AAD issues Choosing Wisely recommendations

The American Academy of Dermatology has joined the Choosing Wisely campaign, recently releasing its list of five specific tests or procedures that are commonly performed but are not always necessary and might even cause harm. The AAD is among more than 60 (and soon to be some 80) physician organizations participating in the campaign, which aims to encourage dialogue between patients and their doctors.

Dermatologists need to know what’s on the list because patients will likely inquire about what’s on it, according to Brett M. Coldiron, M.D., AAD president-elect.

The AAD’s list of “Five Things Physicians and Patients Should Question” are:

1.              Don’t prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection.

2.              Don’t perform sentinel lymph node biopsy or other diagnostic tests for the evaluation of early, thin melanoma because they do not improve survival.

3.              Don’t treat uncomplicated, nonmelanoma skin cancer less than 1 cm in size on the trunk and extremities with Mohs micrographic surgery.

4.              Don’t use oral antibiotics for treatment of atopic dermatitis unless there is clinical evidence of infection.

5.              Don’t routinely use topical antibiotics on a surgical wound.

The rationale and studies used to create the list are posted at ChoosingWisely.org.

What is Choosing Wisely?

Launched in 2012, Choosing Wisely is an initiative of the ABIM Foundation. Each of the medical societies participating creates and submits one or more evidence-based lists of five “things physicians and patients should question.”

To help get the word out, Consumer Reports is developing and distributing educational patient information based on the lists. The goal is to improve patient-doctor communication and, ultimately, the quality and cost-effectiveness of healthcare. The campaign’s goal is not to influence coverage decisions or exclusions; nor is it to govern physicians’ decisions, according to ChoosingWisely.org.

Deciding on the big five

Dr. Coldiron says the process for developing the Choosing Wisely list involved creating a committee with representation from all AAD’s major taskforces and workgroups, including those groups that develop guidelines. The committee searched the literature, met on conference calls and whittled the list to the five items the committee believed were most supported by literature, would reduce morbidity and save money.

The recommendations are meant to influence - not govern - dermatology practice.

“No two of us practice exactly alike,” says Lisa Garner, M.D., AAD vice president and a dermatologist practicing in Garland, Texas. “(But) if you are doing something that is listed here … it should make you think and consider why you’ve chosen this particular route of care for the patient.”

Some dermatologists, for example, may feel very strongly about using topical antibiotics on certain patients with surgical wounds, Dr. Coldiron says.

“There are some patients who aren’t necessarily the cleanest and (dermatologists are) worried their wounds might get infected,” he says. “… But I don’t think they should do it routinely.”

Dermatologists might also disagree with the recommendation concerning oral antibiotics and atopic dermatitis.

“A lot of the dermatologists think the antibiotic is anti-inflammatory … but we think the risks of a drug reaction or drug resistance is greater than (any benefit),” Dr. Coldiron says. “A patient is not going to know when their atopic dermatitis appears clinically infected. But the doctor knows. So, that (recommendation) is really aimed at the doctor.”

Still, the recommendations make clinical sense. The Mohs recommendation, for example, is straight out of the appropriate use criteria, Dr. Coldiron says.

In agreement

There are things on the list most clinicians will agree with, Dr. Garner says.

“I stopped using topical antibiotics on my biopsies and small excisions many years ago. There are areas where you do a procedure where the risk of infection is much higher, so I think there certainly are exceptions. There are things that have to be taken into consideration: The patient’s overall health. Is that patient immunosuppressed? Where is the location of the procedure?” Dr. Garner says.

Julie Hodge, M.D., a dermatologist in Fullerton, Calif., and assistant clinical professor at University of California, Irvine, says she agrees, for the most part, with the AAD’s Choosing Wisely list. She, too, stopped routinely using topical antibiotics on surgical wounds about 10 years ago.

“I just use Aquaphor (Beiersdorf), and I’ve found it to be wonderful. It’s more cost-effective, and I don’t see any allergic reactions anymore to the antibiotic preparations, which I used to use fairly routinely. And I see no change in infection rates at all,” Dr. Hodge says.

Dr. Hodge says she agrees with the recommendation not to treat uncomplicated, nonmelanoma skin cancer less than 1 cm in size on the trunk and extremities.

“I never recommend Mohs surgery on the trunk or extremities,” Dr. Hodge says. “I find the extra couple of millimeters of margins to clear the wound is very easy to do, doesn’t affect the closure, changes the scarring very little and changes the outcome very little. I think I’ve had one positive margin in the last five years.”

While she thinks there might be controversy among dermatologists with the sentinel node recommendation, she agrees with it.

“I think the data is pretty clear that (sentinel node biopsy) doesn’t improve survival. But some people feel that they sort of want to have all the information, and it might impact whether or not you treat a patient with something like interferon,” Dr. Hodge says. “The trouble is we can’t prove - at least on a study or a statistical basis - that sentinel node biopsy makes a difference in survival, but anecdotally I think that some people that may disagree.”

And although Dr. Hodge says she agrees with the recommendation not to prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection, she says that one could be hard for some to follow.

“Scrapings are technique-dependent and not everyone has access to dermatophyte cultures, but I agree with carefully evaluating the need to treat thickened toenails,” she says.

A ‘positive move’

Dr. Coldiron says the AAD’s decision to participate is a positive move for the specialty and patients. Choosing Wisely, he says, empowers patients.

“The whole movement here is from paternalistic doctor-directed care to patients starting to accept responsibility for their own care,” he says. “This is a good thing. These recommendations will improve the quality of care you deliver. They’ll decrease the number of complications you get. They will enhance patient care, save patients money, and they’ll open a bridge of dialogue between you and your patients.”