Attention on prevention: Derms should identify candidates for HPV, herpes, chickenpox vaccines

September 1, 2008

Although dermatologists rarely administer vaccines to prevent skin diseases such as genital HPV, they could be missing an opportunity to help patients avoid these diseases and their consequences, an expert says.

Key Points

"The issue for dermatologists is, why do we need to get involved with vaccines when vaccines are really more of a primary care screening issue?" says Neal D. Bhatia, M.D., associate clinical professor of dermatology, University of Wisconsin, Madison, Wis.

However, he says that what's been lost in this discussion - and in the training of many older dermatologists - is the fact that by playing a preventive role, dermatologists can help patients avoid the consequences of many disease states.

"We can make health maintenance more of an issue for us, rather than just being there when it's too late," he says.

With Gardasil (human papillomavirus quadrivalent [types 6, 11, 16 and 18] vaccine, recombinant; Merck), many patients mistakenly assume that it's a cure for genital warts rather than a preventive measure, Dr. Bhatia says. It also isn't a cure for the common wart.

Nevertheless, he says, "The value of the vaccine is significant. If a physician can vaccinate someone against four of the most common HPV strains - even if they've had genital warts once, they can still be vaccinated against the other three strains and reduce their risk of cervical cancer."

Vaccine expense

However, newer vaccines can involve significant expenses that it might not make sense for dermatologists to bear, Dr. Bhatia says.

In particular, he says Gardasil requires a series of three injections (costing around $360 total) that female patients should begin receiving before becoming sexually active.

"But few of those patients' parents are thinking they should take them to the dermatologist for this vaccine. They're thinking they should take them to a pediatrician," Dr. Bhatia says.

Under these circumstances, he says, "We're not going to foot that bill in the dermatology office to keep the vaccine on hand for the occasional patient who needs it."

Another significant concern for dermatologists is whether insurance companies and Medicare will validate dermatologists' ability to prescribe and administer these vaccines as their primary-care colleagues do, since there is risk of not being reimbursed for the vaccines, he says.

Most managed-care and commercial insurance plans cover Gardasil's cost, Dr. Bhatia says.

If they don't, he says a patient's health savings account could cover it, or the patient could pay it out-of-pocket and deduct it from taxes.

Being attuned

"What's interesting is that Gardasil is now being used off-label. It's approved up to age 26, but many women in their 30s and 40s are getting the vaccine as prevention and paying for it on their own," Dr. Bhatia tells Dermatology Times.

Conversely, he says that with Zostavax (zoster vaccine live, Oka/Merck), patients think they'll go to their primary care doctors for the vaccine, or to their dermatologists only when they have shingles.

"It's a double-edged sword: Dermatologists should at least be attuned to what role the vaccines play, but they may not be the ones administering them," Dr. Bhatia says.

When properly used, Zostavax can reduce the incidence rate of herpes zoster by more than 50 percent, he says.