May 2015 – Maui Derm

Presented by Guy Webster, MD, PhD

Written by Judy Seraphine, MSc

In this presentation at Maui Derm 2015, Dr Webster discusses the proper use of antibiotics, i.e., “antibiotic stewardship” and how the use of isotretinoin can help us avoid the use of antibiotics.

Dr Webster states that the philosophy of antibiotic use used to be “bacteria are bad, kill them all.” The yang of that philosophy, which we are beginning to appreciate more, is that bacteria are really a part of our personal ecosystem, whether on the skin or in the gut, and that if we mess with our own personal ecosystem, we may cause problems. There’s reasonable data showing that antibiotic use among children at a young age can lead to increased weight gain as they get older due to changes in their flora that become stable.

Remember that antimicrobials are in many soaps and personal products. In fact, 75% of adults have detectable levels of antimicrobials. Topical antibiotics are available over-the-counter and are not regulated (e.g., polymyxin, neomycin, bacitracin). Dr Webster feels that the big problem with antibiotic usage is in farming. The concept here is that antibiotics promote animal growth. The United States uses 29 tons of agricultural antibiotics per year. Resistant strains, as well as antibiotics themselves, can get into wastewater from livestock and poultry farms leading to a potentially altered microbial ecosystem as well as causing disease.

MRSA has also been seen in animals. Strain ST398 was a sensitive Euro human strain that crossed into animals. The use of tetracycline to increase hog weight gave birth to resistant ST398 variants, including MRSA. This strain is now recovered from human infection as well as supermarket beef and pork (30%) and shopping cart handles (10%). There is a clear crossover from the farm to the community. (Nature 499:398, 2013) Data suggest that 30% of farm workers using tetracycline feed have tetracycline-resistant MRSA nasal colonization. On the contrary, only 2% of workers from antibiotic-free farms carry nasal MRSA.

Dr Webster asks us to think about this question—in the face of ongoing agricultural abuses, will what we do with the use of antibiotics make a difference?

The dermatology specialty has a long history of profligate antibiotic usage and until recently, most dermatologists were not study-driven as many diseases are too rare to easily study. We also know that many diseases are said to respond to antibiotics; however, they are not infections (e.g. acne, rosacea, eczema, hidradinitis, bullous pemphigoid).

How do we decide how/when to use a long-term antibiotic?

Long-term antibiotic use is defensible when you are treating a real disease that could harm the patient and clearly responds to antibiotics, and there is nothing more sensible, safe, and/or affordable.

Granuloma annulare (GA) is a great example. There are case reports published in several journals supporting the long-term use of antibiotics for GA; however, recent studies have shown little benefit and this is probably something that we, as dermatologists, should stop doing.

Doxycycline is clearly effective for the treatment of mild-to-moderate bullous pemphigoid. It has demonstrated superior safety as compared to prednisone and may be given for years.

Reasonable evidence and randomized controlled trials support the use of doxycycline and minocycline for the treatment of acne. The use of cephalexin, azithromycin, penicillin, ampicillin, ciprofloxacin, and TMP/SXT is only supported by anecdote or smaller studies. While many dermatologists prefer personal experience over data, Dr Webster believes that we need to shift away from this and use what has shown to be effective in studies.

The duration of oral antibiotics for the treatment of acne has not been widely studied. Recent guidelines suggest that it should be limited to three to six months. A retrospective cohort study, published in 2014, found that the mean duration of use was 129 days and among the 31,634 courses, 57.8% did not use concomitant retinoid therapy. Although the duration of antibiotic usage is decreasing compared with previous data, some patients are still receiving them for longer periods than they probably need; thus increasing exposure and cost.

Data show that the use of topical retinoid plus an antibiotic is effective for the treatment of acne and after three months, if patients are on the topical retinoid alone, they tend to do as well as those patients who are on combination therapy or an antibiotic alone. The key is to utilize the retinoid from the beginning.

One concern for all clinicians is the development of resistant strains with the use of long-term antibiotics. Unlike the current beliefs about the long-term use of antimicrobial agents, one study found that the prolonged use of tetracycline antibiotics commonly used for acne treatment lowered the prevalence of colonization by S aureus and did not increase resistance to the tetracycline antibiotics. (Antibiotics, Acne, and Staphylococcus aureus Colonization Matthew Fanelli, MD, Eli Kupperman, BA, Ebbing Lautenbach, MD, MPH, Paul H. Edelstein, MD, and David J. Margolis, MD, PhD)

Minimizing Antibiotic Use

Besides giving an antibiotic with a retinoid, you need to consider patient fears, common sense, cost and adverse events. The UK is very concerned about resistance and they tend to use isotretinoin much faster.

Clinical Pearls

No topical monotherapy
- Add benzoyl peroxide to minimize resistance
Oral antibiotics should be given with a topical retinoid
- Allows for discontinuation of antibiotic after three months in most
Earlier switch to isotretinoin or spironolactone when antibiotic + retinoid fails

Isotretinoin Issues

Isotretinoin has been used for many years and, in fact, the longer we use it, the safer we have deemed it to be. Isotretinoin resistance can develop from inadequate dosing, virilization, being taken on an empty stomach, young patients with bad disease, and competing medications. Data show that a meal high in fat increases the absorption of isotretinoin.

Common adverse events (AEs) among patients taking isotretinoin include dry skin, dry lips, high triglycerides and acne flares. Uncommon AEs include elevated CK and elevated AST and ALT. Patients may also experience dry eyes, decreased night vision, depression, and acne fulminans, i.e., an eruption of bad acne in a patient who may have had relatively trivial acne.

Isotretinoin-induced acne fulminans is uncommon, but devastating. It is most often seen early in the treatment of patients, usually on too high of a dose, with moderate-to-severe chest acne. If someone presents with a few nodules on their chest, Dr Webster will often start them at 20mg/day of isotretinoin along with one month of prednisone 20mg/day.

Isotretinoin and bowel disease has become a worry. There have been scattered reports of patients flaring as well as scattered reports of safe usage. Retrospective studies have shown no link or a very weak link between IBD flares and isotretinoin usage. There may; however, be a link between acne and IBD and antibiotics and IBD. (J. Invest Derm 2012, doi:10.1038/jid.2012.387)

Many small studies, although not all adequate, have been conducted looking at the association between isotretinoin and bone mineral density (BMD). A recent study using DEXA found that there was no change from the beginning to the end of isotretinoin treatment in patients’ BMD.

Regarding depression, studies have shown that there are no differences in depression among teens taking isotretinoin versus antibiotics and that there is no greater risk of suicide in isotretinoin versus non-isotretinoin. But, there are always case reports where someone is on the drug and gets depressed, goes off the drug and gets better, then goes back on and gets depressed again. Those outliers probably have something real going on. Studies have been conducted looking at patients with bipolar disease. If you have a known bipolar teen whom you are looking to put on isotretinoin, you may want to consult with the psychiatrist.

Jeff Benabio, MD

In this presentation at Maui Derm 2015, Dr Benabio reviews some important issues around social media and medicine. Dr Benabio reminds us that there’s a general feeling of malaise among physicians. Why do we suppose there is such angst in healthcare? One reason to consider is that doctors are uncomfortable with the idea that they are being rated on the Internet.

There are several factors that have contributed to the changes we see in healthcare; these include the digitalization of healthcare, consumerism and healthcare reform. Social media is one of the main digital aspects of medicine. When we think about social media, try not to think just “FaceBook.” Social media a lot more—it is all of the tools that allow us to connect and share with other people.

It is important to remember is that it’s not just about the numbers. What we need to understand is why the numbers [of views/hits] can be so astronomically high and why that can be important in healthcare. The numbers are high because a. the information has essentially become free; b. we are wired to connect; and c. smartphones are ubiquitous. When we put all of this together, we see very different behaviors. We can see this in business and in healthcare. Consumers/Patients are acting differently because information is free and everyone can connect to everyone.

Economists have discussed the idea that we are reaching a state whereby consumers, i.e., patients have what’s referred to as “perfect information.” Patients now have almost “perfect information” about their disease, their hospital, their health plan, their doctor, etc. They can choose what they do about it. For us, as healthcare providers, we need to understand that this is where our patients are going to get their information. We need to know the information that’s out there, particularly the information about our practices and ourselves.

There are whole fields of study around what’s called ‘behavioral economics.’ Studies are looking at how consumers behave in certain situations. This is the same thing in healthcare, i.e., how patients behave when they have information that they didn’t have before. Consumers used to choose products based on a. prior information; b. other opinions; and c. marketing. Today, things are fundamentally different. Prior experience is no longer perfect; in fact, consumers are nowhere near as loyal to brands as they used to be. Your prior experience is not nearly as informative as other people’s opinions. We can begin to question whether we know what’s right or whether the crowd knows what’s right. We, as consumers, truly believe that other people have good information. Marketing, today, is much easier to ignore.

If we consider healthcare, a recent study showed that 62% of consumers/patients have used online reviews to learn about doctors and this number is continuing to grow. There are websites, such as healthgrades, that provide very good information. The whole purpose of healthgrades is to provide accurate information to consumers about their healthcare choices. Healthgrades retrieves their information from quality metrics and national service metrics. In a few years, your data may be publicly reported as they are already doing that now with hospitals and consumers love it.

While consumers like healthgrades, they trust Yelp more than any other review site. As physicians, that may be a hard pill to swallow. Consumers use Yelp for other decisions with very good accuracy. A 2014 paper by Hanauer and colleagues surveyed patients regarding physician-rating sites. They found that 40% of patients say online reviews are very important and 35% of patients selected a physician based on a positive review. Additionally, 37% of patients avoided a physician with negative reviews.

Doctors are very concerned with how these reviews are filtered. Do you have to pay for advertising in order to obtain positive reviews? Dr Benabio has done some research on this question. A recent study, using regression analyses, looked at correlations between whether physicians had paid for advertising or not and whether that had any impact on if Yelp filtered the review. It turns out that the factors that were significant were having either a one-star or five-star review. Whether or not you were a Yelp advertiser or not did not make a difference.

For the most part, our patients love us. The average score for a doctor is 9.3 out of 10. Patients are interested in wait times, billing/payment, staff friendliness, ease of scheduling, and office environment/cleanliness.

Consumers of all types use Google. Eighty-six percent of patients Google their symptoms before they see a doctor. Google is running “pilot” physician consultations with patients when they search for healthcare-related topics. Consumers are realizing that they can get point-of-question care live from platforms like Google. HealthTap is another site that is aggressively recruiting physicians to participate in point-of-question care. HealthTap is connecting these questions with patients to enable them to do live video visits with a doctor. Doctors are now doing house calls again…they are meeting patients wherever they are. This is a normal expectation for consumers.

Another site, Iodine, allows patients to input their medications and then provides them with perfect information from other patients’ ratings on that prescription/product. Real Self is a similar platform for cosmetics. Today’s patients want transparency. A Deloitte study found three out of four consumers believe providers should publish quality of care information on the Internet. Two out of three patients believe that providers should publish their prices online.

Other Social Media Sites

Twitter is technically a microblog. It’s a way to say “what are you doing?” It’s a powerful tool to share information and report news. About one in four physicians use social media daily, mostly for keeping up with healthcare news. Plastic surgeons tend to lead with 50% of them using Twitter. Virtually all surveys of physicians who use social media say that it has a positive effect, i.e., it increases patient engagement, improves care delivery and patients are more satisfied. Doctors also feel more connected to patients and peers and it is a great tool for education.

Doximity is a social networking site for doctors. It allows you to take topics from a journal and engage in a conversation with your colleagues. Doximity also has very interesting crowd-source data.

What about Instagram? Instagram is a photo application that tends to be very much in the moment. There are 150 million active users and it’s the most popular social media site for teenagers.

How does social media affect healthcare usage? The American Academy of Facial Plastic and Reconstructive Surgery conducted a poll and found that one in three respondents in a survey pool of 2700 of its members said that they had seen an increase of procedure requests as a result of patients’ social media awareness.

In the last few years, FaceBook has gone public and as a result, they are now filtering posts. This is trying to drive you towards paying for advertising. As it turns out, people respond better to ads than they do random posts.

Summary

In conclusion, we need to recognize that the future of dermatology and healthcare is digital. As physicians, we needn’t use all of the existing social media sites but we must understand social media as it is changing what it means to be a patient. Sincerity and commitment to our patients is “always in.”

MauiDerm News Editor-Judy L. Seraphine, MSc