Day 2: Highlights

Friday, February 10, 2017

Acne Therapies

James Del Rosso, DO

New acne therapies are proving to be efficacious among all types of patients. An emergence of adult women with acne are coming into dermatology offices nationwide and it has caused providers to realize that there are few clinical trials studying this subset of acne patients. However, even with the lack of evidence-based data, physicians are finding that using similar treatments in their adult males and females, as they would typically use for their adolescents, is just as effective. New therapies such as EpiDuo (adapalene 0.1% and benzoyl peroxide 2.5%), EpiDuo Forte (adapalene 0.3% and benzoyl peroxide 2.5%), Aczone (dapsone gel 7.5% or dapsone 5% gel), ONEXTON (clindamycin phosphate 1.2% and benzoyl peroxide 3.75% gel), Veltin (clindamycin phosphate 1.2% and tretinoin gel .025%), and Ziana (clindamycin 1% and tretinoin 0.025% gel) are all newer topical acne medications that are working well for patients. One factor to always consider when choosing an acne therapy is the severity of the patient’s acne. If the patient’s acne is mild to moderate, prescribing stronger medications may not necessarily be more effective. Other important details have been discovered with Aczone. Once daily application of Aczone 7.5% gel has nearly no systemic absorption and is even less than the twice daily 5% Aczone gel formulation. This is important to tell your patients who are skeptical about starting an acne therapy. When evaluating patients using Aczone, the Investigator Global Assessment (IGA) is a better way to evaluate improvement rather than performing individual lesion counts. With ONEXTON, patients are noticing time of onset (about a 25% reduction in acne) at an average of 2-3 weeks. 

Antibiotics are a long-standing therapy used for acne and the therapies used today are similar to what has been used for years. The two most common oral antibiotics prescribed are doxycycline and minocycline. The main concern with using these medications is antibiotic resistance. Oral antibiotics can cause generalized resistance, and topical antibiotics provide an easy way to transfer the resistance to not only the treatment area, but to other areas on the body via the hands. Using topical benzoyl peroxide is a must when using antibiotics and will decrease the risk of resistance. Other side effects to using these medications are gastrointestinal upset and esophagitis. Newer formulations with an enteric coating have lessened these effects. It is imperative to be aware of the duration of therapy when refilling prescriptions for oral antibiotics. It is well known that using oral antibiotics for less than six months is ideal, however studies have shown that many providers are leaving their patients on these medications for longer than 12 months. Remember that if your patient is not improving, do not be afraid to move on to oral isotretinoin for better control.

Light and Laser Devices for Acne

David Goldberg, MD, JD

Acne is a disorder that is normal at any age. It affects 80 percent of the population and is responsible for 30 percent of complaints in dermatological patients. Energy based devices can provide a great alternative for treating acne, because they do not require patient adherence or systemic medications, and most importantly, they work. 

There are many different types of energy based devices. Intense Pulsed Light (IPL) photoactivates porphyrins to destroy Propionibacterium acnes (P. acnes) and sebaceous glands. It is excellent for treating both inflammatory and noninflammatory acne. Newer modalities have suction assisted needle IPL to “clean out” comedonal acne by removing sebum. Also, there are multiple colored Broad Band Lights (BBL) which use a mixture of blue, yellow, and infra-red light. Infrared Lasers (IR) work by a different mechanism and target water to penetrate deeper into the dermis and destroy sebaceous glands. The advantage of this laser, unlike IPL, is that it is safer in darker skin types. Another modality, Pulsed Dye Laser (PDL) at 595nm, has typically been used for vascular lesions, but so far has not had very efficacious results. Potassium titanyl phosphate laser (KTP) has traditionally been used for rosacea and telangiectasia and may be useful for acne. Photodynamic therapy (PDT) is currently the best way to treat acne and works by activating protoporphyrin IX. Fractional lasers work well for acne scarring as well as acne. Radiofrequency (RF), which can be used with micro-needling to enhance its efficacy, produces thermal energy and coagulates sebaceous glands. 

Newer energy devices utilize metallic nanoparticles. They have promising results thus far and are very well tolerated, but have not yet been approved. These devices use gold or silver nanoparticles which are placed into the sebaceous unit to act as chromophores. Therefore, when laser or light heats the particle, it destroys the sebaceous gland and has shown to reduce inflammatory lesions by 61%. Silver nanoparticles offer an advantage because they can be activated by different types of hair removal lasers and are absorbed 4 times better than gold. This technology may provide not only treatment for acne, but also for the termination of white or light colored hair.

Low level light therapy (LLLT) is another alternative used for acne therapy. Because it does not have any heat effects, it does not cause any discomfort to the patient. It can reduce inflammation, decrease the amount of P. acnes, and slow the proliferation of keratinocytes in patients of all skin types. Types of light used are blue light, which is antimicrobial, and red light, which is antimicrobial and anti-inflammatory. These two lights can be used separately or together. Studies using LLLT led to the development of at-home light masks which are sold over the counter in many drug stores. In conclusion, energy-based devices are effective and provide an alternative to systemic treatment, do not require patient adherence, and have little adverse effects.

Isotretinoin Update

Guy Webster, MD, PhD

When it comes to prescribing oral isotretinoin, confusion regarding the best formulation and dosage are widespread among dermatologists. In the past, when prescribing isotretinoin, providers were skeptical about whether the generic version was as effective as the brand name preparation. After reviewing many clinical studies, most failed to demonstrate a disadvantage to using generic versions. In regards to dosage, whether a higher dosage (290 mg/kg) is more effective than traditional dosing (120 mg/kg) remains controversial. Some argue that patients experience less relapse with higher dosages versus lower dosages; however, clinical studies have failed to demonstrate this. 

Higher dosing may come with a greater risk of side effects, which is a typically a major concern of most patients and/or patient guardians, even at standard dosing. The more common side effects seen when using oral isotretinoin are dry skin, dry lips, acne flares, and elevated levels of triglycerides. Some uncommon adverse effects are elevated creatine kinase (CK), elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT), dry eyes, decreased night vision, depression, and acne fulminans. Acne fulminans is an uncommon but devastating side effect and is most often seen early in therapy with patients having moderate to severe chest acne. This incident can easily be misinterpreted as the patient not responding and needing a higher dosage of isotretinoin, but this is the worst thing that can be done. When this occurs, the dose should be lowered and oral prednisone prescribed. Therefore, it always needs to be in the differential when seeing a patient worsen on isotretinoin. 

In the past, there has been controversy regarding isotretinoin and its link to inflammatory bowel disease (IBD). There have been scattered reports showing flaring of IBD when starting isotretinoin; however, further studies have proven this link to be false and this should be explained to patients. There have also been studies demonstrating a possible link between isotretinoin and decreased bone turnover, but with proper well-controlled clinical trials, this has also failed to be proven. 

Other claims, such as isotretinoin causing depression, has been seen in a limited number of case reports. Researchers now know that this medication can cause mood changes, but the extent of the previous claim has not been proven. When drawing routine labs for patients taking isotretinoin, AST, ALT, gamma glutamyl transpeptidase (GGT), CK, lipids, and complete blood cell count (CBC) are commonly requested. Data has shown that it may be more useful to only check GGT instead of AST and ALT to get a more accurate representation of isotretinoin’s effect on the liver. Also, ordering CK levels are important to check if there is any damage occurring to the muscle. These levels can be elevated, especially in boys, and should be factored into determining the proper dosage. Waiting to start isotretinoin until after the sport season and/or modifying the dose may be necessary to reduce CK elevations and the risk of rhabdomyolysis. 

Lastly, it is well known that a high-fat meal enhances the absorption of isotretinoin, but the amount of fat truly necessary is not conducive to a healthy diet. Newer formulations have been created to provide almost the same amount of absorption whether the patient is fed or fasting.

American Academy of Dermatology Update

Abel Torres, MD, JD

The American Academy of Dermatology (AAD) is growing each year and currently has 18,000 members. During this lecture, Abel Torres, MD, explained how the AAD is advocating for change and solving many of the current issues faced in clinical practice. 

Updates and analysis on changes during the beginning of Mr. Trump’s presidency and how they affect the specialty of dermatology can be found on the first “100 days” blog online. The AAD leadership has been working on improving access to treatment. The 21st Century Cures Act, recently passed in December of 2016, supports medical innovation and patient access to new drugs. 

The academy is working with many providers on step therapy, which assists with getting prior authorizations approved. In January of 2017, 35 percent of patients lost coverage for Cosentyx, Enbrel, and Otezla. The AAD has urged reconsideration of this policy so that patients already on these medications can be “grandfathered” in and continue receiving insurance coverage. 

In addition, the AAD has led the fight on Narrow Networks bringing their concern to Congress along with federal and state regulators. The AAD has started the new practice management center to ease the stress on dermatologists and their staff members. This should help to lessen the burden of prior authorizations. 

DataDerm is a system that collects data from dermatologists nationwide and is helping to create guidelines and appropriate use criteria. The Burden of Skin Disease, an article to be published in the spring 2017 issue of the Journal of the American Academy of Dermatology (JAAD), shows this practical application of scientific data. 

Furthermore, the AAD is committed to education and offered more than 500 CME credits in 2015, many of which were free to members. In February 2016, they implemented a question-of-the-week which will award 0.25 CME credits to participants. The academy wants to advocate that dermatologists treat a lot of serious disease, not just skin cancer. Multiple media campaigns by the AAD continue to encourage limiting sun exposure and keeping your skin healthy. Screening programs have provided 2.5 million screenings since 1985 and 28,590 suspected melanomas have been found. Camp Discovery continues to allow several children in the United States with serious skin conditions to be able to interact with others like them.

How to Deal with Large Deductibles

David Wagener, MBA, CPA

In dealing with large deductibles, the challenge is clear. In addition to visit-based copays, patients’ insurance typically carries a sizeable deductible. Making patient collections is a business’s critical function, and failing to do so can spell disaster. 

The revenue cycle begins before the patient even arrives in the office. Financial clearance can be achieved prior to the patient visit – request registration information from the incoming patient that is sufficient to verify insurance coverage. The key principle is ‘Refer patients to their insurance carrier for explanation of their coverage and financial responsibility’ – it is not your job or your staff’s job to do so. Patients need to understand that their payment is due immediately after services are rendered. Office staff should call the number on the back of the patient’s insurance card for explanation of their benefits and coverage.

Another strategy is to collect all money, including the copay, unmet deductibles, prior balances, and deposits (a lot of offices collect deposits for cosmetic procedures), at the time of service. It should not be overlooked that Point of Service collections can be stressful on all concerned – should the physician pause and ask the patient to agree to the out-of-pocket cost before initiating routine services such as biopsies and destructions? The answer is not clear, but the speaker, David Wagener, MBA, CPA, suggests collecting copays before the visits and trying to collect deductibles, but he also notes that physicians should practice and perform procedures they deem medically necessary. 

Training employees on how to collect is critical – greet each patient warmly by name, provide eye contact, and state the balance as a fact and avoid implying it is an estimate or a negotiable amount. However, employees need to be sensitive to avoid others overhearing amounts due. Instead of asking, “Would you like to pay?” instead ask, “How would you like to take care of the balance today?” 

Offices need to be ready for refunds. Over-collecting on accounts occurs which may be due to wrong information from insurance companies regarding billing/claims. It is important to promptly refund material amounts, and it is in office’s best interest to enclose a note thanking the patient – this is an opportunity to say something pleasant to the patient. 

Knowledge is power – determine expected patient responsibility as early in the revenue cycle as possible. Patients may act shocked, but they should not be – refer them to their plans regarding questions about their coverage. What patients owe is not up for debate, but training employees is key.