“Apply to Affected Area BID x 2 Weeks Then PRN”

I’ll bet that everyone reading this article has written a prescription for a topical steroid with these instructions on it this week.

The reality is that a generic topical treatment may simply not be the best option for many patients. Yet we are often forced into step therapy by payers—so-called nonmedical switching. At the same time, we may also forget that often our own medical decision-making inherently includes step therapy that is taught to us in medical school training under the guise of protecting patients from financial toxicity; in these ways step therapy has become ingrained into the management of our patients.

As dermatologists, we have the primary goal of providing optimal care for our patients, which includes ensuring they receive the most effective treatment as quickly as possible. Step therapy, a process in which patients are required to try to fail on less expensive or preferred treatments before accessing more costly or second-tier options, can delay the delivery of appropriate care and potentially worsen patients’ conditions.

Delaying effective treatment can prolong patients’ suffering, causing physical pain; psychological distress; and, most importantly, a decreased quality of life. Skin conditions like psoriasis, eczema, hidradenitis suppurativa, and acne can have significant impacts on mental health and self-esteem, making timely treatment crucial for overall well-being. If left untreated or undertreated, dermatological disease can worsen over time. For instance, psoriasis may progress, leading to complications like joint damage from psoriatic arthritis. Similarly, chronic conditions like atopic dermatitis can be debilitating for patients with long-term sequelae that are more difficult to manage if not treated early.

We all know from our clinical practices that patients are most likely to adhere to recommended treatments when they are started on the most appropriate and effective therapies. Patients are more likely to adhere to a treatment regimen that produces noticeable improvements in their condition with tolerable adverse effect profiles. In contrast, if patients experience little to no improvement due to an ineffective treatment, they may become discouraged and less adherent to subsequent treatment recommendations and follow-up visits. To use a baseball analogy, while for some patients a trial-and-error approach may be tolerable with 3 strikes or treatment attempts, there are many others for whom after 1 strike the treating physician will be immediately “out” and off their therapeutic team.

Dermatologists and national dermatology organizations such as the American Academy of Dermatology have been champions in fighting step therapy mandates across the country. At its core, step therapy legislation that endeavors to be cost-effective by controlling first-line health care costs may have the unintended consequences of delaying effective treatment, which leads to increased health care utilization in the long run and patient suffering through the entire episode of care. As dermatologists, we have a duty to act in the best interests of our patients and to align the cost of care with a holistic understanding for the benefits that this care brings to patients; myopic cost-benefit analyses that look only at list prices and survival outcomes and don’t take into consideration patient assistance programs and broader metrics inclusive of patient well-being are not appropriate for the range of impactful skin disease that we treat as dermatologists.

Another less often discussed aspect of nonmedical switching is that in our busy practice settings with already high administrative burdens, it is admittedly less time-consuming to write a prescription for generic topical medications or other first-line modalities that sail through insurance review. However, to truly advocate for our patients with impactful skin disease, it is our duty to understand our patients’ perspective on the value of available treatments and to work collaboratively to ensure access to the most effective treatments through anti–step therapy initiatives, patient access, and compassionate care programs. To provide high-quality dermatology care, we must become stalwart advocates for our patients and resist nonmedical switching and our own training pathways that may have promoted rote prescriptions for twice-a-day topical applications for every patient when for many conditions there are now more effective therapeutic options available.

Subjecting patients to a trial-and-error process of ineffective treatments solely based on cost considerations directly conflicts with our broader ethical obligations as physicians. Opting for the most appropriate treatment from the outset aligns with the principle of beneficence and prioritizing patients’ well-being. For dermatologists, prioritizing timely access to the most effective treatments for our patients not only promotes better health outcomes and patient satisfaction but also upholds the ethical principles of our profession. Avoiding step therapy and opting for the correct treatments sooner can lead to improved patient care, reduced disease burden, and more truly cost-effective health care.

Aaron Farberg, MD, FAAD, is a double board-certified dermatologist, a Mohs surgeon, and chief medical officer at Bare Dermatology in Dallas, Texas. He joined the Dermatology Times Editorial Advisory Board in March 2023 and is currently serving as spring editor in chief.