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Dermatologists Prefer Topical Corticosteroids For Children With Alopecia
A survey of pediatric dermatologists revealed that topical corticosteroids are the most common first-line treatment for children with alopecia, regardless of age or hair loss severity.
Pediatric alopecia areata (PAA) dermatologists prefer class 1 and 2 topical corticosteroids as first-line treatment therapy, a new survey analysis finds. The survey findings were published in the December issue of the Journal of the American Academy of Dermatology.
Researchers, led by Nanette Silverberg, M.D., chief, pediatric dermatology, Department of Dermatology, Mount Sinai Health Systems, Icahn School of Medicine at Mount Sinai, analyzed 53 responses from dermatologists who treat pediatric alopecia areata (PAA). Data were categorized between therapy of choice for children 8 years or younger and therapy of choice for children ages 8 years or older with alopecia areata. The two patient categories were divided based on the extent of scalp involvement (less than 25% or more than 25%), and the providers were categorized as either fellowship trained (FT) or nonfellowship trained (NFT).
Researchers found for children aged 8 years or younger, fellowship trained pediatric dermatologists were most likely to choose class 1 topical corticosteroids as first-line therapy for all patients regardless of scalp involvement. Although nonfellowship trained pediatric dermatologists were also most likely to prescribe class 1 corticosteroids for patients with more than 25% scalp involvement (53.8%), they were most likely to prescribe class 2 topical corticosteroids for patients with less than 25% involvement (42.9%).
For children aged 8 years and older, both fellowship-trained and nonfellowship-trained pediatric dermatologists preferred class 1 topical corticosteroids in patients with less than 25% scalp involvement and those with greater than 25% involvement.
The second-line therapy treatment preferences were not as consistent. Among nonfellowship-trained pediatric dermatologists, intralesional triamcinolone was the most common second-line therapy for children 8 years or younger with less than 25% scalp involvement (46.2%). However, fellowship-trained respondents were most likely to choose oral methotrexate for patients 8 years and younger with more than 25% scalp involvement (38.5%). Nonfellowship-trained respondents leaned toward topical minoxidil 5% solution for patients with more than 25% involvement (53.8%) and intralesional triamcinolone for patients with less than 25% involvement (76.9%).
However, for children 8 years and older with less than 25% involvement, intralesional triamcinolone was the most common second-line therapy among both fellowship-trained and nonfellowship-trained providers. For children 8 years and older with more than 25% scalp involvement, oral methotrexate and minoxidil 5% solution were the most preferred second-line therapy among fellowship-trained and nonfellowship-trained providers, respectively.
Study limitations included selection bias, potentially hindering the measure of association and may not have accurately reflected the targeted population. The sample size was also skewed towards junior respondents' perception. The length of the therapeutic trial, types of counseling practices, and any long-term monitoring was neglected within the study.
The survey data is significant to general practitioners treating alopecia areata by demonstrating the consistent practice patterns depicted. Additional drug safety and efficacy studies with topical and oral Janus kinase inhibitors for patients with pediatric alopecia areata are necessary to continue successful research.
Reference
Bitterman D, Bitterman D, Sink J, et al. Survey of pediatric dermatologist views on treatment for alopecia areata. JAAD Int. 2023;13:71-73. Doi:10.1016/j.Jdin.2023.06.016
This story first appeared on American Journal of Managed Care
Topical Corticosteroids: The Preferred First-Line Treatment For Pediatric Alopecia Areata
A survey of pediatric dermatologists revealed that topical corticosteroids are the most common first-line treatment for children with alopecia areata, regardless of age or hair loss severity.
Doctor examining child's scalpImage Credit: New Africa - stock.Adobe.Com
A survey analysis conducted among pediatric alopecia areata (PAA) dermatologists, found class 1 and 2 topical corticosteroids as the preferred first-line treatment therapy, whereas second-line therapy had differing results within the categorized demographics.
The FDA has not approved any therapies for treatment of PAA, making research in this space particularly valuable. When potential medication approvals for patients with PAA occur, this survey data will aid pediatric dermatologists' (PDs) make more informed decisions regarding preferred therapies.
Out of 121 survey recipients, 53 responses were recorded, observed, and analyzed. Data were categorized between therapy of choice for children 8 years or younger and therapy of choice for children ages 8 years or older with AA. The 2 patient categories were divided based on the extent of scalp involvement (less than 25% or more than 25%), and the providers were categorized as either fellowship trained (FT) or nonfellowship trained (NFT). Therapies were catalogued based on how often they were prescribed as a first-line or second-line therapy.
For children aged 8 years or younger, FT PDs were most likely to choose class 1 topical corticosteroids as first-line therapy for all patients regardless of scalp involvement (< 25% involvement: 79.5%; > 25% involvement: 66.7%). Although NFT PD were also most likely to prescribe class 1 corticosteroids for patients with more than 25% scalp involvement (53.8%), they were most likely to prescribe class 2 topical corticosteroids for patients with less than 25% involvement (42.9%).
For children aged 8 years and older, both FT and NFT PDs preferred class 1 topical corticosteroids in patients with less than 25% scalp involvement (FT: 74.4%; NFT: 58.3%) and those with greater than 25% involvement FT: 50%; NFT: 61.5%).
The second-line therapy treatment preferences were not as consistent. Among FT PDs, intralesional triamcinolone was the most common second-line therapy for children 8 years or younger with less than 25% scalp involvement (46.2%). However, FT respondents were most likely to choose oral methotrexate for patients 8 years and younger with more than 25% scalp involvement (38.5%). NFT respondents leaned toward topical minoxidil 5% solution for patients with more than 25% involvement (53.8%) and intralesional triamcinolone for patients with less than 25% involvement (76.9%).
However, for children 8 years and older with less than 25% involvement, intralesional triamcinolone was the most common second-line therapy among both FT and NFT providers (FT: 46.2%; NFT:76.9%). For children 8 years and older with more than 25% scalp involvement, oral methotrexate (FT: 43.2%) and minoxidil 5% solution (NFT: 46.2%) were the most preferred second-line therapy among FT and NFT providers, respectively.
Study limitations included selection bias, potentially hindering the measure of association and may not have accurately reflected the targeted population. The sample size was also skewed towards junior respondents' perception. The length of the therapeutic trial, types of counseling practices, and any long-term monitoring was neglected within the study.
The survey data is significant to general practitioners treating AA by demonstrating the consistent practice patterns depicted. Additional drug safety and efficacy studies with topical and oral Janus kinase inhibitors for patients with PAA are necessary to continue successful research.
Reference
Bitterman D, Bitterman D, Sink J, et al. Survey of pediatric dermatologist views on treatment for alopecia areata. JAAD Int. 2023;13:71-73. Doi:10.1016/j.Jdin.2023.06.016
CDC Report Highlights Urgent Need For Guideline Adherence In Prescribing Antifungal Medications
The US Centers for Disease Control and Prevention (CDC) has recently assessed prescription volumes, rates, and costs for topical antifungal medications in the context of the recent emergence of severe antimicrobial-resistant superficial fungal infections in the United States.
The study is published in CDC's Morbidity and Mortality Weekly Report.
Study: Topical Antifungal Prescribing for Medicare Part D Beneficiaries — United States, 2021. Image Credit: HenadziPechan / Shutterstock
The estimated prevalence of superficial fungal skin infections is more than 20% worldwide. Because of the recent emergence and spread of antimicrobial-resistant fungal skin infections, South Asia has witnessed large outbreaks of extensive, recalcitrant infections that are difficult to treat using topical antifungal medications or first-line therapies. Overuse or misuse of antifungal-corticosteroid combination creams is mainly responsible for the emergence of antimicrobial-resistant fungal infections.
Recent outbreaks of antimicrobial-resistant fungal infections with extensive skin lesions have been detected in at least 11 US states. In the United States, dermatologists rarely perform confirmatory diagnostic tests for fungal skin infections and mostly rely on visual inspection for infection diagnosis. This leads to higher rates of prescriptions for non-recommended topical antifungal medications.
To establish and promote a correct guideline for the proper use of these medications, the CDC has assessed prescribing volumes of topical antifungal medications among Medicare Part D beneficiaries in the United States during 2021.
Study designThe 2021 Medicare Part D prescription drug benefit program includes approximately 48.8 million beneficiaries. The Centers for Medicare & Medicaid Services (CMS) Medicare Part D dataset contains information on the total number of prescriptions and drug costs.
This dataset was used to examine prescription volumes, total costs, and average costs for topical antifungal medications and topical antifungal-corticosteroid combination medications. The study also calculated prescription rates per 1,000 beneficiaries and prescription rates per prescriber.
Important observationsAccording to the study analysis, a total of 6.5 million topical antifungal prescriptions were written for Medicare Part D beneficiaries during 2021. This corresponded to a total cost of 231 million USD. The overall rate of prescriptions was 134 prescriptions per 1000 beneficiaries. The prescription rate was highest in the Northeast, followed by the South.
The most commonly prescribed medicines were ketoconazole, nystatin, and clotrimazole-betamethasone dipropionate. The average per-prescription cost was highest for efinaconazole, followed by tavaborole and oxiconazole. The lowest average per prescription cost was for nystatin, followed by clotrimazole-betamethasone dipropionate, clotrimazole, and ketoconazole.
Regarding prescribers, topical antifungal medications were prescribed by 12.8% of 1,017,417 unique prescribers. The prescription volume per provider was highest for dermatologists, followed by podiatrists and primary care physicians. Primary care physicians wrote the most prescriptions, followed by nurse practitioners, dermatologists, and podiatrists. The top 10% of prescribers wrote 44.2% of all topical antifungal prescriptions.
Study significanceThe study finds that 6.5 million topical antifungal prescriptions were filled for Medicare Part D beneficiaries during 2021, at a total cost of 231 million USD. This corresponds to one prescription for every eight beneficiaries.
Primary care physicians, nurse practitioners, and physician assistants wrote the most prescriptions. This highlights the need for implementing appropriate drug-prescribing guidelines in these groups. Furthermore, dermatologists and podiatrists had higher per-provider prescribing rates than other groups. This indicates that patients with fungal skin infections more frequently visit dermatologists and podiatrists.
The study identifies clotrimazole-betamethasone dipropionate as the most commonly prescribed medication. Overuse or misuse of this antifungal-corticosteroid combination can lead to the emergence of antimicrobial-resistant fungal skin infections. This combination therapy contains a high-potency steroid that can damage the skin and suppress the hypothalamic-pituitary-adrenal axis if used for a prolonged time or over a large body surface area.
Considering the risks associated with clotrimazole-betamethasone dipropionate combination therapy, clinicians should consider prescribing alternative therapies, such as antifungal monotherapy along with a short course of low-potency corticosteroid treatment to control severe symptoms (severe pruritis).
Overall, the study highlights the need to evaluate current practices of antifungal use carefully. Healthcare providers should prescribe topical antifungal medications, especially antifungal-corticosteroid combination, more reasonably for suspected superficial fungal infections. They should consider laboratory testing to confirm a diagnosis. They should also educate the patients about the correct use of topical antifungal medications.
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