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Managing Patients With Alopecia
What does the patient need to know at the first visit?
When I communicate with alopecia patients at the first visit, I make sure they know that I’m there to help them—that I won’t minimize their concerns and that I understand how important their condition is to them. Alopecia can be frustrating for both the patient and the physician, and there often is a confounding background of psychosocial stress and/or a history of physicians who have dismissed the patient’s concerns about his or her hair loss as trivial. Establishing an effective doctor-patient relationship is key in treating alopecia. Physicians sometimes may be left feeling like the patient wants to keep them in the room until his or her hair regrows, but in reality you simply need to reassure the patient that you are comfortable with the evaluation and treatment of alopecia and that several steps will be required but you will get started today.
How do you use punch biopsies to determine the best treatment options?
My most important tips regarding alopecia diagnosis relate to scalp biopsies, which usually are required in distinguishing chronic cutaneous lupus erythematosus from other scarring alopecias. First, an absorbable gelatin compressed sponge is your best friend. A small strip inserted into the punch biopsy wound results in prompt hemostasis without the need for sutures, and the resulting scar often looks as good or better than that produced by suturing. Next, don’t biopsy the active advancing borders of an alopecia patch, as the findings usually are nonspecific. Instead, biopsy a well-established portion that has been present for at least 4 to 6 months but is still active. In inconclusive cases, a biopsy of a scarred area stained with Verhoeff elastic stain can demonstrate characteristic patterns of elastic tissue loss and often establish a diagnosis. It is important to distinguish chronic cutaneous lupus erythematosus from other forms of scarring alopecia, as it is more likely to respond to antimalarials.
What are your go-to treatments? Are your recommendations anecdotal or evidence based?
There isn’t an extensive arsenal of evidence-based therapy for refractory scarring alopecia, but that doesn’t mean we don’t have effective therapies; it simply means that our treatments are based on experience without accompanying randomized controlled trials. We need to produce more evidence, but patients with severe disease still need to be treated in the meantime. It’s important to remember that therapeutic complacency can result in permanent irreversible scarring. The presence of easily extractable anagen hairs is a sign of active disease. This simple test is helpful to monitor therapeutic progress.
Topical and intralesional corticosteroids can be extremely useful and often are underused. In general, the risk of scarring and atrophy from untreated disease is much greater than that from the corticosteroid. On the scalp, atrophy often presents as erythema, which should not be confused with erythema related to active disease. Dermoscopy is useful to demonstrate that the redness represents dermal atrophy with prominence of the subpapillary plexus of vessels.
When systemic therapy is required, antimalarials, retinoids, dapsone, thalidomide, sulfasalazine, mycophenolate mofetil, and methotrexate have all been used successfully in the setting of cutaneous lupus erythematosus, while topical tazarotene and topical calcineurin inhibitors are generally disappointing.
For the treatment of lichen planopilaris, intralesional corticosteroids, oral retinoids, and excimer laser can be effective. In contrast, antimalarials usually are not effective in preventing disease progression. The peroxisome proliferator-activated receptor-γ agonist pioglitazone can be effective, but reported results vary widely. In my experience, mycophenolate mofetil is generally reliable in patients with refractory disease. Dutasteride can be effective as a first-line therapy in the setting of frontal fibrosing alopecia, although some of the noted improvement may relate to the nonscarring portion of the disease in patients with a background of pattern alopecia.
How do you keep patients compliant with treatment?
Again, the key to treatment compliance is to establish an effective doctor-patient relationship. Whenever possible, begin with adequately potent therapy to give patients an early response. Don’t hesitate to use prednisone initially for inflammatory scarring alopecia. Patients need to see signs of progress in order to stay compliant with treatment, and long trials of ineffective therapies destroy trust. Adequate doses of intralesional or oral corticosteroids often are appropriate to ensure an early response with subsequent transition to steroid-sparing agents.
What do you do if they refuse treatment?
Try to find out why—often it’s simply fear of side effects. Patient education is key, and it can help tremendously to share with them the number of patients you have treated safely with the medication in question and assure them that you know how to monitor for the important side effects.
What resources do you recommend to patients for more information?
It is helpful to keep a handy list of patient advocacy Web sites. Well-established support groups such as the National Alopecia Areata Foundation (https://www.naaf.org) and the Cicatricial Alopecia Research Foundation (http://www.carfintl.org) provide excellent information for patients and help to support research to improve outcomes for these difficult disorders.
What does the patient need to know at the first visit?
When I communicate with alopecia patients at the first visit, I make sure they know that I’m there to help them—that I won’t minimize their concerns and that I understand how important their condition is to them. Alopecia can be frustrating for both the patient and the physician, and there often is a confounding background of psychosocial stress and/or a history of physicians who have dismissed the patient’s concerns about his or her hair loss as trivial. Establishing an effective doctor-patient relationship is key in treating alopecia. Physicians sometimes may be left feeling like the patient wants to keep them in the room until his or her hair regrows, but in reality you simply need to reassure the patient that you are comfortable with the evaluation and treatment of alopecia and that several steps will be required but you will get started today.
How do you use punch biopsies to determine the best treatment options?
My most important tips regarding alopecia diagnosis relate to scalp biopsies, which usually are required in distinguishing chronic cutaneous lupus erythematosus from other scarring alopecias. First, an absorbable gelatin compressed sponge is your best friend. A small strip inserted into the punch biopsy wound results in prompt hemostasis without the need for sutures, and the resulting scar often looks as good or better than that produced by suturing. Next, don’t biopsy the active advancing borders of an alopecia patch, as the findings usually are nonspecific. Instead, biopsy a well-established portion that has been present for at least 4 to 6 months but is still active. In inconclusive cases, a biopsy of a scarred area stained with Verhoeff elastic stain can demonstrate characteristic patterns of elastic tissue loss and often establish a diagnosis. It is important to distinguish chronic cutaneous lupus erythematosus from other forms of scarring alopecia, as it is more likely to respond to antimalarials.
What are your go-to treatments? Are your recommendations anecdotal or evidence based?
There isn’t an extensive arsenal of evidence-based therapy for refractory scarring alopecia, but that doesn’t mean we don’t have effective therapies; it simply means that our treatments are based on experience without accompanying randomized controlled trials. We need to produce more evidence, but patients with severe disease still need to be treated in the meantime. It’s important to remember that therapeutic complacency can result in permanent irreversible scarring. The presence of easily extractable anagen hairs is a sign of active disease. This simple test is helpful to monitor therapeutic progress.
Topical and intralesional corticosteroids can be extremely useful and often are underused. In general, the risk of scarring and atrophy from untreated disease is much greater than that from the corticosteroid. On the scalp, atrophy often presents as erythema, which should not be confused with erythema related to active disease. Dermoscopy is useful to demonstrate that the redness represents dermal atrophy with prominence of the subpapillary plexus of vessels.
When systemic therapy is required, antimalarials, retinoids, dapsone, thalidomide, sulfasalazine, mycophenolate mofetil, and methotrexate have all been used successfully in the setting of cutaneous lupus erythematosus, while topical tazarotene and topical calcineurin inhibitors are generally disappointing.
For the treatment of lichen planopilaris, intralesional corticosteroids, oral retinoids, and excimer laser can be effective. In contrast, antimalarials usually are not effective in preventing disease progression. The peroxisome proliferator-activated receptor-γ agonist pioglitazone can be effective, but reported results vary widely. In my experience, mycophenolate mofetil is generally reliable in patients with refractory disease. Dutasteride can be effective as a first-line therapy in the setting of frontal fibrosing alopecia, although some of the noted improvement may relate to the nonscarring portion of the disease in patients with a background of pattern alopecia.
How do you keep patients compliant with treatment?
Again, the key to treatment compliance is to establish an effective doctor-patient relationship. Whenever possible, begin with adequately potent therapy to give patients an early response. Don’t hesitate to use prednisone initially for inflammatory scarring alopecia. Patients need to see signs of progress in order to stay compliant with treatment, and long trials of ineffective therapies destroy trust. Adequate doses of intralesional or oral corticosteroids often are appropriate to ensure an early response with subsequent transition to steroid-sparing agents.
What do you do if they refuse treatment?
Try to find out why—often it’s simply fear of side effects. Patient education is key, and it can help tremendously to share with them the number of patients you have treated safely with the medication in question and assure them that you know how to monitor for the important side effects.
What resources do you recommend to patients for more information?
It is helpful to keep a handy list of patient advocacy Web sites. Well-established support groups such as the National Alopecia Areata Foundation (https://www.naaf.org) and the Cicatricial Alopecia Research Foundation (http://www.carfintl.org) provide excellent information for patients and help to support research to improve outcomes for these difficult disorders.
What does the patient need to know at the first visit?
When I communicate with alopecia patients at the first visit, I make sure they know that I’m there to help them—that I won’t minimize their concerns and that I understand how important their condition is to them. Alopecia can be frustrating for both the patient and the physician, and there often is a confounding background of psychosocial stress and/or a history of physicians who have dismissed the patient’s concerns about his or her hair loss as trivial. Establishing an effective doctor-patient relationship is key in treating alopecia. Physicians sometimes may be left feeling like the patient wants to keep them in the room until his or her hair regrows, but in reality you simply need to reassure the patient that you are comfortable with the evaluation and treatment of alopecia and that several steps will be required but you will get started today.
How do you use punch biopsies to determine the best treatment options?
My most important tips regarding alopecia diagnosis relate to scalp biopsies, which usually are required in distinguishing chronic cutaneous lupus erythematosus from other scarring alopecias. First, an absorbable gelatin compressed sponge is your best friend. A small strip inserted into the punch biopsy wound results in prompt hemostasis without the need for sutures, and the resulting scar often looks as good or better than that produced by suturing. Next, don’t biopsy the active advancing borders of an alopecia patch, as the findings usually are nonspecific. Instead, biopsy a well-established portion that has been present for at least 4 to 6 months but is still active. In inconclusive cases, a biopsy of a scarred area stained with Verhoeff elastic stain can demonstrate characteristic patterns of elastic tissue loss and often establish a diagnosis. It is important to distinguish chronic cutaneous lupus erythematosus from other forms of scarring alopecia, as it is more likely to respond to antimalarials.
What are your go-to treatments? Are your recommendations anecdotal or evidence based?
There isn’t an extensive arsenal of evidence-based therapy for refractory scarring alopecia, but that doesn’t mean we don’t have effective therapies; it simply means that our treatments are based on experience without accompanying randomized controlled trials. We need to produce more evidence, but patients with severe disease still need to be treated in the meantime. It’s important to remember that therapeutic complacency can result in permanent irreversible scarring. The presence of easily extractable anagen hairs is a sign of active disease. This simple test is helpful to monitor therapeutic progress.
Topical and intralesional corticosteroids can be extremely useful and often are underused. In general, the risk of scarring and atrophy from untreated disease is much greater than that from the corticosteroid. On the scalp, atrophy often presents as erythema, which should not be confused with erythema related to active disease. Dermoscopy is useful to demonstrate that the redness represents dermal atrophy with prominence of the subpapillary plexus of vessels.
When systemic therapy is required, antimalarials, retinoids, dapsone, thalidomide, sulfasalazine, mycophenolate mofetil, and methotrexate have all been used successfully in the setting of cutaneous lupus erythematosus, while topical tazarotene and topical calcineurin inhibitors are generally disappointing.
For the treatment of lichen planopilaris, intralesional corticosteroids, oral retinoids, and excimer laser can be effective. In contrast, antimalarials usually are not effective in preventing disease progression. The peroxisome proliferator-activated receptor-γ agonist pioglitazone can be effective, but reported results vary widely. In my experience, mycophenolate mofetil is generally reliable in patients with refractory disease. Dutasteride can be effective as a first-line therapy in the setting of frontal fibrosing alopecia, although some of the noted improvement may relate to the nonscarring portion of the disease in patients with a background of pattern alopecia.
How do you keep patients compliant with treatment?
Again, the key to treatment compliance is to establish an effective doctor-patient relationship. Whenever possible, begin with adequately potent therapy to give patients an early response. Don’t hesitate to use prednisone initially for inflammatory scarring alopecia. Patients need to see signs of progress in order to stay compliant with treatment, and long trials of ineffective therapies destroy trust. Adequate doses of intralesional or oral corticosteroids often are appropriate to ensure an early response with subsequent transition to steroid-sparing agents.
What do you do if they refuse treatment?
Try to find out why—often it’s simply fear of side effects. Patient education is key, and it can help tremendously to share with them the number of patients you have treated safely with the medication in question and assure them that you know how to monitor for the important side effects.
What resources do you recommend to patients for more information?
It is helpful to keep a handy list of patient advocacy Web sites. Well-established support groups such as the National Alopecia Areata Foundation (https://www.naaf.org) and the Cicatricial Alopecia Research Foundation (http://www.carfintl.org) provide excellent information for patients and help to support research to improve outcomes for these difficult disorders.
Spironolactone for Adult Female Acne
What should you do during the first visit for a patient you may start on spironolactone?
Some women will come in asking about spironolactone for acne, so it is important to identify potential candidates for antihormonal therapy:
- Women with acne flares that cycle with menstruation
- Women with adult-onset acne or persistent-recurrent acne past teenaged years, even in the absence of clinical or laboratory signs of hyperandrogenism
- Women on oral contraceptives (OCs) who exhibit moderate to severe acne, especially with a hormonal pattern clinically
- Women not responding to conventional therapy and not wanting to use oral isotretinoin or who are not candidates for oral isotretinoin
Evaluation of these women with acne for the possibility of hormonal imbalance may be necessary, with the 2 most common causes of hyperandrogenism being polycystic ovary syndrome and congenital adrenal hyperplasia. The presence of alopecia, hirsutism, acanthosis nigricans, or other signs of androgen excess, in combination with dysmenorrhea or amenorrhea, may be an indication that the patient has an underlying medical condition that needs to be addressed. Blood tests including testosterone, dehydroepiandrosterone, follicle-stimulating hormone, and luteinizing hormone would be appropriate screening tests and should be performed during the menstrual period or week prior; the patient should not be on an OC or have been on one within the last 6 weeks of testing.
Prior to initiating therapy with spironolactone, it is important to establish that there is no history of renal dysfunction; that the patient does not utilize salt substitutes, which may contain potassium in place of sodium; and that the patient is not taking potassium supplements, other potassium-sparing diuretics (ie, amiloride, triamterene), angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers.
Of note, the patient should not be currently or actively trying to become pregnant. Even though it has a category C rating, there is substantial theoretical risk for teratogenicity, especially in a male fetus (ie, feminization of a male fetus). However, there are no reports linking spironolactone with human congenital defects, and no well-controlled, prospective studies evaluating spironolactone exposure in pregnant women.
What does the patient need to know at the first visit?
Because patients have Dr. Internet on call within seconds on their smartphones and tablets, there are several points I review with patients as a semipreemptive strike.
Spironolactone is not approved by the US Food and Drug Administration for the treatment of acne; however, it has been used for decades for acne and even longer for the management of high blood pressure (since 1957!). Because it is a potassium-sparing diuretic, patients need to be careful not to get too much of a good thing (ie, potassium). I counsel patients on potassium intake, including sources such as diet (ie, fruit/fruit drinks), coconut water (very popular right now), and over-the-counter nutritional supplements.
Spironolactone is used in varying doses depending on the situation (25–200 mg daily), but it is important to start with a lower dose and escalate in a stepwise fashion, if needed, depending on how the patient is doing. I usually tell the patient it requires at least one boost in the dosage (around 50 mg twice daily) to appreciate notable results; however, patients will often have some improvement even at the lowest dose of 25 mg twice daily within 4 weeks of treatment initiation, which is when I have them return for reevaluation.
Spironolactone will help with acne on the face, back, and chest.
The majority of sides effects associated with spironolactone are dose dependent; low-dose therapy (25–50 mg daily) generally is well tolerated, and even 100 mg daily is not problematic in most cases. Dose-dependent side effects include frequent urination, menstrual irregularities, breast tenderness and/or enlargement, low blood pressure, hyperkalemia, and reduced libido. Of note, a recent study (Plovanich et al) found that the incidence of hyperkalemia in healthy young women taking spironolactone for acne is equivalent to the baseline rate of hyperkalemia in this specific population. Therefore, routine potassium monitoring is unnecessary for healthy women taking spironolactone for acne. I tend not to check potassium in these patients unless I head to higher doses due to poor response or I am treating female pattern alopecia, which often requires higher dosing.
Spironolactone has sufficient data to suggest that long-term use appears to be safe overall. There was one long-term study with patients who received spironolactone for up to 8 years for the treatment of acne vulgaris (Shaw and White).
Spironolactone can be used as monotherapy or in combination with OCs safely. In fact, by prescribing spironolactone in combination with OCs you can kill 3 birds with 1 stone from efficacy (the synergy between the two often allows for lower dosing of spironolactone without compromising impact), contraception prevention, and dysmenorrhea perspectives. I do offer OCs to eligible patients who are starting on spironolactone. In general, spironolactone can be used safely in combination with oral antibiotics, though oral antibiotic use should be short-term to limit rising rates of antimicrobial resistance. Of note, there may be risk for hyperkalemia when spironolactone is combined with trimethoprim-sulfamethoxazole, so its use should be avoided in this setting.
How do you keep patients compliant with treatment?
If androgens are playing a notable role in the patient’s acne, some response is usually noted by even the first return visit, which I always make for 4 weeks later, unlike with other acne treatment regimens, which I usually make for 7 to 8 weeks later. Even though most treatments require at least 8 weeks to show any sign of improvement, even spironolactone at times, close follow-up allows me to increase the dose, which is often needed, or change to another medication if the patient is not tolerating it. Given that I stress it will require taking the medication every day in a consistent fashion to allow me to effectively evaluate it, the short time frame between visits also enhances compliance, as it encourages the patient to actually take the medication and incorporate it into her routine.
What do you do if patients refuse treatment?
I always tell my patients they are the captains and I am helping them navigate through their disease. I will, however, discuss the chronicity of acne as well as the long-term sequelae of this inflammatory disease including scarring and postinflammatory pigment alteration for which there are no great treatments. I also tell them that if there is any issue with the medication, we simply stop, and the likelihood for severe adverse events is exceedingly low based on the evidence and anecdotal experience.
Suggested Readings
Plovanich M, Weng QY, Mostaghimi A. Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. JAMA Dermatol. 2015;151:941-944.
Schmidt TH, Shinkai K. Evidence-based approach to cutaneous hyperandrogenism in women. J Am Acad Dermatol. 2015;73:672-690.
Shaw JC, White LE. Long-term safety of spironolactone in acne: results of an 8-year followup study. J Cutan Med Surg. 2002;6:541-545.
What should you do during the first visit for a patient you may start on spironolactone?
Some women will come in asking about spironolactone for acne, so it is important to identify potential candidates for antihormonal therapy:
- Women with acne flares that cycle with menstruation
- Women with adult-onset acne or persistent-recurrent acne past teenaged years, even in the absence of clinical or laboratory signs of hyperandrogenism
- Women on oral contraceptives (OCs) who exhibit moderate to severe acne, especially with a hormonal pattern clinically
- Women not responding to conventional therapy and not wanting to use oral isotretinoin or who are not candidates for oral isotretinoin
Evaluation of these women with acne for the possibility of hormonal imbalance may be necessary, with the 2 most common causes of hyperandrogenism being polycystic ovary syndrome and congenital adrenal hyperplasia. The presence of alopecia, hirsutism, acanthosis nigricans, or other signs of androgen excess, in combination with dysmenorrhea or amenorrhea, may be an indication that the patient has an underlying medical condition that needs to be addressed. Blood tests including testosterone, dehydroepiandrosterone, follicle-stimulating hormone, and luteinizing hormone would be appropriate screening tests and should be performed during the menstrual period or week prior; the patient should not be on an OC or have been on one within the last 6 weeks of testing.
Prior to initiating therapy with spironolactone, it is important to establish that there is no history of renal dysfunction; that the patient does not utilize salt substitutes, which may contain potassium in place of sodium; and that the patient is not taking potassium supplements, other potassium-sparing diuretics (ie, amiloride, triamterene), angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers.
Of note, the patient should not be currently or actively trying to become pregnant. Even though it has a category C rating, there is substantial theoretical risk for teratogenicity, especially in a male fetus (ie, feminization of a male fetus). However, there are no reports linking spironolactone with human congenital defects, and no well-controlled, prospective studies evaluating spironolactone exposure in pregnant women.
What does the patient need to know at the first visit?
Because patients have Dr. Internet on call within seconds on their smartphones and tablets, there are several points I review with patients as a semipreemptive strike.
Spironolactone is not approved by the US Food and Drug Administration for the treatment of acne; however, it has been used for decades for acne and even longer for the management of high blood pressure (since 1957!). Because it is a potassium-sparing diuretic, patients need to be careful not to get too much of a good thing (ie, potassium). I counsel patients on potassium intake, including sources such as diet (ie, fruit/fruit drinks), coconut water (very popular right now), and over-the-counter nutritional supplements.
Spironolactone is used in varying doses depending on the situation (25–200 mg daily), but it is important to start with a lower dose and escalate in a stepwise fashion, if needed, depending on how the patient is doing. I usually tell the patient it requires at least one boost in the dosage (around 50 mg twice daily) to appreciate notable results; however, patients will often have some improvement even at the lowest dose of 25 mg twice daily within 4 weeks of treatment initiation, which is when I have them return for reevaluation.
Spironolactone will help with acne on the face, back, and chest.
The majority of sides effects associated with spironolactone are dose dependent; low-dose therapy (25–50 mg daily) generally is well tolerated, and even 100 mg daily is not problematic in most cases. Dose-dependent side effects include frequent urination, menstrual irregularities, breast tenderness and/or enlargement, low blood pressure, hyperkalemia, and reduced libido. Of note, a recent study (Plovanich et al) found that the incidence of hyperkalemia in healthy young women taking spironolactone for acne is equivalent to the baseline rate of hyperkalemia in this specific population. Therefore, routine potassium monitoring is unnecessary for healthy women taking spironolactone for acne. I tend not to check potassium in these patients unless I head to higher doses due to poor response or I am treating female pattern alopecia, which often requires higher dosing.
Spironolactone has sufficient data to suggest that long-term use appears to be safe overall. There was one long-term study with patients who received spironolactone for up to 8 years for the treatment of acne vulgaris (Shaw and White).
Spironolactone can be used as monotherapy or in combination with OCs safely. In fact, by prescribing spironolactone in combination with OCs you can kill 3 birds with 1 stone from efficacy (the synergy between the two often allows for lower dosing of spironolactone without compromising impact), contraception prevention, and dysmenorrhea perspectives. I do offer OCs to eligible patients who are starting on spironolactone. In general, spironolactone can be used safely in combination with oral antibiotics, though oral antibiotic use should be short-term to limit rising rates of antimicrobial resistance. Of note, there may be risk for hyperkalemia when spironolactone is combined with trimethoprim-sulfamethoxazole, so its use should be avoided in this setting.
How do you keep patients compliant with treatment?
If androgens are playing a notable role in the patient’s acne, some response is usually noted by even the first return visit, which I always make for 4 weeks later, unlike with other acne treatment regimens, which I usually make for 7 to 8 weeks later. Even though most treatments require at least 8 weeks to show any sign of improvement, even spironolactone at times, close follow-up allows me to increase the dose, which is often needed, or change to another medication if the patient is not tolerating it. Given that I stress it will require taking the medication every day in a consistent fashion to allow me to effectively evaluate it, the short time frame between visits also enhances compliance, as it encourages the patient to actually take the medication and incorporate it into her routine.
What do you do if patients refuse treatment?
I always tell my patients they are the captains and I am helping them navigate through their disease. I will, however, discuss the chronicity of acne as well as the long-term sequelae of this inflammatory disease including scarring and postinflammatory pigment alteration for which there are no great treatments. I also tell them that if there is any issue with the medication, we simply stop, and the likelihood for severe adverse events is exceedingly low based on the evidence and anecdotal experience.
What should you do during the first visit for a patient you may start on spironolactone?
Some women will come in asking about spironolactone for acne, so it is important to identify potential candidates for antihormonal therapy:
- Women with acne flares that cycle with menstruation
- Women with adult-onset acne or persistent-recurrent acne past teenaged years, even in the absence of clinical or laboratory signs of hyperandrogenism
- Women on oral contraceptives (OCs) who exhibit moderate to severe acne, especially with a hormonal pattern clinically
- Women not responding to conventional therapy and not wanting to use oral isotretinoin or who are not candidates for oral isotretinoin
Evaluation of these women with acne for the possibility of hormonal imbalance may be necessary, with the 2 most common causes of hyperandrogenism being polycystic ovary syndrome and congenital adrenal hyperplasia. The presence of alopecia, hirsutism, acanthosis nigricans, or other signs of androgen excess, in combination with dysmenorrhea or amenorrhea, may be an indication that the patient has an underlying medical condition that needs to be addressed. Blood tests including testosterone, dehydroepiandrosterone, follicle-stimulating hormone, and luteinizing hormone would be appropriate screening tests and should be performed during the menstrual period or week prior; the patient should not be on an OC or have been on one within the last 6 weeks of testing.
Prior to initiating therapy with spironolactone, it is important to establish that there is no history of renal dysfunction; that the patient does not utilize salt substitutes, which may contain potassium in place of sodium; and that the patient is not taking potassium supplements, other potassium-sparing diuretics (ie, amiloride, triamterene), angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers.
Of note, the patient should not be currently or actively trying to become pregnant. Even though it has a category C rating, there is substantial theoretical risk for teratogenicity, especially in a male fetus (ie, feminization of a male fetus). However, there are no reports linking spironolactone with human congenital defects, and no well-controlled, prospective studies evaluating spironolactone exposure in pregnant women.
What does the patient need to know at the first visit?
Because patients have Dr. Internet on call within seconds on their smartphones and tablets, there are several points I review with patients as a semipreemptive strike.
Spironolactone is not approved by the US Food and Drug Administration for the treatment of acne; however, it has been used for decades for acne and even longer for the management of high blood pressure (since 1957!). Because it is a potassium-sparing diuretic, patients need to be careful not to get too much of a good thing (ie, potassium). I counsel patients on potassium intake, including sources such as diet (ie, fruit/fruit drinks), coconut water (very popular right now), and over-the-counter nutritional supplements.
Spironolactone is used in varying doses depending on the situation (25–200 mg daily), but it is important to start with a lower dose and escalate in a stepwise fashion, if needed, depending on how the patient is doing. I usually tell the patient it requires at least one boost in the dosage (around 50 mg twice daily) to appreciate notable results; however, patients will often have some improvement even at the lowest dose of 25 mg twice daily within 4 weeks of treatment initiation, which is when I have them return for reevaluation.
Spironolactone will help with acne on the face, back, and chest.
The majority of sides effects associated with spironolactone are dose dependent; low-dose therapy (25–50 mg daily) generally is well tolerated, and even 100 mg daily is not problematic in most cases. Dose-dependent side effects include frequent urination, menstrual irregularities, breast tenderness and/or enlargement, low blood pressure, hyperkalemia, and reduced libido. Of note, a recent study (Plovanich et al) found that the incidence of hyperkalemia in healthy young women taking spironolactone for acne is equivalent to the baseline rate of hyperkalemia in this specific population. Therefore, routine potassium monitoring is unnecessary for healthy women taking spironolactone for acne. I tend not to check potassium in these patients unless I head to higher doses due to poor response or I am treating female pattern alopecia, which often requires higher dosing.
Spironolactone has sufficient data to suggest that long-term use appears to be safe overall. There was one long-term study with patients who received spironolactone for up to 8 years for the treatment of acne vulgaris (Shaw and White).
Spironolactone can be used as monotherapy or in combination with OCs safely. In fact, by prescribing spironolactone in combination with OCs you can kill 3 birds with 1 stone from efficacy (the synergy between the two often allows for lower dosing of spironolactone without compromising impact), contraception prevention, and dysmenorrhea perspectives. I do offer OCs to eligible patients who are starting on spironolactone. In general, spironolactone can be used safely in combination with oral antibiotics, though oral antibiotic use should be short-term to limit rising rates of antimicrobial resistance. Of note, there may be risk for hyperkalemia when spironolactone is combined with trimethoprim-sulfamethoxazole, so its use should be avoided in this setting.
How do you keep patients compliant with treatment?
If androgens are playing a notable role in the patient’s acne, some response is usually noted by even the first return visit, which I always make for 4 weeks later, unlike with other acne treatment regimens, which I usually make for 7 to 8 weeks later. Even though most treatments require at least 8 weeks to show any sign of improvement, even spironolactone at times, close follow-up allows me to increase the dose, which is often needed, or change to another medication if the patient is not tolerating it. Given that I stress it will require taking the medication every day in a consistent fashion to allow me to effectively evaluate it, the short time frame between visits also enhances compliance, as it encourages the patient to actually take the medication and incorporate it into her routine.
What do you do if patients refuse treatment?
I always tell my patients they are the captains and I am helping them navigate through their disease. I will, however, discuss the chronicity of acne as well as the long-term sequelae of this inflammatory disease including scarring and postinflammatory pigment alteration for which there are no great treatments. I also tell them that if there is any issue with the medication, we simply stop, and the likelihood for severe adverse events is exceedingly low based on the evidence and anecdotal experience.
Suggested Readings
Plovanich M, Weng QY, Mostaghimi A. Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. JAMA Dermatol. 2015;151:941-944.
Schmidt TH, Shinkai K. Evidence-based approach to cutaneous hyperandrogenism in women. J Am Acad Dermatol. 2015;73:672-690.
Shaw JC, White LE. Long-term safety of spironolactone in acne: results of an 8-year followup study. J Cutan Med Surg. 2002;6:541-545.
Suggested Readings
Plovanich M, Weng QY, Mostaghimi A. Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. JAMA Dermatol. 2015;151:941-944.
Schmidt TH, Shinkai K. Evidence-based approach to cutaneous hyperandrogenism in women. J Am Acad Dermatol. 2015;73:672-690.
Shaw JC, White LE. Long-term safety of spironolactone in acne: results of an 8-year followup study. J Cutan Med Surg. 2002;6:541-545.
Individualizing Care for Melanoma Patients
What does your patient need to know at the first visit?
Melanoma patient visits and communications are complicated. When possible, you can preview the surgical and prognostic expectations with the patient when you see the lesion clinically for the first time, especially for a lesion that you’re sure is melanoma before it even hits the specimen cup. Sometimes you have to convey important biopsy and treatment information over the telephone, or sometimes you have the luxury of an extra clinic visit to discuss it with the patient and perhaps a family member in person.
During the first set of conversations, I explain the things that are tangible: the depth of the lesion, the relationship it has to prognosis, surgical options based on staging, further testing/referrals, and known risk factors. Then I wait. The digestion phase is critical before you hang up and schedule a surgery.
Probably the most important thing I tell patients is that melanoma is unpredictable. Not everyone has the same kind of “surgery,” we don’t say “remission,” we don’t have a certain “chemo” that we know will be best, and not everyone will need “CAT scans.” I tell patients that they’re stuck with me. Skin examinations, talk of sun protection, photography of nevi, upkeep of health maintenance visits with other specialists (eg, primary care physician, optometry/ophthalmology, gynecology, dentistry), and education of family members on melanoma risk factors will be the norm.
What are your go-to treatments?
In the past, surgical management was perhaps streamlined, but as we learn more about melanoma tumor biology, the less we can form generalizable guidelines for surgery, margin control, and lymph node perusal. Wide local excision is paramount, but the evidence that guidelines for 0.5-cm, 1-cm, and 2-cm margins or greater fit for all types of tumors is lacking, and many have challenged the recommended margins, particularly for lentigo maligna subtypes (Kunishige et al).
The 0.75-mm Breslow depth threshold guides my sentinel lymph node (SLN) discussion, with upstaging based on primary tumor mitotic index and/or ulceration. But SLN biopsy is always still a discussion and not a foregone conclusion because the risk-benefit ratio and prognostic/survival data are very difficult to dissect for some cases. Certainly, mention of SLN biopsy morbidity, including lymphedema, is warranted before the patient consents. Then there is further explanation that more invasive lymphadenectomy could occur based on SLN findings. If applicable in advanced cases, options for imaging and adjuvant therapy are introduced by us but then primarily led by oncologists.
Patients are generally pleased that the approach to melanoma surgery, reconstruction, SLN biopsy, and oncologic care is increasingly becoming (almost) harmoniously multidisciplinary. Larger institutions have streamlined their melanoma providers into shared clinics or at least regional networks—dermatologists, plastic/otolaryngology/oncologic surgeons, oncologists, and radiation oncologists, for instance—and simplified patient access based on individual tumor treatment plans. Dr. Christopher J. Miller at Penn Medicine (Philadelphia, Pennsylvania) is excelling at a collaborative surgical approach for melanoma between dermatologic surgery and specialties such as otolaryngology and also spearheading the Mohs micrographic surgery approach for primary melanoma as possible standard of care for some cases (Etzkorn et al).
Also evolving is the access to clinical trials and care coordination regarding the most novel metastatic melanoma therapies, which can now be a short drive away for most patients as the National Cancer Institute broadens its clinical trial reach.
After the diagnosis of melanoma is made, care is becoming much more individualized for surgery and beyond, but true morbidity and mortality benefit for the more complicated regimens has become anybody’s guess as this research field grossly and rapidly swells. Then these discussions with the patient become longer and more open-ended.
How do you keep patients compliant with treatment?
Initial surgery and multidisciplinary management requires meticulous communication between providers to ensure that pathology reports, surgical findings, imaging, wound care, and follow-up are transparent. The easier it is for patients to navigate the medical system(s), the more likely they are to comply. Voicemail, e-mails, text messages, and/or mailings are standard for different offices for reminders, but an old-fashioned telephone call goes a long way for a patient who has melanoma on his/her mind. Adherence to sun protection, health maintenance, and skin examination appointments is then the challenge.
Sun protection strategies were well-represented in the Cutis July issue’s Practical Pearls featuring Dr. Vincent A. DeLeo. My script for sunscreen-averse patients as I leave the room is “Take a mosey through the sunscreen aisle. You may be surprised at what you find.” And sporting goods stores are chock full of UPF (UV protection factor) clothing options. I’m not a scolder, but I do utilize the power of repetition/the squeaky wheel.
Patient delay or cancellation of skin checks requires other types of surveillance. Here at Geisinger Health System (State College, Pennsylvania), when melanoma patients check out, they are placed in a “priority appointment” slot, meaning that if they cancel, their names are automatically put on an electronic list that is compiled weekly by our schedulers to ensure that patients are called for another appointment. To avert telephone tag and delay of care, melanoma patients also get our direct nurses station extension and are encouraged to use our chart e-mail system to communicate with us if they notice a new or changing skin lesion.
What do you do if they refuse treatment?
Initial consent and compliance with melanoma wide local excision are rarely challenged by a well-informed patient, but what I find more common is delay in treatment and nonadherence to periodic skin examinations.
What resources do you recommend to patients for more information?
The National Comprehensive Cancer Network clini-cal practice guideline resource in oncology (melanoma) is the place to start, as their Web site is easily naviga-ble for patients and providers (http://www.nccn.org).
The American Academy of Dermatology (http://www.aad.org) and Skin Cancer Foundation (http://www.skincancer.org) Web sites also provide useful information, and there are always copies of their key melanoma and nevi surveillance pamphlets in our office.
Most recently, my melanoma patients have been inspired by another local patient and her cause: a 28-year-old woman with metastatic melanoma on a National Cancer Institute BRAF inhibitor clinical trial who plans to run an Ironman race this year (Thomason, Ames). Her motivation to maintain her baseline health and fitness while still reaching for this further remarkable goal gives fellow melanoma patients a source for enthusiasm and hope.
Inspiration and adherence come in all shapes and sizes for patients with melanoma. I find you need to throw multiple resources and strategies at them and see what sticks.
Suggested Readings
Ames C. Local runner fights cancer. WeAreCentralPA Web site. http://www.wearecentralpa.com/news/local-runner-fights -cancer#.VZw92-pJ2AU.mailto. Published June 30, 2015. Accessed August 14, 2015.
DeLeo VA. Patient compliance with photoprotection. Cutis. 2015;96:13-14.
Etzkorn JR, Sobanko JF, Elenitsas R, et al. Low recurrence rates for in situ and invasive melanomas using Mohs micrographic surgery with melanoma antigen recognized by T cells 1 (MART-1) immunostaining: tissue processing methodology to optimize pathologic staging and margin assessment. J Am Acad Dermatol. 2015;72:840-850.
Kunishige JH, Brodland DG, Zitelli JA. Larger surgical margins are required for lentigo maligna and other melanoma in situ. J Am Acad Dermatol. 2012;67:1069-1071.
NCCN clinical practice guidelines in oncology: melanoma. National Comprehensive Cancer Network Web site. http://www.nccn.org/professionals/physician_gls/pdf/melanoma.pdf. Updated March 11, 2015. Accessed August 14, 2015.
Thomason M. My story: April Salinas. Live In Our Skinz! Blog. http://blog.uvskinz.com/2015/01/30/my-story-april -salinas/#sthash.yvSRVglT.YGLDn95T.dpbs. Published January 30, 2015. Accessed August 14, 2015.
What does your patient need to know at the first visit?
Melanoma patient visits and communications are complicated. When possible, you can preview the surgical and prognostic expectations with the patient when you see the lesion clinically for the first time, especially for a lesion that you’re sure is melanoma before it even hits the specimen cup. Sometimes you have to convey important biopsy and treatment information over the telephone, or sometimes you have the luxury of an extra clinic visit to discuss it with the patient and perhaps a family member in person.
During the first set of conversations, I explain the things that are tangible: the depth of the lesion, the relationship it has to prognosis, surgical options based on staging, further testing/referrals, and known risk factors. Then I wait. The digestion phase is critical before you hang up and schedule a surgery.
Probably the most important thing I tell patients is that melanoma is unpredictable. Not everyone has the same kind of “surgery,” we don’t say “remission,” we don’t have a certain “chemo” that we know will be best, and not everyone will need “CAT scans.” I tell patients that they’re stuck with me. Skin examinations, talk of sun protection, photography of nevi, upkeep of health maintenance visits with other specialists (eg, primary care physician, optometry/ophthalmology, gynecology, dentistry), and education of family members on melanoma risk factors will be the norm.
What are your go-to treatments?
In the past, surgical management was perhaps streamlined, but as we learn more about melanoma tumor biology, the less we can form generalizable guidelines for surgery, margin control, and lymph node perusal. Wide local excision is paramount, but the evidence that guidelines for 0.5-cm, 1-cm, and 2-cm margins or greater fit for all types of tumors is lacking, and many have challenged the recommended margins, particularly for lentigo maligna subtypes (Kunishige et al).
The 0.75-mm Breslow depth threshold guides my sentinel lymph node (SLN) discussion, with upstaging based on primary tumor mitotic index and/or ulceration. But SLN biopsy is always still a discussion and not a foregone conclusion because the risk-benefit ratio and prognostic/survival data are very difficult to dissect for some cases. Certainly, mention of SLN biopsy morbidity, including lymphedema, is warranted before the patient consents. Then there is further explanation that more invasive lymphadenectomy could occur based on SLN findings. If applicable in advanced cases, options for imaging and adjuvant therapy are introduced by us but then primarily led by oncologists.
Patients are generally pleased that the approach to melanoma surgery, reconstruction, SLN biopsy, and oncologic care is increasingly becoming (almost) harmoniously multidisciplinary. Larger institutions have streamlined their melanoma providers into shared clinics or at least regional networks—dermatologists, plastic/otolaryngology/oncologic surgeons, oncologists, and radiation oncologists, for instance—and simplified patient access based on individual tumor treatment plans. Dr. Christopher J. Miller at Penn Medicine (Philadelphia, Pennsylvania) is excelling at a collaborative surgical approach for melanoma between dermatologic surgery and specialties such as otolaryngology and also spearheading the Mohs micrographic surgery approach for primary melanoma as possible standard of care for some cases (Etzkorn et al).
Also evolving is the access to clinical trials and care coordination regarding the most novel metastatic melanoma therapies, which can now be a short drive away for most patients as the National Cancer Institute broadens its clinical trial reach.
After the diagnosis of melanoma is made, care is becoming much more individualized for surgery and beyond, but true morbidity and mortality benefit for the more complicated regimens has become anybody’s guess as this research field grossly and rapidly swells. Then these discussions with the patient become longer and more open-ended.
How do you keep patients compliant with treatment?
Initial surgery and multidisciplinary management requires meticulous communication between providers to ensure that pathology reports, surgical findings, imaging, wound care, and follow-up are transparent. The easier it is for patients to navigate the medical system(s), the more likely they are to comply. Voicemail, e-mails, text messages, and/or mailings are standard for different offices for reminders, but an old-fashioned telephone call goes a long way for a patient who has melanoma on his/her mind. Adherence to sun protection, health maintenance, and skin examination appointments is then the challenge.
Sun protection strategies were well-represented in the Cutis July issue’s Practical Pearls featuring Dr. Vincent A. DeLeo. My script for sunscreen-averse patients as I leave the room is “Take a mosey through the sunscreen aisle. You may be surprised at what you find.” And sporting goods stores are chock full of UPF (UV protection factor) clothing options. I’m not a scolder, but I do utilize the power of repetition/the squeaky wheel.
Patient delay or cancellation of skin checks requires other types of surveillance. Here at Geisinger Health System (State College, Pennsylvania), when melanoma patients check out, they are placed in a “priority appointment” slot, meaning that if they cancel, their names are automatically put on an electronic list that is compiled weekly by our schedulers to ensure that patients are called for another appointment. To avert telephone tag and delay of care, melanoma patients also get our direct nurses station extension and are encouraged to use our chart e-mail system to communicate with us if they notice a new or changing skin lesion.
What do you do if they refuse treatment?
Initial consent and compliance with melanoma wide local excision are rarely challenged by a well-informed patient, but what I find more common is delay in treatment and nonadherence to periodic skin examinations.
What resources do you recommend to patients for more information?
The National Comprehensive Cancer Network clini-cal practice guideline resource in oncology (melanoma) is the place to start, as their Web site is easily naviga-ble for patients and providers (http://www.nccn.org).
The American Academy of Dermatology (http://www.aad.org) and Skin Cancer Foundation (http://www.skincancer.org) Web sites also provide useful information, and there are always copies of their key melanoma and nevi surveillance pamphlets in our office.
Most recently, my melanoma patients have been inspired by another local patient and her cause: a 28-year-old woman with metastatic melanoma on a National Cancer Institute BRAF inhibitor clinical trial who plans to run an Ironman race this year (Thomason, Ames). Her motivation to maintain her baseline health and fitness while still reaching for this further remarkable goal gives fellow melanoma patients a source for enthusiasm and hope.
Inspiration and adherence come in all shapes and sizes for patients with melanoma. I find you need to throw multiple resources and strategies at them and see what sticks.
What does your patient need to know at the first visit?
Melanoma patient visits and communications are complicated. When possible, you can preview the surgical and prognostic expectations with the patient when you see the lesion clinically for the first time, especially for a lesion that you’re sure is melanoma before it even hits the specimen cup. Sometimes you have to convey important biopsy and treatment information over the telephone, or sometimes you have the luxury of an extra clinic visit to discuss it with the patient and perhaps a family member in person.
During the first set of conversations, I explain the things that are tangible: the depth of the lesion, the relationship it has to prognosis, surgical options based on staging, further testing/referrals, and known risk factors. Then I wait. The digestion phase is critical before you hang up and schedule a surgery.
Probably the most important thing I tell patients is that melanoma is unpredictable. Not everyone has the same kind of “surgery,” we don’t say “remission,” we don’t have a certain “chemo” that we know will be best, and not everyone will need “CAT scans.” I tell patients that they’re stuck with me. Skin examinations, talk of sun protection, photography of nevi, upkeep of health maintenance visits with other specialists (eg, primary care physician, optometry/ophthalmology, gynecology, dentistry), and education of family members on melanoma risk factors will be the norm.
What are your go-to treatments?
In the past, surgical management was perhaps streamlined, but as we learn more about melanoma tumor biology, the less we can form generalizable guidelines for surgery, margin control, and lymph node perusal. Wide local excision is paramount, but the evidence that guidelines for 0.5-cm, 1-cm, and 2-cm margins or greater fit for all types of tumors is lacking, and many have challenged the recommended margins, particularly for lentigo maligna subtypes (Kunishige et al).
The 0.75-mm Breslow depth threshold guides my sentinel lymph node (SLN) discussion, with upstaging based on primary tumor mitotic index and/or ulceration. But SLN biopsy is always still a discussion and not a foregone conclusion because the risk-benefit ratio and prognostic/survival data are very difficult to dissect for some cases. Certainly, mention of SLN biopsy morbidity, including lymphedema, is warranted before the patient consents. Then there is further explanation that more invasive lymphadenectomy could occur based on SLN findings. If applicable in advanced cases, options for imaging and adjuvant therapy are introduced by us but then primarily led by oncologists.
Patients are generally pleased that the approach to melanoma surgery, reconstruction, SLN biopsy, and oncologic care is increasingly becoming (almost) harmoniously multidisciplinary. Larger institutions have streamlined their melanoma providers into shared clinics or at least regional networks—dermatologists, plastic/otolaryngology/oncologic surgeons, oncologists, and radiation oncologists, for instance—and simplified patient access based on individual tumor treatment plans. Dr. Christopher J. Miller at Penn Medicine (Philadelphia, Pennsylvania) is excelling at a collaborative surgical approach for melanoma between dermatologic surgery and specialties such as otolaryngology and also spearheading the Mohs micrographic surgery approach for primary melanoma as possible standard of care for some cases (Etzkorn et al).
Also evolving is the access to clinical trials and care coordination regarding the most novel metastatic melanoma therapies, which can now be a short drive away for most patients as the National Cancer Institute broadens its clinical trial reach.
After the diagnosis of melanoma is made, care is becoming much more individualized for surgery and beyond, but true morbidity and mortality benefit for the more complicated regimens has become anybody’s guess as this research field grossly and rapidly swells. Then these discussions with the patient become longer and more open-ended.
How do you keep patients compliant with treatment?
Initial surgery and multidisciplinary management requires meticulous communication between providers to ensure that pathology reports, surgical findings, imaging, wound care, and follow-up are transparent. The easier it is for patients to navigate the medical system(s), the more likely they are to comply. Voicemail, e-mails, text messages, and/or mailings are standard for different offices for reminders, but an old-fashioned telephone call goes a long way for a patient who has melanoma on his/her mind. Adherence to sun protection, health maintenance, and skin examination appointments is then the challenge.
Sun protection strategies were well-represented in the Cutis July issue’s Practical Pearls featuring Dr. Vincent A. DeLeo. My script for sunscreen-averse patients as I leave the room is “Take a mosey through the sunscreen aisle. You may be surprised at what you find.” And sporting goods stores are chock full of UPF (UV protection factor) clothing options. I’m not a scolder, but I do utilize the power of repetition/the squeaky wheel.
Patient delay or cancellation of skin checks requires other types of surveillance. Here at Geisinger Health System (State College, Pennsylvania), when melanoma patients check out, they are placed in a “priority appointment” slot, meaning that if they cancel, their names are automatically put on an electronic list that is compiled weekly by our schedulers to ensure that patients are called for another appointment. To avert telephone tag and delay of care, melanoma patients also get our direct nurses station extension and are encouraged to use our chart e-mail system to communicate with us if they notice a new or changing skin lesion.
What do you do if they refuse treatment?
Initial consent and compliance with melanoma wide local excision are rarely challenged by a well-informed patient, but what I find more common is delay in treatment and nonadherence to periodic skin examinations.
What resources do you recommend to patients for more information?
The National Comprehensive Cancer Network clini-cal practice guideline resource in oncology (melanoma) is the place to start, as their Web site is easily naviga-ble for patients and providers (http://www.nccn.org).
The American Academy of Dermatology (http://www.aad.org) and Skin Cancer Foundation (http://www.skincancer.org) Web sites also provide useful information, and there are always copies of their key melanoma and nevi surveillance pamphlets in our office.
Most recently, my melanoma patients have been inspired by another local patient and her cause: a 28-year-old woman with metastatic melanoma on a National Cancer Institute BRAF inhibitor clinical trial who plans to run an Ironman race this year (Thomason, Ames). Her motivation to maintain her baseline health and fitness while still reaching for this further remarkable goal gives fellow melanoma patients a source for enthusiasm and hope.
Inspiration and adherence come in all shapes and sizes for patients with melanoma. I find you need to throw multiple resources and strategies at them and see what sticks.
Suggested Readings
Ames C. Local runner fights cancer. WeAreCentralPA Web site. http://www.wearecentralpa.com/news/local-runner-fights -cancer#.VZw92-pJ2AU.mailto. Published June 30, 2015. Accessed August 14, 2015.
DeLeo VA. Patient compliance with photoprotection. Cutis. 2015;96:13-14.
Etzkorn JR, Sobanko JF, Elenitsas R, et al. Low recurrence rates for in situ and invasive melanomas using Mohs micrographic surgery with melanoma antigen recognized by T cells 1 (MART-1) immunostaining: tissue processing methodology to optimize pathologic staging and margin assessment. J Am Acad Dermatol. 2015;72:840-850.
Kunishige JH, Brodland DG, Zitelli JA. Larger surgical margins are required for lentigo maligna and other melanoma in situ. J Am Acad Dermatol. 2012;67:1069-1071.
NCCN clinical practice guidelines in oncology: melanoma. National Comprehensive Cancer Network Web site. http://www.nccn.org/professionals/physician_gls/pdf/melanoma.pdf. Updated March 11, 2015. Accessed August 14, 2015.
Thomason M. My story: April Salinas. Live In Our Skinz! Blog. http://blog.uvskinz.com/2015/01/30/my-story-april -salinas/#sthash.yvSRVglT.YGLDn95T.dpbs. Published January 30, 2015. Accessed August 14, 2015.
Suggested Readings
Ames C. Local runner fights cancer. WeAreCentralPA Web site. http://www.wearecentralpa.com/news/local-runner-fights -cancer#.VZw92-pJ2AU.mailto. Published June 30, 2015. Accessed August 14, 2015.
DeLeo VA. Patient compliance with photoprotection. Cutis. 2015;96:13-14.
Etzkorn JR, Sobanko JF, Elenitsas R, et al. Low recurrence rates for in situ and invasive melanomas using Mohs micrographic surgery with melanoma antigen recognized by T cells 1 (MART-1) immunostaining: tissue processing methodology to optimize pathologic staging and margin assessment. J Am Acad Dermatol. 2015;72:840-850.
Kunishige JH, Brodland DG, Zitelli JA. Larger surgical margins are required for lentigo maligna and other melanoma in situ. J Am Acad Dermatol. 2012;67:1069-1071.
NCCN clinical practice guidelines in oncology: melanoma. National Comprehensive Cancer Network Web site. http://www.nccn.org/professionals/physician_gls/pdf/melanoma.pdf. Updated March 11, 2015. Accessed August 14, 2015.
Thomason M. My story: April Salinas. Live In Our Skinz! Blog. http://blog.uvskinz.com/2015/01/30/my-story-april -salinas/#sthash.yvSRVglT.YGLDn95T.dpbs. Published January 30, 2015. Accessed August 14, 2015.
Treating Psoriasis in Pregnant Women
What do your patients need to know at the first visit?
Pregnant patients need to know that it is important to carefully monitor them throughout their pregnancy. Although many drugs are not contraindicated, it is still important for the dermatologist to consult with the patient’s obstetrician to discuss risks and benefits of different therapies. Some women see an improvement in the severity of their psoriasis during pregnancy, while others report their condition gets worse. Changes in severity of psoriasis vary by individual and from pregnancy to pregnancy.
What are your go-to treatments? What are the side effects?
UV therapy, particularly narrowband UVB, is a good choice during pregnancy. Excimer laser is another good choice. Topical therapies are standardly employed. Although many of these topical therapies are pregnancy category C, we still employ them regularly in consultation with the patient’s obstetrician. Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry (http: //www.pregnancystudies.org) would be good options. This registry is analyzing whether medications that are used to treat autoimmune diseases are safe to take during pregnancy. Specifically, the investigators are looking at medications used to treat Crohn disease, rheumatoid arthritis, psoriasis, psoriatic arthritis, and multiple sclerosis. Generally speaking, systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Women of childbearing potential should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects with each of those treatments.
How do you keep patients compliant with treatment?
We see the patients regularly, and I am always available to take telephone calls if any questions arise.
What do you do if patients refuse treatment?
We keep the dialogue ongoing and monitor their condition. They may change their attitude if their condition worsens.
What resources do you recommend to patients for more information?
Patients should consult the National Psoriasis Foundation (http://www.psoriasis.org).
What do your patients need to know at the first visit?
Pregnant patients need to know that it is important to carefully monitor them throughout their pregnancy. Although many drugs are not contraindicated, it is still important for the dermatologist to consult with the patient’s obstetrician to discuss risks and benefits of different therapies. Some women see an improvement in the severity of their psoriasis during pregnancy, while others report their condition gets worse. Changes in severity of psoriasis vary by individual and from pregnancy to pregnancy.
What are your go-to treatments? What are the side effects?
UV therapy, particularly narrowband UVB, is a good choice during pregnancy. Excimer laser is another good choice. Topical therapies are standardly employed. Although many of these topical therapies are pregnancy category C, we still employ them regularly in consultation with the patient’s obstetrician. Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry (http: //www.pregnancystudies.org) would be good options. This registry is analyzing whether medications that are used to treat autoimmune diseases are safe to take during pregnancy. Specifically, the investigators are looking at medications used to treat Crohn disease, rheumatoid arthritis, psoriasis, psoriatic arthritis, and multiple sclerosis. Generally speaking, systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Women of childbearing potential should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects with each of those treatments.
How do you keep patients compliant with treatment?
We see the patients regularly, and I am always available to take telephone calls if any questions arise.
What do you do if patients refuse treatment?
We keep the dialogue ongoing and monitor their condition. They may change their attitude if their condition worsens.
What resources do you recommend to patients for more information?
Patients should consult the National Psoriasis Foundation (http://www.psoriasis.org).
What do your patients need to know at the first visit?
Pregnant patients need to know that it is important to carefully monitor them throughout their pregnancy. Although many drugs are not contraindicated, it is still important for the dermatologist to consult with the patient’s obstetrician to discuss risks and benefits of different therapies. Some women see an improvement in the severity of their psoriasis during pregnancy, while others report their condition gets worse. Changes in severity of psoriasis vary by individual and from pregnancy to pregnancy.
What are your go-to treatments? What are the side effects?
UV therapy, particularly narrowband UVB, is a good choice during pregnancy. Excimer laser is another good choice. Topical therapies are standardly employed. Although many of these topical therapies are pregnancy category C, we still employ them regularly in consultation with the patient’s obstetrician. Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry (http: //www.pregnancystudies.org) would be good options. This registry is analyzing whether medications that are used to treat autoimmune diseases are safe to take during pregnancy. Specifically, the investigators are looking at medications used to treat Crohn disease, rheumatoid arthritis, psoriasis, psoriatic arthritis, and multiple sclerosis. Generally speaking, systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Women of childbearing potential should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects with each of those treatments.
How do you keep patients compliant with treatment?
We see the patients regularly, and I am always available to take telephone calls if any questions arise.
What do you do if patients refuse treatment?
We keep the dialogue ongoing and monitor their condition. They may change their attitude if their condition worsens.
What resources do you recommend to patients for more information?
Patients should consult the National Psoriasis Foundation (http://www.psoriasis.org).
Patient Compliance With Photoprotection
What does your patient need to know at the first visit?
Patients need a realistic approach to photoprotection based on their genetics, including Fitzpatrick skin type and family history of melanoma and nonmelanoma skin cancer; skin examination for photodamage and photoaging as well as number and type of pigmented lesions; and lifestyle history, which should include location of residence as well as occupation and recreational pursuits. This discussion should, as usual, include questions about general health, systemic and skin disease, and medication usage, with particular focus on photoaggravated diseases such as lupus and melasma as well as ongoing use of topical agents and systemic photosensitizers. These inquiries should lead to a frank discussion of the patient’s risk for developing photodamage and skin cancer and other specific conditions that alter the advice you would give.
What are your go-to treatments? Is your recommendation anecdotal or evidence based? What are the side effects?
I always recommend that my patients use a product that they like, which may sound simplistic. But if the patient doesn’t like the feel and look of the sunscreen, he/she won’t use it. Patients routinely should use a sunscreen with a sun protection factor (SPF) of 30 or higher that also carries a “broad spectrum” label. At the beach or during sweaty sports, patients should use one with a water-resistant SPF.
I prefer spray sunscreens for application on the back if the patient is alone without someone to help apply sunscreen to hard-to-reach areas and for male scalps. But you never know how much spray to use, so use a lot!
If patients are at the beach, playing sports, or watching sports outside, then they should reapply sunscreen every 2 hours. If patients work indoors and use a facial sunscreen in the morning, that’s sufficient.
Although there is no evidence that sunscreens are harmful for children older than 6 months of age and pregnant women, if patients in these special populations have concerns, I recommend using agents with inorganic compounds (physical blockers) such as titanium dioxide and zinc oxide only. Children are best protected with clothing and hats.
The evidence supports this approach. Patients really don’t need SPF 30 protection, but no one uses the amount of product that will result in the SPF listed on the bottle. So if patients use an SPF 30 or greater, they will get at least an SPF 15, which is sufficient everywhere but at the equator. Using SPF 30 the way we all apply it will give SPF 15–level protection.
There is evidence that sunscreens prevent squamous cell carcinoma, actinic keratosis, and photoaging. Early evidence, less strong but positive, also suggests protection against basal cell carcinoma and melanoma.
The biggest side effect is not using the sunscreen. Others include irritation and allergy. Irritation is common, but finding a product to use without irritation should be easy. Allergy is rarer, and when it occurs, it is usually due to the preservative or fragrance, not the active ingredients. If allergy does occur, patch testing by a dermatologist is necessary to determine the allergen.
Although it is still controversial, wearing sunscreens religiously can lead to vitamin D insufficiency or deficiency, which is particularly true for individuals with skin of color—Fitzpatrick skin types IV, V, and VI—and those cancer patients who adhere to rigorous photoprotection. These patients should be encouraged to take supplemental vitamin D3 and I suggest 2000 IU; this recommendation is my opinion and is not evidence based.
As to the literature in the laypress about hormonal changes from benzophenone, cancer from retinoids, and nanoparticle toxicity: There is no evidence to support those claims.
How do you keep patients compliant with treatment?
Keep telling them, and then tell them again.
What do you do if they refuse treatment?
Tell them to see someone else.
What resources do you recommend to patients for more information?
Consult the American Academy of Dermatology Web site (www.aad.org) and the Skin Cancer Foundation (www.skincancer.org).
Editorial Note
Practical Pearls From the Cutis® Board is a new feature that will appear in print and online (www.cutis.com). Each month a member of the Cutis Editorial Board will provide pearls relating to the practice needs of dermatologists. Future topics will include:
- Electronic Medical Record Implementation
- Injection Technique With Fillers
- Psoriasis Treatment in Pregnancy
- Technology to Aid in Melanoma Diagnosis
- Plus more
Looking for pearls on a specific topic? The Editorial Board welcomes your feedback on potential topics. Send an e-mail to the Editorial Office ([email protected]) with your suggestions.
What does your patient need to know at the first visit?
Patients need a realistic approach to photoprotection based on their genetics, including Fitzpatrick skin type and family history of melanoma and nonmelanoma skin cancer; skin examination for photodamage and photoaging as well as number and type of pigmented lesions; and lifestyle history, which should include location of residence as well as occupation and recreational pursuits. This discussion should, as usual, include questions about general health, systemic and skin disease, and medication usage, with particular focus on photoaggravated diseases such as lupus and melasma as well as ongoing use of topical agents and systemic photosensitizers. These inquiries should lead to a frank discussion of the patient’s risk for developing photodamage and skin cancer and other specific conditions that alter the advice you would give.
What are your go-to treatments? Is your recommendation anecdotal or evidence based? What are the side effects?
I always recommend that my patients use a product that they like, which may sound simplistic. But if the patient doesn’t like the feel and look of the sunscreen, he/she won’t use it. Patients routinely should use a sunscreen with a sun protection factor (SPF) of 30 or higher that also carries a “broad spectrum” label. At the beach or during sweaty sports, patients should use one with a water-resistant SPF.
I prefer spray sunscreens for application on the back if the patient is alone without someone to help apply sunscreen to hard-to-reach areas and for male scalps. But you never know how much spray to use, so use a lot!
If patients are at the beach, playing sports, or watching sports outside, then they should reapply sunscreen every 2 hours. If patients work indoors and use a facial sunscreen in the morning, that’s sufficient.
Although there is no evidence that sunscreens are harmful for children older than 6 months of age and pregnant women, if patients in these special populations have concerns, I recommend using agents with inorganic compounds (physical blockers) such as titanium dioxide and zinc oxide only. Children are best protected with clothing and hats.
The evidence supports this approach. Patients really don’t need SPF 30 protection, but no one uses the amount of product that will result in the SPF listed on the bottle. So if patients use an SPF 30 or greater, they will get at least an SPF 15, which is sufficient everywhere but at the equator. Using SPF 30 the way we all apply it will give SPF 15–level protection.
There is evidence that sunscreens prevent squamous cell carcinoma, actinic keratosis, and photoaging. Early evidence, less strong but positive, also suggests protection against basal cell carcinoma and melanoma.
The biggest side effect is not using the sunscreen. Others include irritation and allergy. Irritation is common, but finding a product to use without irritation should be easy. Allergy is rarer, and when it occurs, it is usually due to the preservative or fragrance, not the active ingredients. If allergy does occur, patch testing by a dermatologist is necessary to determine the allergen.
Although it is still controversial, wearing sunscreens religiously can lead to vitamin D insufficiency or deficiency, which is particularly true for individuals with skin of color—Fitzpatrick skin types IV, V, and VI—and those cancer patients who adhere to rigorous photoprotection. These patients should be encouraged to take supplemental vitamin D3 and I suggest 2000 IU; this recommendation is my opinion and is not evidence based.
As to the literature in the laypress about hormonal changes from benzophenone, cancer from retinoids, and nanoparticle toxicity: There is no evidence to support those claims.
How do you keep patients compliant with treatment?
Keep telling them, and then tell them again.
What do you do if they refuse treatment?
Tell them to see someone else.
What resources do you recommend to patients for more information?
Consult the American Academy of Dermatology Web site (www.aad.org) and the Skin Cancer Foundation (www.skincancer.org).
Editorial Note
Practical Pearls From the Cutis® Board is a new feature that will appear in print and online (www.cutis.com). Each month a member of the Cutis Editorial Board will provide pearls relating to the practice needs of dermatologists. Future topics will include:
- Electronic Medical Record Implementation
- Injection Technique With Fillers
- Psoriasis Treatment in Pregnancy
- Technology to Aid in Melanoma Diagnosis
- Plus more
Looking for pearls on a specific topic? The Editorial Board welcomes your feedback on potential topics. Send an e-mail to the Editorial Office ([email protected]) with your suggestions.
What does your patient need to know at the first visit?
Patients need a realistic approach to photoprotection based on their genetics, including Fitzpatrick skin type and family history of melanoma and nonmelanoma skin cancer; skin examination for photodamage and photoaging as well as number and type of pigmented lesions; and lifestyle history, which should include location of residence as well as occupation and recreational pursuits. This discussion should, as usual, include questions about general health, systemic and skin disease, and medication usage, with particular focus on photoaggravated diseases such as lupus and melasma as well as ongoing use of topical agents and systemic photosensitizers. These inquiries should lead to a frank discussion of the patient’s risk for developing photodamage and skin cancer and other specific conditions that alter the advice you would give.
What are your go-to treatments? Is your recommendation anecdotal or evidence based? What are the side effects?
I always recommend that my patients use a product that they like, which may sound simplistic. But if the patient doesn’t like the feel and look of the sunscreen, he/she won’t use it. Patients routinely should use a sunscreen with a sun protection factor (SPF) of 30 or higher that also carries a “broad spectrum” label. At the beach or during sweaty sports, patients should use one with a water-resistant SPF.
I prefer spray sunscreens for application on the back if the patient is alone without someone to help apply sunscreen to hard-to-reach areas and for male scalps. But you never know how much spray to use, so use a lot!
If patients are at the beach, playing sports, or watching sports outside, then they should reapply sunscreen every 2 hours. If patients work indoors and use a facial sunscreen in the morning, that’s sufficient.
Although there is no evidence that sunscreens are harmful for children older than 6 months of age and pregnant women, if patients in these special populations have concerns, I recommend using agents with inorganic compounds (physical blockers) such as titanium dioxide and zinc oxide only. Children are best protected with clothing and hats.
The evidence supports this approach. Patients really don’t need SPF 30 protection, but no one uses the amount of product that will result in the SPF listed on the bottle. So if patients use an SPF 30 or greater, they will get at least an SPF 15, which is sufficient everywhere but at the equator. Using SPF 30 the way we all apply it will give SPF 15–level protection.
There is evidence that sunscreens prevent squamous cell carcinoma, actinic keratosis, and photoaging. Early evidence, less strong but positive, also suggests protection against basal cell carcinoma and melanoma.
The biggest side effect is not using the sunscreen. Others include irritation and allergy. Irritation is common, but finding a product to use without irritation should be easy. Allergy is rarer, and when it occurs, it is usually due to the preservative or fragrance, not the active ingredients. If allergy does occur, patch testing by a dermatologist is necessary to determine the allergen.
Although it is still controversial, wearing sunscreens religiously can lead to vitamin D insufficiency or deficiency, which is particularly true for individuals with skin of color—Fitzpatrick skin types IV, V, and VI—and those cancer patients who adhere to rigorous photoprotection. These patients should be encouraged to take supplemental vitamin D3 and I suggest 2000 IU; this recommendation is my opinion and is not evidence based.
As to the literature in the laypress about hormonal changes from benzophenone, cancer from retinoids, and nanoparticle toxicity: There is no evidence to support those claims.
How do you keep patients compliant with treatment?
Keep telling them, and then tell them again.
What do you do if they refuse treatment?
Tell them to see someone else.
What resources do you recommend to patients for more information?
Consult the American Academy of Dermatology Web site (www.aad.org) and the Skin Cancer Foundation (www.skincancer.org).
Editorial Note
Practical Pearls From the Cutis® Board is a new feature that will appear in print and online (www.cutis.com). Each month a member of the Cutis Editorial Board will provide pearls relating to the practice needs of dermatologists. Future topics will include:
- Electronic Medical Record Implementation
- Injection Technique With Fillers
- Psoriasis Treatment in Pregnancy
- Technology to Aid in Melanoma Diagnosis
- Plus more
Looking for pearls on a specific topic? The Editorial Board welcomes your feedback on potential topics. Send an e-mail to the Editorial Office ([email protected]) with your suggestions.
