Advances in Dermatology for 2019 and Beyond
Are you up on some of the latest trends and technology in your practice?
We’ve come a long way since 1801 when the first school for dermatology, Hôpital Saint-Louis in Paris, came to be which was around the same time that one of the first dermatology textbooks came into existence. Essentially skincare has been around since human existence but dermatology advances have drastically changed what the field looks like—and we’re all the better for it.
I doubt back in 1801 they envisioned the existence of electronic health records, telemedicine and Mohs surgery. While no one truly knows what dermatology will look like in the year 3000, we do know that recent advances in dermatology have and will help set the stage for the future of the specialty as a whole. While the list of recent dermatology advances is a lengthy one, I wanted to focus on a handful of them I personally find most intriguing and relevant.
- Skin cancer detection and treatment
- Light therapy
- Skin protection
- Dermatology software
Let’s dive into some of the recent advances in dermatology.
The Evolution of Skin Cancer Treatments
Skin cancer has been on the rise, which means treatment efforts continue to evolve and improve. According to a statistic from the Skin Cancer Foundation, between 2009 and 2019 the number of new invasive melanoma cases diagnosed annually increased by 54 percent. And with basal cell carcinoma and squamous cell carcinoma ranking as the first and second most common skin cancers in the U.S., treatments have changed to adapt to common diseases such as these. While we’re improving at identifying and diagnosing melanomas, the alarming growth of this deadly tumor predicates the need for evolving treatments.
Mohs micrographic surgery has been used to treat basal and squamous cell carcinomas since it was developed in the 1930s. Of course our technique is vastly different than the original technique employed by Fred Mohs in 1938. This procedure has also now become the treatment of choice for difficult tumors such as dermatofibrosarcoma protuberans. When Mohs micrographic surgery is coupled with immunoperoxidase (and other special stains) it can be used to effectively treat difficult in situ and invasive melanomas of the head and neck. I finished my dermatology residency in 2009 and since then I have seen the use of Mohs surgery increase disproportionately to the rate of skin cancer. This disproportionality puts this procedure at risk for higher regulation by insurers. The Mohs Appropriate Use Criteria were developed in 2012 and adherence to these guidelines will help to protect practitioners of this invaluable technique.
From a non-surgical perspective immunotherapy/biological/radiation/pharmacologic therapy to treat skin cancer has grown and will continue to grow in importance. For example, the first treatments for metastatic melanoma which have been shown to prolong life have come to market. These immunotherapy treatments include:
- Immune checkpoint inhibitors
- PD-1 inhibitors
- CTLA-4 inhibitors
- Cytokines Interferon-alfa and interleukin-2)
- Oncolytic virus therapy
- Bacille Calmette-Guerin (BCG) vaccine
While some of these new treatments may not stand the test of time nor replace cutaneous surgical intervention I think we will see an increase in patients desiring and asking for non-surgical treatments. In my own practice, I have been utilizing our local radiation oncologist more frequently for tumors in which surgical intervention may cause unnecessary psychological distress or lead to postoperative problems.
Diagnosing and Treating Disease With a Laser Microscope
What if dermatologists could both diagnose diseases and perform precision surgery all without cutting skin? Seems like this may become a viable option very soon. Based on a study by the University of British Columbia researchers, the multiphoton excitation microscope developed has been shown to scan living tissue but what sets this technology apart from other lasers is the ability to treat the tissue by intensifying the heat from the laser. This laser has been shown to “pinpoint the exact location of the abnormality, diagnose it and treat it instantly.” This technology demonstrates promise to extend beyond diagnosing and treating skin cancers but also working in other medical specialties as it could be utilized to “treat any structure of the body that is reached by light and requires extremely precise treatment.”
Time will tell how effective and accessible this new laser will be, but from the initial study it is quite promising and has the potential to revolutionize skin cancer detection and treatment. Who knows, it may even shift the use case of Mohs Surgery and spark even more dermatology advances.
Looking Towards the Light
As more and more dermatology practices are increasingly focusing on the cosmetic side of treatments for business, various laser and LED light therapies seem to be popping up. But do they work and why do patients seem to want more of it?
First, how effective are they? Based on my experience and hearing from both colleagues and patients, the jury is still out. Red and blue light are commonly used for such treatments. Blue light therapy can kill bacteria under the skin and thus are often utilized after masks or extractions to treat acne to help kill the bacteria. Red light has been seen to stimulate collagen and can help reduce inflammation. Typically multiple sessions are needed to see results but there’s not enough data yet to indicate long-term effectiveness.
So why the demand? The noninvasive nature and very little if any negative side effects are appealing to patients. Since acne and aging skin are prevalent concerns among most patients at some point in their lifetime, it’s seen as an “easy” and accessible treatment. Additionally the price point is often lower than other aesthetic options on the market. The impact of celebrity culture and reality T.V. has also spawned an increased interest in some of these “Hollywood” treatments.
Better Skin Protection
With the sun as the culprit behind many damaging skin conditions, awareness and education on skin protection has improved, but there’s still a long way to go. Back in February the Food and Drug Administration (FDA) proposed a rule to improve requirements for sunscreen products in the U.S. The proposal is intended to benefit consumers and improve protection from the sun. In the proposal it addresses provisions such as:
- Active ingredient safety
- Dosage forms
- SPF and broad-spectrum requirements
- How products are labeled for consumer ease of use
It’s shocking that some of the essential requirements for such preventive tools like sunscreen have failed to be updated for decades. Bringing today’s scientific innovations for safety and effectiveness is a much needed. The full proposed rule can be accessed on the Federal Register site.
There has also been an increase in the number of brands and products offering ultraviolet protection factor (UPF) clothing items, which is another great innovation that has improved over the last almost two decades in the U.S. The increased options and styles of the clothing items paired with increased awareness of sun safety will continue to grow this industry and hopefully help lead to a decrease in skin cancer diagnoses.
An Ongoing Debate: Coverage for Biologics
The increasing cost of prescription drugs is certainly an epidemic. Biologics have proven to be one of the most expensive drug classes for patients with psoriasis. With the over 8 million Americans and 2-3% of the worldwide population having this disease, cost-prohibitive drugs make an effective treatment out of reach for most. During a 10-year period, a patient with moderate-to-severe psoriasis could spend nearly $200,000 regardless of the biologic prescribed. This is mind blowing for a drug that is a proven effective and safer option than other treatments but an unfathomably expensive one. How many of you with psoriasis would choose cyclosporine over a biologic for yourself or a family member?
Why such exorbitant costs? The culprit seems to be patent protections that prevent other drug options such as biosimilars from competing and all this at the expense of the patient and the insurance system as a whole. Hopefully changes to legislation and insurance will help make these drugs a realistic option for more patients.
Tech Focus: Dermatology Software
When it comes to dermatology advances with treatments and the tools you want your practice to be at the forefront. The same rings true when it comes to dermatology software to help drive clinical, operational and financial success for your business.
Dermatology software can include:
- Your electronic health record (EHR) system
- Practice management software
- Analytics platform
- And patient engagement tools such as a kiosk for and patient portal
Like the different types of lasers and other tools out there’s no doubt you have options and it takes time to research and find the dermatology technology that’s right for you and your practice. Detailed below are just some of the features I feel should be at the top of the list when evaluating your options.
- An all-in-one solution: The less vendors you have to work with the better. Having one platform that’s integrated helps you avoid oftentimes expensive and inefficient bridges between an EHR and practice management system. Trying to make systems work together that weren’t designed to do so can easily result in efficiencies and frustrations for you and your staff. Plus, it is often more efficient to communicate with one vendor versus multiple points of contact.
- Built for dermatology: There are certainly even more options for EHRs if you opt for one that is not built with the dermatologist in mind, but beware beware. We very well know that each medical specialty’s workflow and needs are not all the same so why try to make a square peg fit into a round hole? An EHR system that is built by dermatologists for dermatologists enables robust specialty-specific content to transform your EHR experience.
- Cloud-based: Like most of our technology today it operates using cloud technology versus servers. Having a cloud EHR (compared to a server) can make a world of difference. The cloud can help you save on costs as you don’t have physical servers to maintain and will probably need less if any IT staff. Perhaps one of the biggest perks is the mobility it provides to you both in and outside of the office. We all know patients need prescriptions or have questions when you’re conveniently not in the office.
- Intuitive: Technology should help assist in enhancing your practice, rather than hinder the quality of care you provide. Seek out an EHR system that in addition to dermatology knowledge built-in comes equipped with:
- A touch-based iPad interface and an interactive body atlas
- Adaptive learning engine
- Automated suggested coding
- Built-in Merit-based Incentive Payments System (MIPS) reporting
- Integrated photography
- Drawing board
It’s important to see a demo not just online but also in person. If you are ready to transition to a new dermatology EHR system, make a point to meet the vendor at an upcoming conference to see the software in person and meet the team behind the product. This can really help you make a decision one way or another.
- A Leading Health IT Vendor: In addition to the functionality and features offered, you should look into the company’s reputation and stability in the market as well as the implementation, training and ongoing support options they provide. We all want to do business with people and companies we like and trust and when it comes to your dermatology software vendor, they should feel like an extension of your team. Ask the difficult questions, ask to speak with current users and see what conferences they will be exhibiting at throughout the year.
When it comes to recent advances in dermatology for diagnostic options, treatments, sun protection and technology tools, there’s no shortage of options to bring the best solutions to your practice. If you’re like myself and most other physicians I know, we became medical professionals to help improve the experience and treatment our patients receive. Keeping ourselves and our practices educated on what works best is part of what makes our profession challenging but all the more rewarding.
Jordan Miller, MD
Senior Medical Director of Dermatology
Dr. Jordan Miller is the Senior Medical Director of Dermatology. As one of Modernizing Medicine’s first clients, he quickly became a “super-user.” Today, as a practicing dermatologist, Dr. Miller leads development of the dermatology-specific electronic health record system and works with clients to create specialty-specific software.