Five Things Dermatologists Shouldn't Do
Gary Goldenberg, MD, Stephanie Cajigal
Disclosures December 11, 2013
- Ophthalmologic Manifestations of Atopic Dermatitis
- Pressure Ulcers and Wound Care
- Cutaneous Melanoma
In October 2013, the American Academy of Dermatology released a list of 5 skin tests and procedures that dermatologists should avoid. The Academy followed in the footsteps of 42 other specialty societies that have published similar lists as part of the ABIM Foundation's "Choosing Wisely" campaign, which is meant to encourage physicians to question the benefit of some commonly used tests and procedures.
Medscape Dermatology Board Member Gary Goldenberg, MD, offered his perspective on what these recommendations mean for clinical practice.
Antibiotics for Nail Fungus
The Recommendation: "Don't prescribe oral anti fungal therapy for suspected nail fungus without confirmation of a fungal infection."
The Rationale: About half of suspected fungal infections are not fungal infections. Other nail conditions could be to blame, and starting patients on treatment before confirming diagnosis could unnecessarily expose them to the side effects of anti fungal therapy.
Dr. Goldenberg's Bottom Line: While the diagnosis of onychomycosis can be made clinically, it is important to confirm this with a nail clipping and with a periodic acid-Schiff or a fungal culture. Some non fungal conditions can clinically mimic onychomycosis. Because oral antifungals have some potential side effects, it is prudent to confirm infection before starting these medications.
Evaluation of Early Melanoma
The Recommendation: "Don't perform sentinel lymph node (SLN) biopsy or other diagnostic tests for the evaluation of early, thin melanoma because they do not improve survival."
The Rationale: Patients with early, thin melanoma (melanoma in situ, T1a melanoma, or T1b melanoma ≤ 0.5 mm) have a high survival rate and a low risk of having the cancer spread to the lymph nodes or other parts of the body.
Dr. Goldenberg's Bottom Line: The controversy of when or whether or not to perform SLN biopsy continues. Evidence shows that there is no survival difference, especially in thin melanomas, with SLN biopsy. Most experts recommend SLN biopsy for melanomas of 0.75 mm or greater for prognostic reasons. Other tests, such as radiographic or laboratory tests, are also not recommended for thin melanomas because there is no correlation with survival.
Treatment of Nonmelanoma Skin Cancer
The Recommendation: "Don't treat uncomplicated, nonmelanoma skin cancer (NMSC) less than 1 cm in size on the trunk and extremities with Mohs micrographic surgery."
The Rationale: In healthy patients, the clinical benefits of using this specialized surgical procedure in these areas of the body do not exceed the potential risks.
Dr. Goldenberg's Bottom Line: According to the most recent appropriate-use criteria, uncomplicated NMSC on the trunk less than 1 cm in size do not require Mohs surgery. A tissue-sparing technique is not necessary in this location, especially because surgical excision or electrodessication and curettage have similar cure rates. The bottom line is that many suggested that Mohs is overused and is not necessary for uncomplicated NMSCs, especially on the trunk.
Antibiotics for Atopic Dermatitis
The Recommendation: "Don't use oral antibiotics for treatment of atopic dermatitis (AD) unless there is clinical evidence of infection."
The Rationale: The routine use of antibiotics to decrease the amount of bacteria on the skin of patients with AD has not definitively been shown to reduce the signs, symptoms, or severity of the disease.
Dr. Goldenberg's Bottom Line: Although some studies have shown improvement of eczema when treatment with a corticosteroid is combined with topical or oral antibiotics and bleach baths, for the majority of eczema patients, antibacterial aren't necessary. Overuse of antibiotics has been associated with bacterial resistance. Antibiotics also have their own side effects, and if they aren't necessary, they shouldn't be used.
Antibiotics for Surgical Wounds
The Recommendation: "Don't routinely use topical antibiotics on a surgical wound."
The Rationale: Using a topical antibiotic has not been shown to reduce the rate of infection more so than using a nonantibiotic ointment or no ointment at all. Antibiotic treatment should only be recommended for wounds that show symptoms of infection.
Dr. Goldenberg's Bottom Line: Dermatologists are acutely aware of the fact that topical antibiotics can cause allergic reactions that may be mistaken for an infection. There is little to no evidence that routine use of topical antibiotics after biopsy procedures decreases the risk for infections.