Dermatologists may be first to encounter patients. Learn how to recognize signs.

Skin symptoms associated with rare cancer

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Michelle Nguyen, M.D., MPH, sits down with Dermatology Times to discuss her recent presentation at the 2020 American Society for Dermatologic Surgery (ASDS) virtual meeting regarding the representation of women dermatologic surgeons in the U.S. 

Women surgeons and Mohs micrographic surgery in the U.S.

There are several different treatment approaches currently being used to address low-risk nonmelanoma skin cancers such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). A recent study found that curettage-cryosurgery (C&C) and electrodesiccation and curettage (ED&C) are two common techniques that have comparable cure rates after a one-year follow-up period, underscoring the sound therapeutic benefit of both treatment approaches.

Of all nonmelanoma skin cancers, BCC comprises approximately 75-80% of these lesions and SCC comprises approximately 20%, experts say. Both are associated with significant morbidity, aesthetic concerns and financial burden. Numerous treatment approaches including surgery, topicals, photodynamic therapy (PDT) and destruction have shown efficacy in clearing these minimally invasive tumors. ED&C is the most common procedure used for minimally invasive BCCs and is recommended as a first-line treatment by the National Comprehensive Cancer Network (NCCN). Similarly, cure rates have also shown to be close to 99% for SCC when this method is used.

In a recent multicenter, prospective, comparative study, Suzel Fournier, M.D., from the oncology division of the CHU of Québec, University of Laval Research Center, Québec, Canada, and colleagues, evaluated the cure rates of minimally invasive BCC and SCC lesions when using C&C or ED&C in a cohort of 100 adult Caucasian male and female patients. Study participants were randomized 1:1 to receive either C&C and ED&C treatment, with cure rates evaluated at six, 12, 18 and 24 months, and aesthetic appearance of scars at 12 months post procedure. Evaluated on a scale from 1-10, the aesthetic appearance of the scars was assessed using the Patient and Observer Scar Assessment Scale (POSAS), which combines the assessments of both physician and patients. The average age of patients receiving C&C (n=53) and ED&C (n=47) treatment was 74 and 77 years, respectively.

Results showed that at the 12-month follow-up, only one patient had a recurrence of cutaneous carcinoma in the C&C cohort (98% cure rate), while no recurrence occurred in the patients treated with ED&C (100% cure rate), statistically demonstrating non-inferiority of the C&C approach, and achieving the primary outcome goal. The aesthetic appearance of scars also showed better results with the C&C approach at the 12-month follow-up, however this was not statistically significant. No other recurrences were recorded in either study group at the 6-, 18-, and 24-month follow-up time points.

Patients’ evaluation of the aesthetic appearance of scars as reflected in the mean POSAS score was 1.39 and 1.50 in the C&C and C&E patient groups, respectively. Data also showed that a global score of 1 (best possible score) was recorded by 74% and 66% of the C&C and ED&C groups, respectively. The researchers noted that the same trend was seen in the clinician evaluations, revealing an overall score of 1 for 36% and 33% of C&C and ED&C study patients, respectively.

According to the researchers, this is the first clinical study evaluating and comparing the efficacy of C&C and ED&C with respect to cure rates and aesthetic appearance of scars for low-risk BCC and SCC tumors.

“Our study tends to demonstrate that C&C provides a high cure rate for minimally invasive basal and squamous cell carcinomas. These findings are comparable to other studies with similar protocols, but longer follow-ups. We’ve demonstrated that the C&C technique seems noninferior to the C&E method found in main guide- lines, and as such we believe that it should be investigated more thoroughly as a first-line therapy,” the study authors wrote.

Regarding aesthetic scar outcomes, the researchers said that future trials could include more objective measurements for scar assessment such as Narrow-Band Spectrophotometry, Tissue Ultrasound Palpation System, and Cutometer Skin Elasticity Meter in order to help minimize potential information bias due to the subjective assessment of scars. In addition, a larger patient study cohort could also help in evaluating the different scars based on anatomical location in future studies.

The authors report no relevant disclosures.

Fournier S, Laroche A, Leblanc M, et al. Prospective Clinical Trial Comparing Curettage and Cryosurgery to Curettage and Electrodesiccation in the Management of Minimally Invasive Basal and Squamous Cell Carcinomas. 

2020 Jul 28;1203475420943258. doi: 10.1177/1203475420943258. Online ahead of print.

Articles

A recent study showed that curettage and cryotherapy, and electrodesiccation and curettage are two techniques that have comparable cure rates. The study’s findings highlight the efficacy and reliability of these treatment approaches for minimally invasive cutaneous carcinomas. 

Trial compares NMSC destructive techniques

John Jesitus is a medical writer based in Westminster, CO.

The efficacy and safety of dupilumab (Dupixent, Sanofi and Regeneron) in children ages 6 to 11 years with severe atopic dermatitis (AD) provides an acceptable option for a previously underserved population, says the principal investigator on the phase 3 LIBERTY AD PEDS trial.

“We finally have dupilumab for an age group where it’s so critical, and there hasn’t been anything other than immunosuppressants to treat these children,” says Amy S. Paller, M.D, chair and professor in the Department of Dermatology, and professor of pediatrics (dermatology) at Northwestern University Feinberg School of Medicine.

Between ages six and 11, she says, children are starting school and forming early social relationships, which are difficult if children are tormented by AD and associated itching and disturbances of sleep and concentration. “Ages 6 to 11 is their time to venture out into the real world and a very critical time for their psychosocial development.”

In the study, investigators randomized 362 patients to dupilumab every two weeks (100 mg if weight <30 kg, 200 mg if ≥ 30 kg), dupilumab every four weeks (300 mg regardless of weight) or placebo. All patients also used topical corticosteroids (TCS). 

At week 16, significantly more patients on dupilumab every two weeks (29.5%) or four weeks (32.8%) achieved the primary endpoint of investigator global assessment (IGA) score of 0 (clear) or 1 (almost clear) versus placebo (11.4%). Eczema Area and Severity Index (EASI) 75 scores were 67.2%, 69.7% and 26.8%, respectively. Whereas twice-monthly dosing proved most effective in all prior dupilumab AD trials, pharmacokinetic values and clinical impact were greater with the 300 mg every four-week dose versus 100 mg every two weeks in children weighing less than 30 kg. 

“Dupilumab did not just affect the objective signs of atopic dermatitis,” Dr. Paller adds, “but incredibly importantly, it also brought down the itch as early as in the first two weeks and profoundly affected quality of life for these young children.”

As in previous dupilumab trials in AD, injection-site reactions and conjunctivitis (mostly mild to moderate) were the only treatment-emergent adverse events (TEAEs) that occurred more frequently with dupilumab than with placebo. The fact that fewer TEAEs overall occurred with dupilumab may stem from dupilumab’s ameliorative effects on comorbid type 2 inflammatory conditions and on skin (fewer skin infections), write Paller et al.

Dupilumab is highly effective in adolescent asthma, says Dr. Paller, and it is being studied for other type 2 comorbidities. “For example, it’s looking very good for eosinophilic esophagitis. It’s also being studied for severe allergic rhinitis and food allergies. So, we know that it has the promise to be effective across a range of Th2-driven disorders.” Such capability would be welcome, she says, because more than 90% of adolescents with moderate AD, and younger children with severe AD, have at least one other type 2 disorder.

“That means that we may be able to treat more than one of their diseases with a single agent.” The asthma or other comorbidities are usually less severe than the AD, Dr. Paller says. But the possibility of stopping other medications used for some of these comorbidities is appealing for families and children, she adds.

Dupilumab’s success against AD in children ages 6 to 11 years is already a breakthrough, says Dr. Paller. “For kids who have never been able to get the control I wanted because I was unwilling to put them on a systemic medication, now I’ll be able to give them something that’s acceptable to parents, that’s not going to require labs every month, and that’s even going to give them better control than a medication like cyclosporine.”

1. Paller AS, Siegfried EC, Thaçi D, et al. Efficacy and safety of dupilumab with concomitant topical corticosteroids in children 6 to 11 years old with severe atopic dermatitis: a randomized, double-blinded, placebo-controlled phase 3 trial [published online ahead of print June 20, 2020]. J Am Acad Dermatol. 2020;S0190-9622(20)31152-X. doi:10.1016/j.jaad.2020.06.054.

Dr. Paller has been an investigator and consultant for AbbVie, Castle Creek, Eli Lilly, Galderma, Lenus, LEO, Novartis and Regeneron; an investigator for Incyte, Janssen and Verrica; and a consultant for Almirall, Amgen, Asana, Boehringer Ingelheim, Celgene, Dermavant, Dermira, Exicure, Forte BioPharma, MEDACorp, Meiji Seika, Novan, Pfizer, Sanofi Genzyme, Sol-Gel and UCB.

In a recent phase 3 trial, dupilumab (Dupixent, Sanofi and Regeneron) demonstrated positive results in itch reduction, skin clearance and quality-of-life. Indicating the biologic as a viable treatment option for severe atopic dermatitis in younger children.  

Dupilumab provides option for severe AD in younger children 

a weekly glimpse into what your patients may be reading in the media about skin health.

finds out if witch hazel is beneficial or detrimental to the skin and gets to the bottom of oily skin myths. Meanwhile, 

explains how to take care of both your skin and mind while on isotretinoin (Accutane), and 

writes about the benefits of vitamin C. Finally, 

dives into the anti-aging benefits of fraxel laser treatments and reveals how to deal with postpartum hair loss.

Is Witch Hazel Good or Bad for Your Skin? Here's What Dermatologists Say About This Controversial Ingredient

How to Take Care of Your Skin and Mind While on Accutane — and After

Why The Hype Over Vitamin C’s Skin Benefits Is Real

Dermatologists Say This Is the Most Common Misconception About Oily Skin

What You Need to Know About Fraxel Laser Treatments

Postpartum Hair Loss Is Real — Here's How to Deal with It

This week’s edition of The Mainstream Patient features stories about postpartum hair loss, vitamin C benefits, witch hazel, fraxel laser treatments, isotretinoin’s effect on both the skin and mind, oily skin myths, plus more.

The Mainstream Patient: October 20

The lack of older adults in trials of systemic immunomodulators for atopic dermatitis (AD) means that available evidence may not be safely generalizable to these patients, according to a recent review. 

“Both psoriasis and atopic dermatitis are common in older adults. And older adults in general are more at risk for adverse events from medications. We need to know how effective and safe medications for psoriasis and atopic dermatitis are in this population,” says lead study author Aaron Drucker, M.D., ScM. Dr. Drucker is a clinician scientist in the Division of Dermatology at Women’s College Hospital and Women’s College Research Institute and assistant professor in the Department of Medicine at the University of Toronto.

Age-related changes in drug metabolism, as well as the likelihood of increased comorbidities and polypharmacy, make older patients more susceptible to drug-related adverse events, study authors write. For example, methotrexate is considered less safe in this population due to reduced renal clearance. Similarly, cyclosporine is contraindicated in patients with renal impairment, uncontrolled hypertension or relevant malignancies; cyclosporine also interacts with many common medications.

Research from the United States and the United Kingdom suggests that the prevalence of AD in people over 65 years old is approximately 7%. Yet according to the review, published online Aug. 19, 2020 in 

, none of the trials analyzed reported separate efficacy or safety outcomes for older adults.

Investigators searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE and clinicaltrials.gov through Nov. 7, 2019. Ultimately, 32 trials including 4547 participants total met inclusion criteria.

Of these 32 trials, 11 (most involving cyclosporine) reported explicit upper age limits ranging from 42 to 70 years. Although seven of 12 dupilumab (Dupixent, Sanofi and Regeneron) trials lacked upper age limits, only 67 of 1472 total participants (4%) were over age 65; the gender of older participants was not reported. Overall, 10 trials included at least one participant age 65 or older.

More than two-thirds of the studies reviewed used eligibility criteria that may have disproportionately excluded older patients. The most frequent examples of such criteria included history or presence of malignant neoplasms (56%), uncontrolled hypertension (28%), renal or pelvic dysfunction (25%), use of drugs likely to interfere with study drugs’ pharmacokinetics (22%) and abnormal laboratory values (19%). 

The situation in AD is not unique, authors add, as stringent criteria of clinical trials in many diseases may indirectly exclude older adults. The widely used major diagnostic criterion of flexural dermatitis may represent another obstacle because flexural dermatitis occurs less commonly in older adults than in younger adults and children. 

Dr. Drucker says he hopes that the study’s findings bring awareness to the dearth of data regarding older adults in studies of systemic AD drugs. “When we pick treatments and counsel our patients on these drugs,” he says. “that should be part of the discussion. We have to do the best with the data we have, which in a way means flying blind. We have to use data from younger people and understand that it’s uncertain whether these data apply to older people.”

To help clarify the safety and efficacy of systemic AD treatments for older patients, Dr. Drucker and colleagues suggest conducting observational studies. While randomized clinical trials are the ideal study design, Dr. Drucker notes, such trials are expensive, resource-intensive and unlikely to occur for drugs already approved.

“Observational studies can be done with fewer resources and can provide very helpful data in more generalizable populations outside of clinical trials,” he says. Future trials also could increase participation of older adults by reducing comorbidity-related exclusion criteria, eliminating age-related exclusion criteria and setting specific recruitment targets for older adults.”

1. Lam M, Zhu JW, Maqbool T, et al. Inclusion of older adults in randomized clinical trials for systemic medications for atopic dermatitis: a systematic review [published online ahead of print Aug 19, 2020]. JAMA Dermatol. 2020;10.1001/jamadermatol.2020.2940. doi:10.1001/jamadermatol.2020.2940

Dr. Drucker has received institutional research funding from Sanofi and Regeneron. He has been a consultant for Sanofi and RTI Health Solutions, and his institution has received educational grants from Sanofi and Regeneron.

A recent review reveals older adults are underrepresented in trials investigating systemic immunomodulators as a treatment for atopic dermatitis. 

Older adults underrepresented in atopic dermatitis research  

Director of Revenue Cycle Management at VitalSkin Dermatology

As we discussed earlier this year, revenue pressure can make running a solo practice difficult for many dermatologists. And managed care contracts can create a major impact on a practice’s revenue.

With the ongoing lack of consolidation in the physician space, most practices won’t have the leverage (or often the knowledge) to negotiate with large health insurance companies. As a result, they often sign standard contracts that hinder their practice. 

In these cases, dermatologists may not spot things that can put them at risk or cost them money. With terms that set year-over-year reimbursement rates and allow insurance companies to control billing and coding rules, a dermatologist’s revenue increases can be offset by stricter billing/coding rules and increased denial rates. 

Fortunately, unlike government contracts, managed care contracts can be negotiated. By taking the right opportunities, understanding the language and avoiding certain pitfalls you can put yourself in a better position to negotiate and get the most out of your agreements. Here are some steps to take (and problems to avoid) that can help you negotiate better managed care contracts. 

When it comes to Medicare Advantage reimbursement rates, make sure they’re equal to CMS Professional Fee for Service rates in your region. More general information on CMS rates can be found 

When reviewing a contract, make sure the items below are outlined in the contract. Doing so will help avoid denials and/or claim issues with appeals, payments, preauthorization, etc. 

Notification prior to term, so you can negotiate the contract 

Take-back period – how far back a payer can take back payments 

Confirm you have easy access to any policies or manuals referred to in the contract. These may contain important details or points of clarification if you run into an issue. 

See if the contract says that stipulations (allowed amounts, policies, etc.) may be amended from “time to time.” If so, what are the notice and remediation periods listed? 

Check if the contract specifies how long a patient needs to be treated after the contract is terminated. 

Check if it refers to any “abnormal” reductions in payment due to modifiers or providers (APPs). 

Clarify and understand what your responsibilities are with coordination of benefits. 

See if your practice is required to wait until payment from the payer before you can collect copayments or coinsurance. This is something new that’s been showing up in contracts recently. 

Look for opportunities to educate payers on how you can differentiate yourself in the market compared to other dermatologists. If you’re in a smaller community and competing against larger hospital-owned groups, you may be able to highlight being a lower-cost alternative. 

Try to identify what a payer needs and how you can fill that need. Perhaps they’re trying to launch and expand their Medicare Advantage plan and need the right network in a certain market to show suitable coverage. You might be able to trade participation in their Medicare Advantage plan for higher rates on the PPO side. 

Investigate opportunities to join a health system or independent IPA or CIN and understand their participation requirements. You may be able to get higher rates through these options compared to what you’re receiving directly.  

Stay alert for stipulations that let the payer adjust and pay claims at a lower level than submitted. 

Surprisingly, some contracts do allow this. Seek to contractually reduce a payer’s ability to change claims by asking the contract to state that the payer must notify you and explain any modifications from the Centers for Medicare and Medicaid Services’ Correct Coding Initiative (CCI). 

Be cautious of contracts that can be extended to affiliates. 

Payers and network PPO contracts may include a statement saying that the agreement is entered into by itself and its affiliates (often in the opening paragraph). If the payer you’re contracting with has affiliates, have the contract specify all of them. This will help stop the network from being “leased.” 

Keep an eye out for unilateral change authority statements. 

Often, payers will give themselves power to make unilateral changes to the agreement. This essentially gives them control to make any changes they want, with you being contractually obligated to accept (no matter what the consequences may be). If you come across this, it’s best to work on getting it removed. The payer may not like it and push back, but the effort will be well worth not locking yourself into a potentially problematic situation. 

Appeal limitations put the burden of finding claim-processing errors on you. And if you don’t report an error within a filing limitation, the payer may not reprocess the claim if it’s over 30 days old. Check the Payment and Reimbursement section of the contract to find anything regarding limitations. 

Depending on your size, you may not have the full ability to negotiate with larger companies and payers from the even position you’d prefer. But there are still things you can do, and ways to educate yourself to put yourself in a better position. 

 The risks from managed care contracts can never be fully avoided, but carefully reviewing everything and identifying potential red flags will help you minimize much of this risk when negotiating. 

Jerri Ivey, director of revenue cycle management at VitalSkin Dermatology, shares steps you can take and ways you can educate yourself in order to negotiate better managed care contracts.  

Negotiating better managed care contracts

discussing telemedicine use in dermatology with Michael Sherling, M.D.

An exclusive video interview with Michelle Nguyen, M.D., MPH, regarding a recent presentation at the 2020 American Society for Dermatologic Surgery (ASDS) virtual meeting about women surgeons and Mohs micrographic surgery in the U.S.

Check back with our website frequently so you don’t miss any of the latest dermatology news.

A glimpse at what to expect from Dermatology Times this week.

What’s new on Dermatology Times: October 19-23

Poll

POLL: Have you ever experienced symptoms of imposter syndrome?

In the previous Selling Your Practice articles, we discussed why so many physicians are selling their practices. Once you have made the decision to sell your practice, we counseled you to continue growing your practice, prepare early and assemble a team of experts. It’s also important to:  

Know the difference between the two most common types of transactions – a capital sale and an asset sale. 

Complete an objective analysis of your practice and develop a financial pro forma. 

Prepare for negotiation by understanding the value of your practice. 

 Next, we turned our focus to identifying and reviewing potential buyers before putting your practice up for sale. That was followed by developing a confidential information memorandum (CIM), approaching potential acquirers, signing non-disclosure agreements, creating and soliciting a letter of intent and negotiating the material terms of a sale of your practice.  

Now that you have your signed the letter of intent, it’s time to discuss the due diligence, legal documentation and final negotiations phases. 

Due diligence is the investigative process a buyer takes before entering into a purchase agreement with a seller. The purpose is to confirm the facts provided in the confidential memorandum, and thoroughly assess the selling practice’s business, assets, capabilities and financial performance, to help the buyer make an informed final decision. The scope of the process depends on the complexity of the letter of intent and the size of the transaction. The more complex and expensive the transaction, the more due diligence will be done. Warning – this can be a lengthy and time-consuming process. 

There are multiple areas that buyers will want to investigate, including the following: 

Organizational: Articles of incorporation, by-laws, minutes of the board of directors, the stock book and ledger, names under which the practice does business, shareholder agreements, etc. 

Practice operations: The organizational chart, a claims audit on billing practices, payor contracts, internal performance data for all operating functions, third-party accreditation files, copies of DEA numbers, APP contracts, collaborative support agreements, etc. 

Debt: All loan and mortgage agreements and liens. In today’s environment, this includes all Paycheck Protection Program loans that haven’t been forgiven already. 

Financial statements: Three to five years of prior audited or compiled financial statements, any prior management letters from independent auditors, current year financial statements and a list of deferred costs, prepaid expenses or unrecorded liabilities. If the financial transaction carries enough risk and/or is material enough, the buyer may have a third-party audit firm complete a quality-of-earnings report. 

Receivables: An accounts receivable aging report, a breakout of revenues and accounts receivable by payor, a list of all accounts receivable that are in dispute and past accounts receivable performance metrics. 

Inventory: An inventory and major supplier listing, contracts and terms.

Fixed assets: A list of property owned by the practice which is included or excluded on the financial statements, including real estate, furniture, fixtures and equipment. This also includes copies of property titles, depreciation schedules, methods of depreciation, an estimate of the remaining useful life, any recent appraisals, etc. Additionally, the buyer will want to visibly inspect all material assets. 

Leases: Copies of any capital or operating leases, including a schedule of any future lease payments. This may include rental agreements for the practice location(s). 

Tax matters: Copies of current and past income tax returns, payroll tax returns, property tax, sales tax returns and personal property tax returns. This should include copies of any correspondence with the IRS or state taxing authorities, any audit results and ongoing disputes and a list of any prior agreements or elections made with the IRS. 

Information technology: Documentation of the major applications used to operate the practice, the hardware and network configuration, third-party support agreements, the data security environment and any third-party cyber security audits and details related to any suspected or confirmed data breaches. 

Human resources: Employment contracts for the practice physicians, advance practice providers or other key employees, as well as copies of the employee benefit plans, employee handbook(s), and a list of all practice employees along with key information such as compensation, bonus, hours worked, title, job description, etc. 

Intellectual property: All trademark registrations and a list of all website domains owned by the practice. 

Contracts: Current government contracts and other contracts relating to commercial drug reimbursement rates, EHR, equipment/supplies, maintenance, IT/telecom, etc. This also includes lists of all oral contracts and copies of confidentiality, noncompetition and similar agreements. 

Litigation: List of claims, lawsuits or investigations against or brought on by seller. Also, all judgements, orders and decrees that the seller is subject to. 

Environmental: Internal reports for current and former property owned by seller, including emission statements/reports, notices or suits served to seller by federal or state regulatory agencies and waste disposal reports. 

Licenses: All federal and state permits, licenses and accreditations held by seller, and all reports and notices relating to laws and regulations from federal or state agencies. 

Compliance: Copies of compliance programs (monitoring, investigation and action policy protocols) and reports/meeting minutes relating to compliance programs, as well as compliance audits for coding, billing and clinical appropriateness. This can also include government audit contractor requests, and any citations for violating federal or state inspections. 

Insurance: Insurance policies and names of all agents, brokers and companies. All policies for property, liability, workers compensation, disability, automobile, etc., should be included. Also disclosed should be current pending claims, claims of more than $50,000 over the last five years, loss experience in that time and historical workers compensation expense. 

Government and third-party payor: Numbers for Medicare and Medicaid, and documentation for liabilities like retroactive adjustments, settlements, overpayments, compliance issues, etc. 

Material findings during the due diligence process that weren’t previously disclosed will often impact the final negotiations and adjustments to previously negotiated terms, and these will also be needed. These findings may even cause the buyer to walk away from the proposed sale. So, as we’ve mentioned in previous articles, sellers should be up front and disclose any material issues early in the process. 

Legal Documentation and Final Negotiations 

Legal documentation can be prepared after the due diligence process is completed, or during the due diligence process. There are often several documents that govern the sale of the practice and are dependent upon the structure of the sale. Regardless, practice sales will include a purchase agreement. 

The purchase agreement is the master document that governs the overall sale of the practice. It often includes the following sections: 

List of assets acquired: Identifies the assets being acquired, including inventory, accounts receivable, fixed assets, real property, intangible assets, etc. 

List of excluded assets: Includes a list of excluded assets that are not part of the practice purchase, such as cash, personal artwork, real property, etc. 

Purchase price: The final purchase price will be outlined in the purchase asset agreement. 

Tax issues: The purchase price will be allocated to each of the purchased assets (usually done with the help of a third-party appraiser) and the remainder of the purchase price will be allocated to goodwill. 

Malpractice insurance: It’s typical for the provider to purchase tail insurance to cover any potential malpractice claims resulting from services provided prior to the sale date. 

Representations and warranties: The seller will make certain representations and warranties of fact that encourage the buyer to purchase the practice. If these representations and warranties prove to be untrue, the buyer will have legal recourse up to and including backing out of the sale. 

Indemnification: In the event the buyer breaches the representations and warranties, the seller will provide an indemnification to reimburse the buyer for costs and expenses incurred by the buyer. Likewise, the seller may ask for an indemnification in the event the buyer breaches their responsibilities. 

Restrictive covenants: Most practice purchases will come with a set of restrictive covenants, including a non-compete provision, and a non-solicitation of employees and patients provision.  

Employment agreement: If there will be an ongoing employment arrangement, a formal employment agreement will often be part of the overall purchase agreement. 

As you can see, the due diligence, legal documentation and final negotiation phases of selling a practice can be lengthy, complex and tedious. But they’re all critical parts of the process. Without a thorough completion of these steps problems may result on either side, causing a longer delay of the sale, or in certain situations a complete termination of the deal. 

Again, being clear, up front and working together with the buyer will help ensure a smoother process for both. We’ll continue our series next month and discuss the final closing process in more depth.

Todd Petersen, CEO of VitalSkin Dermatology, covers the ins and outs of the due diligence, legal documentation and final negotiation stages of selling a practice.  

Selling your practice: The due diligence, legal documentation and final negotiation phases  

In case you missed it, some of this week’s featured content includes tips on how to build your brand as a physician, a new 730 nm picosecond laser for benign pigmented lesions, managing patient volumes during the COVID-19 pandemic, why retinoids can be found in many anti-aging formulations, different professional standards of disclosure, female surgeon representation within Mohs micrographic surgery in the U.S., plus more.

POLL: Is climate change a rising issue within dermatology?

What’s new on Dermatology Times: October 12-16

This week’s edition of The Mainstream Patient features stories about a new toxic-free cosmetics bill in California, the benefits of benzoyl peroxide for acne, the legitimacy of collagen supplements, potential sunscreen changes by the FDA, plus more.

Importance of building your brand as a physician

In this video interview, Paige Velasquez Budde, CEO of Zilker Media, explains the importance of building and shaping your brand as a physician.

Catch up on all of the latest news coming out of the 2020 American Society for Dermatologic Surgery (ASDS) virtual meeting.

730 nm picosecond laser safe, effective for benign pigmented lesions

Lasers typically used for tattoo removal are on the rise as a possible treatment for melasma, with the novel 730 nm picosecond laser (PicoWay, Candela) being the most recently studied device which showed to be safe and effective for treating benign pigmented lesions.

In part two of this video series, Paige Velasquez Budde, CEO of Zilker Media, reveals the benefits of shaping your brand awareness.

Cysteamine cream, tranexamic acid mesotherapy reveal similar efficacy, different safety

Cysteamine cream and tranexamic acid mesotherapy demonstrated similar efficacy but yielded different safety results when being compared as a treatment for melasma, according to a recently published study.

In this month’s Legal Eagle article, David J. Goldberg, M.D., J.D., discusses the different professional standards of disclosure that a physician must fulfill when treating patients.

In the final installment of this video series, Paige Velasquez Budde, CEO of Zilker Media, provides some useful tips for jump starting your brand as a physician.

Since the start of the pandemic, dermatologists have seen an average 50% drop in patient volume. While teledermatology has offered a channel for non-urgent patients and patient visits are rebounding, overall patient volumes are still significantly lower than 2019.

Zoe Diana Draelos, M.D., shares why retinoids can be found in many anti-aging formulations and how to reduce irritation from this potent antioxidant.

Misinformation delays rosacea diagnosis in skin of color patients

The idea that rosacea is uncommon in darker skinned individuals may be due to under-recognition. Careful clinical examination, a thorough history and biopsy in some cases are needed for accurate diagnosis and differentiating rosacea from diseases that may be more common.

Phenotype-based approach advances management

The 21-member global ROSacea Consensus panel developed updated recommendations for rosacea, diagnosis, classification and management to support and promote transition to a phenotype approach in rosacea.

ICYMI, some of the content featured this week includes new 730 nm picosecond laser for benign pigmented lesions, managing patient volumes during the COVID-19 pandemic, tips on how to build your brand as a physician, plus more. 