A clinician’s opinion on ineffective dermatologic therapies

Over the decades, many highly useful treatment modalities have been developed which have greatly improved the lives of our patients. However, many additional therapies with questionable usefulness have also become part of our treatment armamentarium.

Unfortunately, once a “treatment advance” is described in the literature, or is mentioned by a person of authority at a medical meeting or in an online forum, it takes on a life of its own, independent of the subsequent experience of many others, and often after published refutations of the original claim. Review articles and textbooks often perpetuate this by failing to critically assess the data before simply noting that a treatment is an option for a given skin condition.

As a small step toward rectifying many years of ineffective management strategies, I will discuss a few of these “unhelpful” modalities. Admittedly, my conclusions are highly biased by my years as a clinician and by what I read in the literature.

Systemic antibiotics for pityriasis lichenoides and hidradenitis suppurativa: As a specialty, we dermatologists are one of the biggest abusers of systemic antibiotics. By using these drugs for conditions other than infections, we have contributed to the general loss of effectiveness of these medications for the diseases for which they were developed, namely infections.

Since there has been somewhat of a consensus that there are no good options for hidradenitis suppurativa and pityriasis lichenoides and since tetracycline derivatives are quite safe (although no longer inexpensive), they are often used as first-line treatment. Aside from my personal negative experience with the use of these drugs for these indications, there is only scant published data to support this form of treatment.

In my view, hidradenitis suppurativa is basically a surgically correctable condition which requires excisions whenever possible for the best outcome. Pityriasis lichenoides responds extremely well to low dose methotrexate, a safe and inexpensive alternative.

Topical metronidazole for rosacea: After careful review, the Food and Drug Administration approved topical metronidazole for rosacea and it is now the mainstay of therapy for this common dermatosis. I would love to be in a room full of dermatologists and see a show of hands of those who believe that this agent is anything other than of marginal clinical benefit for active disease. 

There is data that suggests that once a patient achieves a remission by some other means, topical metronidazole may help to maintain the improvement. Perhaps we should prescribe this drug only after the patient has gotten better by other means.

Topical corticosteroids for miscellaneous itchy dermatoses: We used to teach our dermatology residents that if the word “dermatitis” or “eczema” is not a part of the diagnosis, topical corticosteroids are not particularly helpful. This would include such conditions as generalized pruritus, sunburn, insect bite reactions, granuloma annulare, necrobiosis lipoidica, pityriasis rosea, cutaneous sarcoidosis, and discoid lupus erythematosus. 

A few of the papulosquamous diseases - namely psoriasis and lichen planus - may respond to topical corticosteroids but the most potent preparations are often needed to see substantial improvement.

Prophylactic antibiotics: Many physicians choose to use prophylactic antibiotics after extensive skin surgery, particularly in those who are immunosuppressed. I suppose that the rationale for this is that bacteria that have colonized the wound will not progress to an actual infection since the antibiotics “cover” them.

In fact, there is a 50-year clinical and published research experience that refutes this notion. Not only do prophylactic antibiotics not prevent infections, but the drugs may also cause selection of resistant organisms if the wound does become clinically infected. If you are concerned about infections, a more prudent approach might be to culture the wound and base your therapeutic decision on the results of that laboratory test.

Pentoxiphylline (Trental, Aventis) for anything: Some years ago, several authoritative voices in dermatology touted the benefits of this medication for such diverse dermatoses as pityriasis lichenoides, livedoid vasculitis, benign pigmented purpura, necrobiosis lipoidica, Raynaud phenomenon, and generalized granuloma annulare.

Case reports describe success with pentoxiphylline and recommend it as a safe and relatively inexpensive alternative. However, do not try to find any controlled clinical trials to support its effectiveness, since, as far as I can discern, there are none. My personal experience is that the drug has never benefitted any of my patients with any dermatosis. Perhaps your experience is different.

In this age of evidence-based medicine, we owe it to our patients to use therapies with an established track record of success. We can no longer afford the luxury of treating based on anecdotes. Our specialty must maintain high scientific standards to remain viable as a serious discipline. We all can contribute to this by carefully evaluating the therapies that we select.