The medical world is changing; this is fact. Exactly how these changes will translate into practice and affect dermatology is unclear. So unclear, in fact, that many are scrambling to address issues that may or may not be relevant as the model for healthcare delivery is debated on national, state and local levels. This leaves dermatology at the apex of a trisection between science, art and policy that warrants further inquiry.
The present push has been to define the practice of medicine in terms of evidence to support medical decision-making and treatment regimens. This has resulted in guidelines of care statements, many of which have been developed for dermatology. One of the earliest treatises set forth care guidelines for acne, a major disease state addressed in dermatology. The guidelines addressed the available treatment options and how they should be used for various acne presentations.
Topical retinoids are listed as an important topical intervention for both noninflammatory and inflammatory acne, yet the largest insurer in my home state of North Carolina has removed all retinoids from the acne formulary, requiring the use of over-the-counter benzoyl peroxide or prescription generic benzoyl peroxide/clindamycin gels. If these preferred treatments are unacceptable because of tolerability or efficacy issues, then a retinoid can be considered for prior approval use. I have a prior approval acceptance rate of 2 percent to date for topical retinoids.
The point of trisection for science, art and policy will determine the future of dermatology. If the trisection occurs with the dominance of policy, dermatology will become an insurance-uncovered specialty. Skin conditions are generally not life-threatening, except for melanoma. Squamous cell and basal cell carcinoma could be considered cosmetic in patients above a certain age limit, and actinic keratoses could be completely uncovered.
All other skin conditions such as psoriasis, atopic dermatitis and rosacea could be simply considered cosmetic, as patients can function at a lower quality of life without treatment. And if the patient desires treatment, the cost for care will be an out-of-pocket expense. Since almost everyone has some type of skin issue, this will result in a huge insurance company savings and a big paradigm shift for dermatologic care.
If the trisection occurs with the dominance of art, dermatology will continue, but not thrive. Funds to drive research will be lacking, as the art will be to use medications currently available to the best possible advantage for the patient. I believe that the art of dermatology is very important and should not be trivialized, as there are many skin conditions in which optimal medications are not presently available, such as lichen planus, pityriasis rubra pilaris and atopic dermatitis. These conditions all benefit from the use of oral and topical corticosteroids, but this therapy covers up the symptoms without addressing the etiology.
If the trisection occurs with the dominance of science, dermatology will see the investment of research funds and the possibility for novel treatments. However, too much focus on evidence leaves dermatology without therapy for many important conditions where little understanding of the disease process yields minimal science for guidelines of care recommendations. Do we quit treating certain conditions because we have no guidelines?
There is no doubt that the future of dermatology will be determined by the trisection of science, art and policy. The balance of these three considerations is important to keep the fulcrum of dermatology stable. How will we find this balance? Through the professional engagement of all dermatologists, I believe.
Zoe Diana Draelos, M.D., is consulting professor of dermatology, Duke University School of Medicine, Durham, N.C.