Are we contributing to the opioid epidemic? A systematic review on systemic opioid use in dermatology

BACKGROUND

Although dermatologists treat many painful skin conditions and perform procedures that may require analgesic use, there is a lack of evidence synthesis on opioid use in dermatology.

OBJECTIVE

To conduct a systematic review of the evidence on the use of opioid analgesics in dermatology.

METHODS

We applied the PRISMA guidelines and systematically reviewed literature that examined opioid use in dermatology published between 1980 and 2020 in the PubMed, EMBASE, and Cochrane databases. This review was registered with PROSPERO (CRD42020204864).

RESULTS

We identified 24 studies that analyzed 52,705,201 patients and 13,099 dermatologists. Between 34% and 87.5% of patients received opioids following dermatologic procedures; however, many did not use the entirety of their prescriptions, and 35-69% did not use any of their prescription. Top opioid prescribers were more likely to be Mohs surgeons, male, and practice in the South. Variability exists in the current evidence for opioid prescribing for nonprocedural dermatologic disease.

CONCLUSION

While opioid prescribing in dermatology is low compared with other specialties, patients are not utilizing the entirety of their prescriptions. Opioid prescribing for nonprocedural dermatologic disease varies; treatments focused on targeting the pathogenesis of these diseases is important to minimize opioid use. Dermatologists should consider limiting opioid prescribing and utilizing nonnarcotic analgesics.

Bullous Dermatoses and Depression: A Systematic Review

IMPORTANCE

There is a lack of evidence synthesis on the association between bullous skin disease and depression.

OBJECTIVE

To synthesize and interpret the current evidence on the association between bullous skin disease and depression.

EVIDENCE REVIEW

This review was conducted according to PRISMA guidelines and reviewed literature related to bullous skin disease and depression in the PubMed, Embase, PsycInfo, and Cochrane databases published between 1945 and February 2021. The quality of each included article was assessed via the Newcastle-Ottawa Scale. This review was registered with PROSPERO (CRD42021230750).

FINDINGS

A total of 17 articles were identified that analyzed a total of 83 910 patients (55.2% female; specifically, 6951 patients with bullous pemphigoid, 1669 patients with pemphigus, and 79 patients with epidermolysis bullosa were analyzed). The prevalence of depressive symptoms among patients with bullous dermatoses ranged from 40% to 80%. The prevalence of depression diagnosis among patients with bullous dermatoses ranged from 11.4% to 28%.

CONCLUSIONS AND RELEVANCE

In this systematic review, high rates of depression and depressive symptoms existed among patients with bullous skin disease. Adequate treatment of bullous dermatoses may be associated with a decrease in mental health burden on patients.

Topical opioid use in dermatologic disease: A systematic review

Topical opioid formulations offer a potential solution to manage pain and decrease the use of systemic opioids. Synthesis of use and efficacy of topical opioids in dermatological conditions has not been well characterized. We conducted a systematic search of the PubMed, Embase, and Cochrane databases from 1980 to February 2021. This study analyzed data from 14 articles and 263 patients on the use of topical opioids for pain related to chronic ulcers, burns, oral lichen planus, photodynamic therapy, and split-thickness skin grafts. Topical opioids included in this review were topical morphine and diamorphine. Common formulations consisted of 0.2-10 mg of opioid compounded with hydrogel or IntraSite gel. Topical opioids were variably effective in the use for pain control related to chronic ulcers and other dermatologic conditions. For example, the use of topical opioids appears to be effective in the reduction of pain related to pressure ulcers. Topical opioids were generally well tolerated. Insufficient data exist to adequately evaluate the efficacy and safety of topical opioid use in the context of nonpressure ulcers, burns, oral lichen planus, photodynamic therapy, and split-thickness skin grafts.

INDIVIDUAL ARTICLE: Safety and Tolerability of Topical Agents for Actinic Keratosis: A Systematic Review of Phase 3 Clinical Trials

BACKGROUND

Topical agents for actinic keratosis (AK), along with cryotherapy and phototherapy, are the most commonly used therapies for areas of skin with multiple AKs. Multiple options for the topical treatment of AK exist; newer therapies aim to balance efficacy with an acceptable safety and tolerability profile for the patient.

OBJECTIVE

To describe the safety and tolerability of FDA-approved topical agents for the treatment of AK.

METHODS

A systematic review of phase III clinical trials of topical agents for AK available on PubMed and clinicaltrials.gov was conducted on January 10th, 2021.

RESULTS

29 phase III clinical trials meeting the inclusion criteria were included in the qualitative synthesis. No serious adverse events or systemic adverse events were determined to be due to topical therapies for AK. The highest rates of treatment-related application-site adverse events and local skin reactions occurred with the various formulations of topical 5-FU and imiquimod; newer topical agents such as ingenol mebutate and tirbanibulin had more favorable tolerability profiles.

CONCLUSIONS

FDA-approved topical agents for the treatment of multiple AKs have minimal safety concerns. Tolerability profiles vary among the available options, and new agents such as tirbanibulin offer a favorable combination of safety, tolerability, and efficacy. J Drugs Dermatol. 2021;20:10(Suppl):s4-11.

Differences in acne therapy prescribing patterns between dermatologists and pediatricians: A population-based study

BACKGROUND/OBJECTIVES

Acne is a common skin condition that may be treated by both dermatologists and pediatricians. However, the treatments provided by dermatologists and pediatricians may differ. We aimed to describe acne therapy prescribing patterns of dermatologists and pediatricians.

METHODS

We performed a population-based, cross-sectional analysis using data from the National Ambulatory Medical Care Survey from 2006 to 2016 for pediatric patients (age ≤ 18 years).

RESULTS

There were approximately 30.5 million (weighted) outpatient acne visits between 2006 and 2016 for pediatric patients; 52% of visits were conducted by dermatologists, 29% by pediatricians, and 19% by other providers. Compared to pediatricians, dermatologists saw older patients (mean age 15.5 ± 0.12 vs 13.5 ± 0.35; P < .001), as well as a higher proportion of white patients (92.5% vs 76.3%; P < .001), non-Hispanic patients (89.5% vs 81.6%; P < .001), and patients with private insurance (84.6% vs 67.8%; P < .001). Compared to patients seen by dermatologists, patients seen by pediatricians were 68% less likely to receive topical retinoids (aOR 0.32, 95% CI 0.22-0.46), 38% less likely to receive topical antibiotics (aOR 0.62, 95% CI 0.41-0.95), and 48% less likely to receive oral antibiotics (adjusted aOR 0.52, 95% CI 0.36-0.75).

CONCLUSIONS

Our findings demonstrate that pediatricians prescribe topical retinoids, topical antibiotics, and oral antibiotics less frequently compared to dermatologists. It is important to understand these differences in prescribing patterns for acne and to identify potential educational gaps.

A new era of moisturizers

BACKGROUND

Moisturizers traditionally function to replenish both the intercellular lipid lamella and natural moisturizing factors, and form a hydrolipid film on the skin surface to decrease transepidermal water loss and improve hydration. As we continue to identify epidermal lipid imbalance in patients with atopic dermatitis, we turn to the use of bioactive ingredients in moisturizers for improving barrier repair and function.

METHODS

This review aims to explore the modern use of moisturizers in targeting various components of the skin barrier, dampening immune response, and restoring microbial balance. We conducted a balanced and comprehensive narrative review of the literature. Studies were identified by searching electronic databases (MEDLINE and PubMed), focusing on studies and trials regarding moisturizers that include endocannabinoids, bioactive lipids, anti-inflammatory agents, antioxidants, and microbiome modulators. Only articles published in English language were included.

RESULTS

The aforementioned ingredients exert additional biological effects to improve skin function by upregulating lipid synthesis, decreasing neurosensory transmission of itch signals, reversing oxidative stress, decreasing inflammatory cell activity and cytokine release, and modulating skin microbiota. The shift from traditional moisturizers to those with bioactive ingredients, anti-inflammatory agents, and microbiome modulating effects opens a realm of possible therapeutic options for patients with barrier-defective cutaneous conditions.

CONCLUSION

Focusing on the disrupted skin barrier as a target for both prevention and treatment and incorporating a combined strategy that utilizes the aforementioned agents to tackle barrier dysfunction from different angles remains a promising area for clinical impact in dermatology.

Mental health outcomes in White patients versus patients with skin of color with psoriasis

OBJECTIVE

To evaluate the relationship between psoriasis and mental health in patients from different racial backgrounds.

METHODS

We performed a nationwide, cross-sectional study evaluating 7,519,662 (weighted) patients, comparing White patients versus patients with skin of color (SOC), using the 2004-2017 Medical Expenditure Panel Survey (MEPS).

RESULTS

Psychological distress (measured by Kessler 6-Item Psychological Distress Scale) was similar between White and SOC patients (4.132 [95% CI,3.679-4.586] and 3.710 [95% CI,2.932-4.488], P=0.407). Depression (measured by Patient Health Questionnaire 2) was similar between White and SOC patients (0.886 [95% CI,0.744-1.027] and 0.748 [95% CI,0.506-0.989], P=0.385). Overall mental health (measured by Mental Component Summary) was similar between White and SOC patients (49.959 [95% CI,48.979-50.939] and 50.257 [95% CI,48.449-52.065], P=0.789). Perceived mental health state (measured by Perceived Mental Health Status) was similar between White and SOC patients (2.159 [95% CI,2.065-2.253] and 2.103 [95% CI,1.911-2.294], P=0.603).

CONCLUSION

There were no significant differences in mental health outcome scores between White and SOC patients with psoriasis. Clinicians should screen for and manage mental health comorbidities in psoriasis patients of all racial backgrounds.