<0.0001) and GPs (OR:2.32 [2.21-2.44]; P<0.0001) were more likely than pediatricians to prescribe treatment vs no treatment. Dermatologists were more likely than GPs to prescribe both no treatment vs treatment and topical vs oral antifungals (OR:1.33 [1.16-1.52]; P<0.0001 and OR:4.20 [3.80-4.65]; P<0.0001), respectively.

DISCUSSION

Our study showed that there is a low treatment rate for onychomycosis, with treatment prescribed at only 20% of visits. Untreated onychomycosis might result in secondary infection, pain, and negative QoL impact.1 Although dermatologists are specialists in nail disease management, they saw only about 25% of onychomycosis visits. Future efforts should be directed towards promoting onychomycosis therapy, and educating both patients and referring physicians that dermatologists are primary resources for nail disorder treatment.J Drugs Dermatol. 2023;22(10):1040-1045 doi:10.36849/JDD.6770.

Women of Childbearing Age With Hidradenitis Suppurativa Frequently Prescribed Medications With Pregnancy Risk

Copy: Hidradenitis suppurativa (HS) disproportionately affects women of childbearing age. As almost half of pregnancies in the United States are unplanned, dermatologists must give special consideration to medication safety when managing patients in this population.

METHODS

We conducted a population-based cross-sectional analysis utilizing the National Ambulatory Medical Care Survey from 2007 to 2018 (most recent years available) in order to characterize the treatment modalities most commonly being used for treatment of hidradenitis suppurativa in women of childbearing age.

RESULTS

There were 43.8 million estimated total visits for females ages 15 to 44 with HS. Women of childbearing age with HS were most commonly seen by general and family practice (28.6%), general surgery (26.9%), and dermatologists (24.6%). Obstetricians saw 1.84% of all visits. Oral clindamycin was the most commonly prescribed drug, followed by amoxicillin-clavulanate, minocycline, naproxen, and trimethoprim-sulfamethoxazole. Adalimumab was prescribed at an estimated 10.3 thousand visits (0.211%). At visits in which medication from the 30 most common therapies was prescribed, 31% of visits included a medication that was pregnancy category C or above.

DISCUSSION

Nearly a third of women of childbearing age with HS are receiving medications considered teratogenic. As many female patients feel that their physicians are not counseling them regarding the impact of HS therapy on childbearing, the results of this study serve as a reminder to dermatologists and non-dermatologists managing skin disease to continue to facilitate conversations about potential pregnancy risk when prescribing medications with pregnancy risk. Peck G, Fleischer AB Jr. Women of childbearing age with hidradenitis suppurativa frequently prescribed medications with pregnancy risk. J Drugs Dermatol. 2023;22(7):706-709. doi:10.36849/JDD.6818.

Workforce requirements for keratinous cysts: clinicians expend 1200 full-time effort years annually

Keratinous cysts are amongst the 10 most common dermatologic ambulatory diagnoses. Thus, we aimed to estimate the time and cost spent annually on management of keratinous cysts. We conducted a cross-sectional study using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey between 2007 and 2018 (most recent years available). Conservatively, $2.1 billion per year was spent on healthcare for keratinous cysts. On average, the full-time work of 1200 (840-1800) physicians and non-physician providers are required to manage keratinous cysts yearly in the outpatient and emergency departments.We used Medicare reimbursement rates for the cost analysis which provides a conservative estimate of the total cost. Keratinous cysts impose a significant time and cost burden on the healthcare system. Treating inflamed, draining, or painful keratinous cysts or ones that occur in undesirable locations such as the face are likely of high-value due to the quality of life impact. Managing asymptomatic keratinous cysts may be of lower value. Given this burden, clinicians should continue to evaluate the value they are providing to the patient when managing keratinous cysts.

Years of dermatology experience and geographic region are associated with outlier performance of excision or destruction for nonmelanoma skin cancer

INTRODUCTION

Treatments for nonmelanoma skin cancer (NMSC) include excision (surgical removal) and destruction (cryotherapy or curettage with or without electrodesiccation) in addition to other methods. Although cure rates are similar between excision and destruction for low-risk NMSCs, excision is substantially more expensive. Performing destruction when appropriate can reduce costs while providing comparable cure rate and cosmesis.

OBJECTIVE

To identify characteristics associated with exclusive (outlier) performance of excision or destruction for NMSC.

METHODS

The study consisted of malignant excision and destruction procedures submitted by dermatologists to Medicare in 2019. Proportions of services for each method were analyzed with respect to geographic region, years of dermatology experience, median income of the practice zip code, and rural-urban commuting area code.

RESULTS

Fewer years of experience predicted a higher proportion of excisions (R²=.7, p<.001) and higher odds of outlier excision performance. Outlier performance of excision was associated with practicing in the South, Midwest, and West, whereas outlier performance of destruction was associated with practicing in the Northeast and Midwest.

CONCLUSIONS

Dermatologists with less experience or in certain geographic regions performed more malignant excision relative to destruction. As the older population of dermatologists retires, the cost of care for NMSC may increase.

Trends in Office Visits for the Five Most Common Skin Diseases in the United States

Objective

We sought to determine the outpatient visit rates for the five most common skin conditions among dermatologists and non-dermatologists.

Methods

We conducted a population-based, cross-sectional analysis using the National Ambulatory Medical Care Survey between 2007 and 2016, the most recent years available.

Results

The five most common skin diagnoses among all medical specialties were contact dermatitis, acne vulgaris, actinic keratosis, benign neoplasm of the skin, and epidermoid cyst, respectively. Actinic keratosis followed by acne vulgaris and benign neoplasm of skin were the three most common visit diagnoses among dermatologists, whereas contact dermatitis, acne vulgaris, and epidermoid cyst were the most common among non-dermatologists. Overall, visits for the five most common skin conditions seen by dermatologists and non-dermatologists remained constant over the study interval.

Limitations

Misclassification bias could be impacting the results of this study. Additionally, the NAMCS samples only non-hospital based outpatient clinicians, and thus cannot describe hospital-based outpatient visits or inpatient hospital care.

Conclusion

Visits for contact dermatitis, acne, actinic keratosis, benign neoplasm of the skin, and epidermoid cysts have remained constant over the last ten years. These conditions represent the most common diagnoses of the skin at both dermatologists and non-dermatologists outpatient visits. Non-dermatologists continue to see almost half of visits for the five most common skin diagnoses. Patients are often referred from the primary care setting for growths of skin and skin lesions; thus, it is not surprising that actinic keratosis has remained the most common diagnosis among dermatologist and benign neoplasm the third most common dermatologic diagnosis.

Workforce Requirements for Skin Cancer and Related Skin Tumors Continue to Increase: Clinicians Expend an Average of 1,740 Full-Time Effort Years Annually

BACKGROUND

With an aging population, estimating workforce requirements for management of common conditions such as skin cancer will be necessary to meet the health care needs of the American people.

OBJECTIVE

The authors aimed to estimate the workforce requirements for managing skin cancer and other skin tumors.

MATERIALS AND METHODS

The authors conducted a population-based, cross-sectional analysis using data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey between the years 2007 and 2016, the most recent years available. The significance threshold was set at a p-value <.05.

RESULTS

The full-time effort of 1,740 (95% confidence interval: 1,340-2,220) clinicians is required to care for skin cancer and other skin tumors each year. The full-time effort years necessary for management of melanoma (p = .006), keratinocytic carcinoma (p < .0001), actinic keratosis (p < .0001), and all skin cancers and tumors (p < .0001) were significantly increasing from 2007 to 2016.

CONCLUSION

Clinicians expend a significant amount of time managing skin cancer and other skin tumors, and the time required for management increased over the study period. These workforce requirement trends can likely be attributed to increased prevalence and incidence rates of cutaneous malignancy secondary to an aging population and increased whole-body skin examinations.

Risk Factors That Are Associated With Outliers in Mohs Micrographic Surgery in the National Medicare Population, 2018

BACKGROUND

Physician variation exists in the mean number of stages performed per Mohs micrographic surgery (MMS) case. Physicians who are outliers in medical practice may be leading to a higher health care cost burden.

OBJECTIVE

To identify factors that influence being a high outlier in the mean stages per MMS case.

MATERIALS AND METHODS

The study comprised a retrospective analysis of 2018 data from physicians who billed Medicare Part B for Current Procedural Terminology (CPT) 17311 and 17312 (MMS of the head, neck, hands, feet, or genitalia) and/or CPT 17313 and 17314 (MMS of the trunk, arms, or legs).

RESULTS

For CPT 17311 and 17312, the odds ratio for being an outlier for a physician in a solo practice relative to a multiphysician facility is 2.4 (1.6-3.8), for a physician who is not an American College of Mohs Surgery (ACMS) member relative to a ACMS member is 2.0 (1.2-3.2), and for a practice located in the West, Northeast, and South is 7.7 (2.8-21.6), 6.2 (2.1-18.6), and 1.8 (0.6-5.4), respectively, relative to in the Midwest.

CONCLUSION

Physicians who are practicing solo, practicing in the West or Northeast, and are not ACMS members are more likely to be a high outlier in the mean stages per MMS case.

Efficacy of biologics and oral small molecules for atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

As new targeted therapies continue to emerge for atopic dermatitis (AD), comparisons between agents are necessary to inform clinical decision-making.

OBJECTIVES

Assess the efficacy of biologics and oral small molecules on the clinical signs, symptoms, and quality of life in AD.

METHODS

A systematic literature review identified phase II and III randomized clinical trials of biologics and oral small molecules in AD. Clinical benefit was assessed for three outcome measures: Eczema Area and Severity Index (EASI), Dermatology Life Quality Index (DLQI), and Peak Pruritus Numerical Rating Scale (PP-NRS) by performing a meta-analysis using the inverse variance heterogeneity model ((IVhet)).

RESULTS

The highest achievement of 75% reduction in EASI was seen with the higher dose of upadacitinib (30 mg) followed by abrocitinib and lebrikizumab, which outperformed dupilumab. Similarly, the highest proportion achieving at least a 4-point reduction of PP-NRS was seen with lebrikizumab followed by upadacitinib and abrocitinib which had greater reduction of itch than dupilumab. Abrocitinib had the greatest improvement in DLQI.

CONCLUSIONS

Upadacitinib, abrocitinib, and lebrikizumab had greater improvement of clinical signs, symptoms, and quality of life in AD compared to dupilumab and other targeted therapies.

Treatment of nail diseases in the emergency department

BACKGROUND

Although Americans seek care for their nail diseases on an outpatient basis, they also seek nail care in the setting of the emergency department (ED).

PURPOSE

This study aims to characterize the treatment of nail diseases at ED visits in the United States from 2009-2018.

METHODS

Data from 2009-2018 was collected from the National Hospital Ambulatory Medical Care Survey for EDs.

RESULTS

There was an estimated 1.54 (95% CI [1.35, 1.74]) million nail visits to the ED from 2009-2018. Whites accounted for the most visits (57%), followed by African Americans (21%). 25-44-year-olds was the age group with the most visits. The South was the region with the most visits (33%). The most common diagnosis was paronychia (42%). Treatments for paronychia included oral antibiotics, incision and drainage, or both.

LIMITATIONS

The accuracy of reporting the correct diagnosis remains the biggest limitation.

CONCLUSIONS

Nail disease visits accounted for over a million visits to the ED from 2009-2018. All ages and sexes were represented in these visits. Paronychia made up the largest portion of visits and was treated with oral antibiotics, incision and drainage, or both.

Global Epidemiology of Urticaria: Increasing Burden among Children, Females and Low-income Regions

Urticaria has a high socioeconomic burden worldwide. However, the global epidemiology of urticaria and its geographical and temporal trends are not well studied. Using the Global Burden of Disease dataset, the aim of this study was to analyse the age-standardized prevalence, incidence, years lived with disability, and mean duration of urticaria in 195 countries from 1990 to 2017. In addition, the relationship between socioeconomic development and urticaria was evaluated. The global prevalence of urticaria in 2017 was 86 million people. Females and children aged 1–4 years were more commonly affected than males and adults, respectively: these differences were outside the 95% uncertainty intervals. Regression analyses showed that a lower gross domestic product per capita was associated with a higher prevalence and incidence of urticaria (p < 0.001). The global prevalence of urticaria, incidence, and years lived with disability have remained stable from 1990 to 2017.

How the National Ambulatory Medical Care Survey has been used to identify health disparities in the care of patients in the United States

BACKGROUND

Healthcare disparities negatively impact patient health outcomes; addressing disparities could improve quality of life and decrease overall healthcare cost. The National Ambulatory Medical Care Survey (NAMCS) is an objective and reliable source for collecting information on United States (U.S.) ambulatory medical care service visits and may be a useful tool for identifying potential disparities in care.

OBJECTIVE

The purpose of this literature review is to describe studies utilizing NAMCS to capture U.S. healthcare disparities.

METHODS

PubMed was searched for scientific articles that utilized NAMCS to determine health disparities in the U.S. The keywords queried included "NAMCS" or "National Ambulatory Medical Care Survey" and "disparity" or "disparities" as a pair or additionally paired with one of the following: "race", "ethnicity", "age", "gender", "geography", or "insurance".

RESULTS

66 studies were found that incorporated NAMCS data from 1980-2016 into their methods to measure outcomes relating to health disparities. Disparities were found in the following categories: race/ethnicity, geographic location, age, insurance type, gender, specialist care versus primary care, body habitus, and preexisting conditions affecting patient outcomes. Disparities were identified in pain management, neurology, dermatology, psychiatry, patient communication access, and non-specialty specific or primary care visits related to disease conditions, screening, and treatment plans.

LIMITATIONS

Only PubMed was utilized as a search engine and may not encompass all studies on NAMCS and health disparities. NAMCS is a cross-sectional database and does not allow for longitudinal analyses.

CONCLUSIONS

NAMCS may be an underused tool given the limited number of articles that identify health disparities using it. Research studies utilizing NAMCS may identify potential disparities ultimately leading to better healthcare outcomes.

Tolerability of and Adherence to Topical Treatments in Atopic Dermatitis: A Narrative Review

Atopic dermatitis (AD) is a common, chronic inflammatory skin disease that oftentimes requires complex therapy. Poor adherence is a major barrier to AD treatment success. An interspecialty, virtual roundtable panel was held, through which clinical dermatologists, allergists, and behavioral and social psychologists discussed AD management and adherence. Relevant literature was reviewed, and the content of this article was organized based on the roundtable discussion. Current guidelines for AD treatment include maintenance and acute therapy for mild-to-severe AD. Therapy is often complex and requires significant patient involvement, which may contribute to poor treatment adherence. Behavioral and social psychology strategies that may help improve adherence include scheduling timely follow-up appointments, using a clearly written eczema action plan (EAP), reducing perceived treatment burden, utilizing anchoring techniques, sharing anecdotes, and rewarding children using positive reinforcement and stickers. There are multiple practical ways by which providers can improve both the management and treatment adherence of patients with AD.

Sanitation, Obesity, and Low Body Mass Index as Risk Factors for Bacterial Skin Infections

BACKGROUND

Bacterial skin infections can cause significant disability and can lead to mortality with inadequate treatment.

OBJECTIVE

To determine whether sanitation and body mass index (BMI) are statistically significant risk factors for the incidence and prognosis of bacterial skin infections.

METHODS

Country-level data regarding the age-standardized rates of incidence, prevalence, and years lived with disability (YLD) from bacterial skin infection per 100 000 persons from the Global Burden of disease dataset, and country-level data on age-standardized prevalence of obesity (BMI ≥30) and low BMI (BMI <18.5) from World Health Organization Global Health Observatory data repository were analyzed. Regression models were created to examine the effects of sanitation, obesity, and low BMI on the burden of bacterial skin infections.

RESULTS

The percentage of population using basic sanitation services was positively associated with incidence, prevalence, and YLD from bacterial skin infections (P < .05). After controlling for sanitation, in countries with more than 50% of the population using basic sanitation services, obesity was positively associated with incidence, prevalence, and YLD from bacterial skin infections (P < .05). In countries with less than or equal to 50% of the population using basic sanitation services, low BMI was positively associated with incidence, prevalence, and YLD from bacterial skin infections (P < .05).

CONCLUSIONS

Improving sanitation access in all countries, reducing the percentage of obese population in countries with good sanitation/hygiene techniques, and addressing malnutrition in countries with poor sanitation/hygiene techniques may help to reduce the burden of bacterial skin infections.

Comparing prescribing patterns for topical corticosteroids based on their FDA indication by age

BACKGROUND/OBJECTIVES

Atopic dermatitis (AD) affects up to 20% of the pediatric population, with a growing prevalence over the past 30 years. Topical corticosteroids (TCS) are commonly used as a first-line topical therapy for AD and are prescribed in 59% of all AD visits. However, some topical corticosteroids are prescribed outside of their age range indications. This paper aims to explore the frequency with which topical corticosteroids are prescribed for AD outside of their FDA-approved age range.

METHODS

Data on prescribing patterns for AD were obtained from the National Ambulatory Medical Care Survey (NAMCS). We assessed the frequency of off-label use of topical corticosteroids with respect to age indications in four specific age-groups, as delineated in the data (0-1, 2-7, 8-18, and 19+ years).

RESULTS

All prescribed topical corticosteroids found in the NAMCS database have an indication for AD or other inflammatory dermatoses or pruritic dermatoses. However, some medications were prescribed outside of their FDA-approved age indications. These off-label prescription rates ranged from 52% for desoximetasone to 0% for halobetasol and alclometasone, or rates lower than could be detected by our study.

CONCLUSIONS

Much like other medications for AD treatment, TCS are sometimes used off-label. The off-label use of topical corticosteroids to treat pediatric AD highlights a gap between clinical practice and regulating guidelines. Additional pediatric studies would offer a greater body of evidence to maintain or expand label indications for the use of TCS in younger patients.

Time to meaningful clinical response in reduction of itch in atopic dermatitis

Introduction: Itch is a distressing atopic dermatitis (AD) symptom that impacts quality of life. With the emergence of multiple new agents for the treatment of AD, the ability and speed with which an agent reduces itch may factor in agent selection. Objective: In this study, the primary objective was to quantify the rate at which agents for AD provide itch reduction using the peak itch numerical rating scale (NRS) data from phase II and III clinical trials. Methods: A PubMed literature search was performed in February 2020 to find phase II and III randomized clinical trials for the treatment of AD published from 2014 to 2020. A TIMEACLIR-Itch value was calculated from NRS data to represent the time to meaningful itch reduction.Results: We find a shorter TIme to achieving a MEAningful CLInical Response for itch reduction (TIMEACLIR-Itch) for small molecule inhibitors when compared to biologic agents. We also observe that nemolizumab achieves TIMEACLIR-Itch more quickly than IL-4 or IL-4/13 agents. Conclusion: These findings support the role that IL-31 has in producing itch and the role Janus kinase inhibitors (JAKinibs) play in itch reduction. This comparison of TIMEACLIR-Itch for different treatments may help guide therapy and management for AD patients.

Time Intervals Until the First Return Office Visit After New Medications

INTRODUCTION

Poor patient adherence to medications is common in dermatology and can result in negative health outcomes. A short interval until the first return office visit after starting a medication can increase adherence.

METHODS

We conducted a retrospective cross-sectional study by using the National Ambulatory Medical Care Survey from 2014 to 2016 to determine the length of time until the scheduled return visit.

RESULTS

Our study examined 10.9 (95% confidence interval 9.43, 12.5) million estimated visits in the NAMCS. Patients with acne, atopic dermatitis, and psoriasis prescribed at least one new medication had dispositions to return at two months or greater or to return as needed at 73.5% (38.8, 100), 49.1% (12.6, 92.0), and 55.0 % (14.0, 100) of visits, respectively.

CONCLUSIONS AND RELEVANCE

The time for a first return visit is frequently more than two months after a new medication is prescribed. Incorporating an earlier visit when prescribing a medication may be a means to improve adherence. J Drugs Dermatol. 2020;19(12): doi:10.36849/JDD.2020.5542.

Emerging systemic therapies for atopic dermatitis: oral small molecules and targeted topical agents

BACKGROUND

Until recently, treatment of atopic dermatitis has been limited to topical corticosteroids, calcineurin inhibitors, phototherapy, and systemic immunomodulatory agents. With improved understanding of the pathogenesis underlying atopic dermatitis, targeted oral small molecules and topical agents are being developed.

OBJECTIVE

Discuss efficacy and safety profiles of emerging oral small molecules and targeted topical agents in phase 2 and 3 clinical trials.

METHODS

A systemic literature review was conducted to identify results of randomized, placebo-controlled trials of oral small molecules and topical Janus kinase inhibitors up to March 1 2020 for the treatment of atopic dermatitis.

RESULTS

Three novel oral small molecules, abrocitinib, upadacitinib, and baricitinib, demonstrated improvement of clinical severity, pruritus, and quality of life with acceptable safety profiles. Apremilast, a phosphodiesterase inhibitor, was less efficacious with use limited by adverse effects. Two novel topical agents, ruxolitinib and delgocitinib, were effective and well-tolerated.

CONCLUSIONS

Targeted therapeutics including oral small molecules and topical agents show promise for the treatment of atopic dermatitis. The use of validated core measures is necessary for future trials in order to adequately compare agents and progress evidence-based medicine.

Emerging systemic therapies for atopic dermatitis: biologics

BACKGROUND

The mainstay of atopic dermatitis treatment has been largely unchanged over the last few decades. With improved understanding of the immunologic pathways underlying atopic dermatitis in recent years, targeted biologic therapies are being developed.

OBJECTIVE

Discuss efficacy and safety profiles of emerging biologics in phase 2 and 3 clinical trials.

METHODS

A systemic literature review was conducted to identify results of randomized, placebo-controlled trials of monoclonal antibodies up to March 1, 2020 for the treatment of atopic dermatitis.

RESULTS

Targeted biologics appear to have acceptable safety profiles. Dupilumab, lebrikizumab, and nemolizumab demonstrate efficacy as agents producing improvement in clinical severity and pruritus.

CONCLUSIONS

The growing class of biologics shows promise in meeting the needs of treatment-resistant atopic dermatitis. The use of validated core measurements is necessary for future trials in order to adequately compare agents and progress evidence-based medicine.

Dermatologists are increasing their use of non-opioid pain medications faster than opioids

INTRODUCTION

There is a lack of consensus in the literature on how and when dermatologists should prescribe pain medications. As there is an ongoing opioid abuse epidemic driven by prescription opioids, it is important for all fields to investigate their own prescribing patterns.

METHODS

We analyzed the National Ambulatory Medical Care Survey from 2007 to 2016 to assess the usage of systemic pain medications amongst dermatologists.

RESULTS

There were 16,777 total visits with dermatologists which represents 368 (95% confidence interval 363, 373) million estimated visits. Opioids were used at 1.4% (1.3, 1.6) of visits. As relative proportions, opioids were 35.6 (31.7, 39.6) of all systemic pain medication and non-opioids were 64.4% (53.8, 74.9). The use of opioid (p=.01 [odds ratio 1.08 (1.02, 1.14)]) and non-opioid (p<.001 [odds ratio 1.12 (1.07, 1.17)]) medications increased over the study interval.

CONCLUSION

Pain medications were used at a relatively small proportion of visits with dermatologists. Opioids were nearly half of all pain medications used. The use of opioids and non-opioids rose over the study interval, however, non-opioids rose at a faster rate. The faster rise of non-opioids may indicate that dermatologists are making an effort to use medications with less potential for abuse.

Increased biologic utilization in Latino patients with psoriasis

INTRODUCTION

Hispanic/Latino populations are more likely to have extensive psoriasis than the non-Hispanic/Latino population. Biologics are indicated for moderate/severe psoriasis or psoriasis with comorbidities. No studies have assessed ethnicity as a predictor of biologic utilization. We aimed to determine if biologic utilization differs between Latinos and non-Latinos with psoriasis.

METHODS

This study utilizes data from the National Ambulatory Medical Care Survey (NAMCS) from 2003 to 2016. Psoriasis visits were selected by International Classification of Diseases, Ninth or Tenth Revision (ICD-9/ICD-10) classification. The primary outcome is biologic use at the time of visit.

RESULTS

Of 1202 psoriasis visits, Latinos consisted of 9.7% (95% Confidence Interval 7.3-12) of the study population and 65% (95%CI 61-69) used private insurance. Multivariate analysis reveals the increased likelihood of biologic utilization in Latinos compared to non-Latinos (Odds Ratio (OR) 2.4, 95% CI 1.1-5.4, p = .03). Independently, private insurance status is associated with increased biologic use compared to public insurance (OR 2.4, 95% CI 1.2-5.0, p = .02). Private insurance status did not differ between Latinos and non-Latinos with psoriasis (OR 1.0, 95% CI 0.5-1.9, p = .98).

CONCLUSIONS

Hispanic/Latino ethnicity and private insurance status are independent predictors of biologic utilization, suggesting that biologic mechanisms may influence the increased use of biologics in Latinos with psoriasis.

An assessment of United States dermatology practices during the COVID-19 outbreak

Objectives: The COVID-19 outbreak is a serious threat to public health and social distancing on the part of individuals can help contain the epidemic. It is unknown if dermatologists are assisting with the public health officials' recommendations for social distancing by closing their practice or limiting their practice to the treatment of emergency conditions. This study examines the activity level of dermatology practices during the United States COVID-19 outbreak.Methods: We performed scripted phone calls to 60 dermatology practices in six different counties in the United Stated during the COVID-19 outbreak. We assessed if practices are open and if they are serving patients with urgent and non-urgent conditions.Results: Of the 60 dermatologists selected for the study, 55 were successfully contacted (92% contact rate). Of these practices, 29 (53%) were open, 17 (31%) were only seeing urgent patients and 9 (16%) were closed. New York, New York had 2 (20%) open offices which was the lowest proportion of any county (p = .04). Counties with higher prevalence had fewer open offices (p < .01, R² = .7).Conclusions: Many practices have restricted their level of operation especially in higher areas of COVID-19 prevalence, likely to help facilitate social distancing.

Baseline patient-reported outcomes from UNITE: an observational, international, multicentre registry to evaluate hidradenitis suppurativa in clinical practice

Background

Hidradenitis suppurativa (HS) is a chronic, inflammatory, skin condition associated with many comorbidities and often has a substantial impact on patients’ lives.

Objectives

To evaluate symptom burden and health‐related quality of life (HRQoL) at baseline in patients with HS in an observational, real‐world, clinical setting using several tools including a validated HS‐specific instrument.

Methods

This study evaluated HRQoL data from the international UNITE HS disease registry. Administration of patient‐reported outcome (PRO) instruments and collection of data were executed per local regulations. All data were assessed using descriptive statistical methods.

Results

PRO data from 529 adults and 65 adolescents were evaluated. Most adults (64.5%) and adolescents (73.8%) were classified as Hurley Stage II with substantial disease burden at baseline. HS had a large effect (mean DLQI = 12.6) and moderate effect (mean CDLQI = 6.9) on the lives of adults and adolescents, respectively. Approximately 58% of adults and 41% of adolescents had anxiety scores beyond the normal range; 30% of adults and 16% of adolescents exhibited symptoms of depression. Based on HSSA and HSIA scores, approximately 30% of adults reported a substantial burden of multiple HS clinical symptoms and more than 45% reported a significant emotional impact of HS that adversely affected their intimate relationships. Only 60% of adults were employed and of those, 64% reported at least some degree of impairment while working because of HS.

Conclusions

Based on PROs collected from patients enrolled in the UNITE registry, a real‐world, clinical setting, HS has a significant negative impact on the everyday lives of patients affected by this disease.