High costs cited as major reason patients do not adhere to their treatments

Has anybody seen the changes in the cost of medications lately? In case you have not noticed, they have soared completely out of control. For example, a bottle of 100 doxycycline capsules used to cost about $4. Today that same bottle is well over $100.  Patients are faced with high copayments for their medications, which is leading to problems of affordability.

Physicians need to play their part too. All to often I see physicians prescribing expensive medications when a suitable generic alternative is available at a fraction of the cost.

Here are my simple recommendations:

Over-the-counter topical medications:

  • Differin Gel 1% — In 2017 this went over the counter. It is great for unclogging pores. There is no reason to get tretinoin (Retin A) or any other topical retinoid before using this for several months. The average cost is $18
  • Benzoyl Peroxide 2.5% – 5% gel–this is great at killing the bacteria that causes acne. in fact, there is nothing better.  This medication will bleach clothes and sheets so be careful. The average cost is about $5-10.
  • Benzoyl Peroxide 10% wash–this works well for acne on the back, chest, and shoulders. Use this once or twice day to these areas in the shower. Use towels that you do not like as they will get discolored.
  • Salicylic Acid–there are many preparations for this which helps to unclog the pores. It does not work nearly as well as Differin, but it can be used in addition to it.
  • Glycolic Acid–there are many preparation for this which also helps to unclog the pores. Some preparation combine this with salicylic acid. The two together work very well, but still not as well as Differin gel.

Always ask  your doctor if one of these above options will be suitable, as they will be FAR cheaper than prescription medications.

Those with deep seated cysts will require oral medications, which are available by prescription only.

Always request generic medications. You can always price them out on goodrx.com and get coupons with that site. For medications that are not covered, try to find one that is covered. In most cases, this insurance carrier is telling you that there is a cheaper alternative that can be prescribed. If you are paying for the medication or have a high copay for it, shop around.

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The Acne One-Two Punch–the best over-the-counter treatment

Finally, patients are able to self-treat mild to moderate inflammatory and comedonal acne with over-the-counter treatments.

Blackheads and whiteheads can now be treated effectively with Differin gel, which went over-the-counter earlier this year. This medication is similar to Retin A, the drug everyone knows about. These medications help to unclog pores are and more effective than any other over-the-counter medication.

Inflammatory lesions, such as red bumps and pustules, can be treated using a 5% benzoyl peroxide gel (use 5% or less as higher concentrations result in more skin irritation).

I do not recommend spot treating as acne is a chronic disease, so the idea is to treat the lesions that one has, but we also want to prevent new lesions from coming up.

Those with cystic or very inflammatory lesions will benefit from oral antibiotics and/or Accutane, both of which require a prescription.

Those with scarring should seek professional advice from a board-certified Dermatologist as soon as possible.

Choose the BEST Mohs’ Surgeon

According to a recent study, there is great variation from one Mohs’ surgeon to another when having Mohs’ surgery. In this study, they found that the mean number of stages per case was 1.47 (range, 1.09-4.11). The variation in range is huge!!! Thirty-five percent of surgeons were persistent outliers (performed more stages than the mean) in all three years of this study. Physicians in solo practice had a 2.35-times likelihood of a persistent high outlier status (OR = 2.35; 95% CI, 1.25-4.35). Now this does not make sense! Think about it, often the most difficult cases are referred to tertiary care centers (academic institutions), yet they were more likely to clear a patient in fewer stages.

Why the great variation? In an academic center, there are residents and fellows assisting on cases. What does that mean for patients? There is less risk for “funny business”–surgeons intentionally taking smaller pieces so that they they will require more stages (in a fee-for-service model, the surgeon is paid for each stage taken).

In my practice, approximately 80% of patients are cleared within the first stage. This falls well within the mean average of 1.47 average stages per patient. Unfortunately, many surgeons fall outside of this mean. This increases cost, may adversely affect cosmetic outcome, increases surgical time for patients, and may lead to increased patient discomfort as additional anesthetic may be needed.

How do you choose a Mohs’ surgeon? That is a difficult question. According to this study, a Mohs’ surgeon in Private Practice is more likely to perform more layers than is necessary than a surgeon who is a full-time academic surgeon. That being said, I know of great surgeons who are in private practice and many who rarely clear a patient in one stage. In fact, some of the best surgeons are in private practice.

What do I recommend? When choosing a Mohs’ Surgeon, one must be more cautious when choosing one who is in Private Practice. In my over 2 decades of performing Mohs’, I can count on one hand how many patients during the initial consultation have asked me what the likelihood of clearing them on the first stage is.

“New” topical treatment for melanoma in situ: Not So Fast!

Melanoma in situ is a common tumor, and often affects the elderly. In some cases, surgery can be extremely extensive and/or patients are not good surgical candidates. For years, Dermatogists have been offering topical imiquimod (Aldara) to these patients as an alternative to surgery, with the full understanding that it is not as good as surgery, but better than nothing.

A recent study published in Dermatologic Surgery looked at long-term recurrence rates for patients who were treated with Aldara. They found that 17% of patients had a recurrence of their tumor, which is far higher than surgical recurrence rates.

In short, some publications talk about a “new” “alternative” to surgery. This is simply not the case. Surgery is the best option and topical treatment with imiquimod, as it has been, should only be considered for those who are not surgical candidates or those who are not expected to outlive their disease.

Hair loss treatments – for men and women

According to a recent article, all treatments that were evaluated were effective in treating hair loss.

For men, 2% minoxidil, 5% minoxidil, low light therapy, and finasteride were all effective.

For women, 2% minoxidil was effective. Unfortunately, other treatments were not evaluated for women.

Recommendations from Dr. Bader: In my experience finasteride is most effective in men with a high compliance rate.  The original 1mg dose was actually pulled out of thin air–no studies to find the most effective dose with the least amount of side effects was used to come up with this dose. I have found that 1mg may not be enough for some patients. 1.25mg (a quarter of a 5mg tablet) works well and some require a 2.5mg dose once or twice a week. I have found that this higher dosing has a greater effect on those who do not get the desired result with a minimal increase in side effects.

For women, I recommend that 5% minoxidil used once daily. This dosing schedule was recently FDA approved, not that this matters. One can buy the 5% minoxidil for men or women, whichever is cheaper. The product is the same. The only difference is the instructions that come with the product. Men are instructed to use the product twice daily. Studies have shown that 5% minoxidil twice a day is no more effective than 2% minoxidil twice a day. For this reason, once a day dosing is recommended for women, not that there is substantially greater risk of using the product twice a day. Side effects from this product include low blood pressure and increased facial hair growth in some. I recommend using the product at night, when one is less affected by lower blood pressure. One should get out of bed slowly to ensure they do not get lightheaded.

New scar treatment for thick scars

Tranilast 8% liposomal gel was shown to be effective in treating scars from cesarean sections. Patients were asked to treat half of their scars with this gel and the other half with placebo. Patients were much more satisfied with the Tranilast side.

Unfortunately, this treatment has not been compared to other treatments, including steroid injections and silicone gel sheets, but at least gives another option for patients with thick scars

FDA approves first treatment for metastatic Merkel Cell Carcinoma

The US Food and Drug Administration has granted accelerated approval to Bavencio (avelumab) for the treatment of  metastatic Merkel cell carcinoma (MCC)–one of the most deadly skin cancers. Prior to this, there have been no FDA-approved treatment for this deadly cancer.