This month’s news from across the specialty

February 1, 2023

In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.  

Is the customer always right? Rude behavior by consumers toward frontline workers in all industries is on the rise. A Harvard Business Review article and podcast highlighted research by Christine Porath, PhD, a professor of management at Georgetown University, who has studied incivility in the workplace for over 20 years. Her surveys in 2005 showed that under half of frontline workers reported experiencing incivility — defined as rudeness, disrespect, or insensitive behaviors — from customers monthly. In 2016, this increased to 62% and in 2022, 76% of frontline workers dealt with rude customers in the last month. She notes that the situation is particularly bad in health care where many nurses, physicians, and technicians report that they experience incivility from patients daily. The intensity of this misbehavior may also be worse toward health care workers, where she cites examples of screaming tirades, racist insults, and spitting.

The after-effects of incivility on frontline workers include difficulty concentrating, increased errors, and decreased willingness to help others. In addition, rude behavior toward frontline workers is associated with a 35% reduction in witnesses’ willingness to use the company’s products and services — even though the witnesses did not directly experience the rude behavior and the company may have done nothing wrong. In addition, coworkers who witness incivility are more likely to quit.

It is clearly important for business leaders to mitigate incivility and support employees who are experiencing rudeness. UMass Memorial Health Care is pointed to as a leader in establishing norms for how health care workers should be treated. It has placed signs at entrances, asks patients to sign a code of conduct before receiving care, and established protocols to de-escalate rude customers. However, the best starting place for all of us may be to spread civility by modeling kindness at the office and in the community by saying, “hello,” “please,” and “thank you.”

I have always found the treatment of patients with facial vitiligo challenging given the few treatment options available and often lack of meaningful clinical improvement. Thus, I was excited to see the FDA approval of topical ruxolitinib in July 2022 for treatment of nonsegmental vitiligo in adult and pediatric patients 12 years of age and older. This is actually the first and only FDA-approved treatment for patients with vitiligo. In two randomized phase 3 clinical trials, application of topical ruxolitinib 1.5% cream twice daily for 24 weeks resulted in greater re-pigmentation of facial skin lesions than vehicle cream among adolescents and adults with nonsegmental vitiligo affecting ≤10% of the body surface area (NEJM. 2022. 387: 1515-6). Participants who used topical ruxolitinib were 3-4 times more likely to achieve a ≥75% improvement from baseline on the facial vitiligo area scoring index (F-VASI) compared to vehicle control. Overall, adverse events were uncommon with application-site acne and pruritus most common (5-6% incidence during 24-week study). The FDA approval of ruxolitinib for vitiligo adds to the 2021 FDA approval of this topical medication for mild-to-moderate atopic dermatitis, highlighting the potential of inhibitors of Janus kinase 1 and 2 to improve our management of dermatologic conditions.

What risk factors should make you consider counseling someone regarding potential temporal nerve damage during Mohs surgery? A study of 616 Mohs cases in the danger zone of the temporal nerve revealed a low percentage with nerve dysfunction (Dermatol Surg. Nov 2022 48:11;1140-5). Twenty-eight cases (4.5%) had dysfunction of the temporal nerve postoperatively. Overall, tumor size was the most associated preoperative clinical parameter associated with temporal nerve damage. Preoperative size greater than or equal to 3 cm was associated with 37.7 times greater odds of nerve dysfunction. Other statistically significant risk factors included immunosuppression, aggressive histology, and recurrent tumors. Immunosuppressed patients were at 2.94 times greater risk. Tumors with aggressive histology had 7.67 times greater risk, and recurrent tumors had 3.93 times greater risk. While temporal nerve damage is rare in Mohs surgery, a thorough preoperative assessment is key to identifying patients in higher risk categories. Immunosuppression, aggressive histology, recurrent tumors, and especially larger preoperative size warrant counseling.

Prior authorizations (PAs) have become one of the leading causes of job dissatisfaction among dermatologists and clinical staff. Additionally, PAs reduce access to dermatologic care, especially for Medicaid patients, due to frequent changes in the formulary and the complicated PA process.

The University of Pennsylvania Department of Dermatology, in collaboration with the Penn Pharmacy, outlined an automated pharmacy substitution program for medications not covered by Medicaid. The appropriate medication substitutes within specific classes of topicals were identified, in order for the pharmacists to implement without the delay of contacting the prescribing dermatologists when medications are not covered or denied. The algorithms involve substituting pharmacologically similar medications when the initial drug prescribed is not covered.

As more substitution algorithms are created, this model could be adapted to each state Medicaid formulary and could reduce the number of PAs submitted and lead to more timely access to dermatologic care for Medicaid patients — who are already disadvantaged in dermatology in most states due to dismal reimbursement for dermatology and the uphill battle of getting treatments covered. Additionally, as advocacy efforts to ultimately eliminate the PA process continue, another area of urgent improvement is the electronic health record (EHR) checkpoint to reduce the need for PAs when sending a prescription. Legislation should require that ALL EHRs are automatically updated to reflect formulary preferences for all insurances. Prior to signing a prescription, the prescriber should immediately and consistently be alerted of the need for a PA or lack of coverage, followed by a short/concise list of only covered alternatives that are equivalent in potency class and vehicle to the one initially prescribed to choose from.

Additional DermWorld Resources