Dermatologists Urged to Combat Medical Overuse

By Marilynn Larkin

November 04, 2019

NEW YORK (Reuters Health) - Dermatologists can reduce medical overuse and mitigate patient morbidity from unnecessary interventions through evidence-based practices, a systematic review reveals.

"This review highlights recent publications in dermatology that call into question the utility of some common practices," Dr. Arash Mostaghimi of Brigham and Women's Hospital in Boston told Reuters Health by email. "Our hope is that it encourages physicians to reevaluate their practices to make sure that their decisions incorporate the latest data in the field."

Some of the studies still need to be replicated, he said. But "the data around the impact of early dermatology consultation to reduce misdiagnosis of cellulitis ( and around reducing rates of re-excision of atypical moles are robust and should be incorporated into guidelines," he continued. "Adopting these practices will reduce unnecessary treatments for patients which are costly and may be harmful."

As reported online October 23 in JAMA Dermatology, Dr. Mostaghimi and colleagues searched the PubMed and Embase databases as well as articles published in eight major dermatology and medical journals from 2017-2018, and identified 38 studies relevant to medical overuse in dermatology. After expert reviewer scoring, 10 articles were selected for analysis based on highest scores and greatest clinical significance.

Selected articles covered topics such as consultation for cellulitis, management of dysplastic nevi, prognostic utility of sentinel lymph node biopsy, laboratory monitoring for terbinafine and isotretinoin, and safe prescribing.

The analyses determined that for cellulitis management, a dermatology consultation is important for reducing misdiagnosis, unnecessary hospitalization, and inappropriate use of antibiotics.

Findings related to common dermatologic procedures demonstrated that clinical observation is safe for dysplastic nevi and that sentinel lymph node biopsy may not have prognostic utility over Breslow thickness.

When monitoring for terbinafine and isotretinoin, patient education about clinical symptoms is likely more effective than standard laboratory test result monitoring.

Further, dermatologists should reconsider the use of cyclosporine in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis, because it may not be superior to supportive care alone and may be nephrotoxic.

Dermatologists should also reevaluate the use of perioperative narcotics, the authors advise.

They state, "This work may help to facilitate management changes to emphasize high-value care in dermatology while promoting awareness and further evaluation of overuse in medicine."

Dr. Mostaghimi added, "In general, physicians are always incorporating new data into their practice to improve patient care. That said, change is always difficult, and it can be challenging to rethink approaches to common problems. Each of the studies included in this review have specific strengths and weaknesses and are not necessarily generalizable to all populations. Physicians will help interpret these findings and determine how best to apply them in clinical settings."

Dr. Adam Friedman, Professor and Interim Chair of Dermatology, Residency Program Director and Director of the Supportive Oncodermatology Clinic at George Washington School of Medicine and Health Science in Washington, DC, commented by email, "This pointed review underscores the 'practice' of medicine. While we are creatures of habit, often adopting practices passed down to us during our training, it is imperative to challenge dogma through clinical or bench investigations in order to either validate established methods or redirect to more meaningful and evidence-based approaches."

"The areas of interest in this study have been hot topics in dermatology for some time now," he told Reuters Health. "They range from the imaginary bilateral cellulitis, which can be appropriately diagnosed by a dermatology consult service as a noninfectious process such as stasis dermatitis, or what appears to be overzealous lab monitoring of patients on either isotretinoin or terbinafine."

"A word of caution when pushing a paradigm shift: don't be a one-study wonder, meaning often several well structured investigations are needed to truly identify a gap in care warranting change," he said. "The authors in essence collated this for the dermatology community, for which we owe some thanks."

"As a practical aside, I have observed that adopting change is often slow," he noted. "For example, there have been several studies chronicling that even after acne treatment guidelines were released on the appropriate use of oral antibiotics (three months at a time), many dermatologists still prescribed for months at a time, well beyond this mark."

"I have considered and applied many of the considerations proposed (in the study), and pass these on to my residents in hopes of disseminating these changes to our daily practice," Dr. Friedman said. "I implore everyone in dermatology to utilize the various resources to stay on top of the literature in order to do the same."


JAMA Dermatol 2019.