This month’s news from across the specialty
What’s hot
November 1, 2022
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
An investigation by the Kaiser Family Foundation shows that medical debt is the most common form of debt on American consumer credit records, at 58% of debts recorded in collections. The scope is huge with 41% of American adults currently paying off medical debt to hospitals or other providers, 25% of Americans owing over $5,000, and 20% who don’t ever expect to be able to pay off their medical debt. The consequences of being in medical debt are significant for individuals and families. Among Americans who are in medical debt, 63% had to cut spending on basic needs like food and clothing, 48% used up all or most of their savings, and 17% declared bankruptcy or lost a home due to medical debt. It is also leads to access problems, as approximately 15% of people in medical debt have been denied access to a hospital, doctor, or other provider because of unpaid bills.
The report reviews how the 2010 Affordable Care Act, although a landmark in expanding insurance coverage and providing significant financial protections for millions, seems to have fallen short of its promise of more affordable care for many Americans. The law did not stop the growth of high-deductible plans requiring patients to pay more out-of-pocket for health care. At the same time, the prices for medical care increased by 16% from 2012-2016 (four times the rate of inflation). The combination of increased prices with elevated out-of-pocket costs resulted in increasing numbers of Americans going into debt.
The investigation found that most Americans (both Republicans and Democrats) would support laws limiting how much patients with health insurance can be asked to pay out of pocket for medical care. However, it is unclear how Americans feel about the potential trade offs for this policy, such as increasing premiums or increased financial pressure and burnout of physicians.
DermWorld Insights & Inquiries
The potential detrimental effects of taking oral antibiotics are increasingly being recognized. In a recent clinical trial (Sci Transl Med. 2021;13(625): eabd8077), investigators randomized healthy volunteers to courses of four commonly prescribed oral antibiotic regimens: doxycycline 20mg or 100mg, cephalexin, or trimethoprim/sulfamethoxazole (TMP/SMX). Individuals who received doxycycline 100mg or TMP/SMX exhibited the greatest changes to their skin microbial communities. All participants on these two regimens had specific emergence, expansion, and persistence of antibiotic-resistant staphylococci. Antibiotic-resistant bacterial strains were even isolated from the skin up to 336 days after the start of antibiotic treatment, suggesting that these effects can be long-lasting. Taken together, this study adds to a growing body of literature that calls for greater antibiotic stewardship in dermatology, as outlined in a recent JAMA Dermatology editorial (doi: 10.1001/jamadermatol.2022.3168. E-pub ahead of print). The authors put forth timely suggestions to promote more appropriate use of oral antibiotics for common dermatologic indications, including acne vulgaris, rosacea, hidradenitis suppurativa, and surgical site infection prophylaxis.
How prevalent is immunohistochemistry use in Mohs surgery? A recent survey of American College of Mohs Surgery members revealed that 40.4% of respondents use at least one immunohistochemical stain during Mohs surgery (Derm Surg. 2022. 48:8: 893-4). The most common stain was Mart-1/Melan-A for melanoma in situ, invasive melanoma, and atypical melanocytic proliferation. Other commonly used stains were MCK and CK7. Immunohistochemistry was also used in selective cases of squamous cell carcinoma. Poor differentiation, single-cell spread, dense inflammation, and perineural invasion were reasons cited for consideration of using immunohistochemistry for cutaneous squamous cell carcinoma. Increasing utilization raises the question of training in the interpretation of immunohistochemistry. Only 32% of respondents received training during their fellowship. As interest in immunohistochemistry grows, lack of confidence in interpreting sections, lack of education, time consumption, and start-up costs were all identified by respondents in this survey as barriers to implementation.
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup at the DermWorld homepage.
Most dermatologists would agree that we might currently be facing one of the most significant lidocaine shortages of our time. The supply chain-induced manufacturing delays are predicted to last for several months to years. Therefore, now is the time to act and swiftly adopt practices of lidocaine conservation that preserve lidocaine and save costs. A short communication in SKIN the Journal of Cutaneous Medicine offers practical approaches that most clinical dermatologists could use during this extended lidocaine shortage, which for some has become a critical issue. Some of the recommendations outlined in the paper include:
Avoid waste from expired products by diligent inventory checking.
Extend the use of a regular vial of lidocaine by diluting to 0.5%. This has been shown in studies to have equivalent pain control as 1.0% lidocaine.
Utilize available lidocaine without epinephrine, by mixing 1:1 with lidocaine with epinephrine to double the supply.
Prefill syringes to only the minimal amount needed for small procedures like biopsies, to decrease waste of unused lidocaine.
Reduce the buffering ratio of lidocaine to sodium bicarbonate to preserve lidocaine, while providing more effective pain control.
Use alternative amide and ester anesthetics safely to avoid toxicity. Do not forget normal saline and diphenhydramine for simple, small procedures.
The shortage also calls for a revision of the current recommendation by the United States Pharmacopoeia to dispose of lidocaine preparations after 24 hours at room temperature, which leads to more waste. The authors included a one-page recipe chart that can be printed and laminated.
You can also read the Academy’s FAQs on the lidocaine shortage or learn more about our lidocaine advocacy for dermatologists.
Editor’s note: These recommendations are those of the authors of the paper published in SKIN the Journal of Cutaneous Medicine.
