PHARMACOLOGY AND THERAPEUTICS

Pediatric Dermatology Vol. 25 No. 6 635639, 2008

Dierences in Acne Treatment Prescribing Patterns of Pediatricians and Dermatologists: An Analysis of Nationally Representative Data
Brad A. Yentzer, M.D., Cynthia E. Irby, B.A., Alan B. Fleischer Jr., M.D., and Steven R. Feldman, M.D., Ph.D.
Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Abstract: Background: Acne vulgaris is a very common disease process that is seen frequently by both pediatricians and dermatologists. However, treatment may be different depending on specialty. Objectives: To compare pediatricians and dermatologists patterns of treatment for acne vulgaris. Methods: National Ambulatory Medical Care Survey data on ofce visits to pediatricians and dermatologists for acne vulgaris were analyzed from 1996 to 2005. Results: During this 10-year time period, dermatologists managed an estimated 18.1 million acne visits and pediatricians managed an estimated 4.6 million acne visits. Dermatologists prescribed topical retinoids considerably more frequently than did pediatricians (46.1% of acne visits for dermatologists vs 12.1% for pediatricians). Conclusions: There is an opportunity for pediatricians to play a greater role in the management of patients with acne. A shift toward greater use of topical retinoids by pediatricians would be more in line with the practice of dermatologists and with current acne treatment consensus guidelines.

Acne vulgaris is a very common disease process that impacts the lives of adolescents, and they have the option to be treated by their pediatrician or to be referred to a dermatologist. Fortunately, there are many safe and eective acne medications. Patients with mild to moderate acne do not necessarily need to be under the care of a dermatologist; their primary care physician can prescribe medications for eective acne treatment. Acne can be treated with both antibiotic and nonantibiotic regimens. Unfortunately, acne is a chronic disorder and long-term use of antibiotics has led to
Address correspondence to Brad A. Yentzer, M.D., Department of Dermatology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1071, or e-mail: byentzer@wfubmc.edu. DOI: 10.1111/j.1525-1470.2008.00790.x

resistant bacteria (1). Nonantibiotic therapies such as topical retinoids and benzoyl peroxide are excellent alternatives to topical antibiotics, and do not produce resistant bacteria. While current consensus guidelines stipulate that oral antibiotics should be used for moderate to severe acne, antibiotics should be used in combination with topical retinoids and should be discontinued once clearance is achieved. The purpose of this study was to assess how acne in adolescents is managed by dermatologists and pediatricians in the United States. We determined the number of

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teenagers being treated for acne by these two specialties, and looked at the most commonly prescribed medications for acne treatment. In addition, we specically compared the use of topical retinoids for the treatment of acne by dermatologists and pediatricians. METHODS We used data from the National Ambulatory Medical Care Survey (NAMCS) to assess treatments used at medical visits for acne. For over 30 years, the NAMCS has obtained data from nonfederally employed physicians regarding outpatient visits in the United States. National Ambulatory Medical Care Survey uses a multistage probability sample design, which produces unbiased national estimates, in which the basic sampling unit is the physician-patient visit. During a randomly assigned 1 week reporting period, the physician records information regarding the reason for the visit, diagnoses, services provided, medications prescribed, referral practices, and the demographic distribution for a randomized sample of patient visits (26). We analyzed data from 1996 to 2005 to determine the number of acne visits to dermatologists versus pediatricians, and the age distribution among the total acne visits to both of these physician specialties. The NAMCS allows for coding of up to three diagnoses. An acne visit is dened as the diagnosis of acne vulgaris being listed as any one of the three possible diagnoses for that visit. We further examined the most commonly mentioned acne medications and the use of topical retinoids for the treatment of acne in pediatricians oces versus dermatologists oces. The term mention indicates medications currently taken by the patient, dispensed in oce, or prescribed by the physician at that visit. As such, we use the term mention and prescribe interchangeably to indicate active treatment with that medication. To better compare the dierences in treatment between pediatricians and dermatologists, the patients were limited to the ages between 10 and 18. We also examined the percentage of dermatologists visits and pediatricians visits in which specic topical retinoids (tretinoin, tazarotene, or adapalene) were mentioned. To help eliminate visits for severe acne, visits in which isotretinoin was prescribed were excluded. In addition, we queried the NAMCS database to assess the proportion of acne visits to dermatologists that were secondary to referral from another physician. RESULTS From 1996 to 2005, there were an estimated 28 million visits to all physicians for acne vulgaris for patients

between 10 and 18 years of age. Of these, dermatologists managed an estimated 18.1 million visits, pediatricians an estimated 4.6 million visits, and 5.3 million visits were managed by other specialties. The age distribution of all acne patients within the ages of 10 and 18 seen by dermatologists and pediatricians for acne management was determined (Fig. 1). Dermatologists treated substantially more patients for acne than pediatricians beginning at the age of 12. In addition, 23% of the acne visits to dermatologists over the 10-year period were from referral. The most commonly prescribed acne medications were determined for pediatricians (Table 1) and

Figure 1. Age distribution of acne visits to dermatologists and pediatricians. When examining the NAMCS data from 1996 to 2005 for patients 10 to 18 years old, dermatologists treated a total of 18.1 million acne visits, while pediatricians treated a total of 4.6 million acne visits. Starting at age 12, dermatologists treated signicantly more patients with acne than pediatricians. TABLE 1. The Most Frequently Prescribed Acne Medications by Pediatricians, 19962005
Medication 1 2 3 4 5 6 7 8 9 10 Benzoyl peroxide Clindamycin Tretinoin Erythromycin Benzaclin (clindamycin 1-benzoyl peroxide 5 topical gel) Benzamycin (erythromycin 3-benzoyl peroxide 5 topical gel) Aapalene Doxycycline Tetracycline Minocycline NAMCS Estimates 785,415 388,124 340,262 329,995 224,056 220,762 214,794 204,528 177,149 172,771 Percentage (%) 17.1 8.4 7.4 7.2 4.9 4.8 4.7 4.4 3.9 3.8

Note that percentage of acne visits was calculated by taking estimated acne visits to the pediatrician in which the medication was prescribed and dividing by the total estimated number of acne visits to pediatricians. Ex: Percentage of acne visits in which Benzoyl Peroxide was prescribed = (785,415 4,600,000).

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TABLE 2. The Most Frequently Prescribed Acne Medications by Dermatologists, 19962005

benzoyl peroxide and clindamycin (Table 1). Dermatologists, on the other hand, prescribed adapalene and tretinoin most frequently (Table 2). Overall, dermatologists prescribed retinoids signicantly more often than did pediatricians (46.1% of acne visits to dermatologists vs 12.1% of acne visits to pediatricians) throughout the 10-year time period. Patient visits in which a specic topical retinoid (tretinoin, tazarotene, or adapalene) was mentioned were also examined from the NAMCS data (Fig. 2). Of the three topical retinoids, adapalene is prescribed most frequently by dermatologists than the others; whereas, tretinoin is mentioned most frequently by pediatricians. Tazarotene is not commonly used in either subset of physicians. DISCUSSION Currently, most acne visits are managed by dermatologists. While the severity of the patients acne was not determined in this analysis, the analysis was restricted to nonisotretinoin visits; therefore, we can assume that the majority of the acne visits were for less severe forms of acne that may not require the care of a specialist. While only 23% of the patient visits to the dermatologist were from referral, this amounts to an estimated 4 million visits referred for mild to moderate acne. Although we are unable to distinguish from which specialty the patient was referred, there is a clear opportunity here for pediatricians to begin treatment for mild to moderate acne early, before it progresses to the point where the patient seeks out a specialist. Only if the patient does not respond or is refractory to treatment, should referral be needed. Pediatricians and dermatologists have dierent prescribing patterns for acne management. The most frequently prescribed medications for acne by dermatologists are topical retinoids. Pediatricians, however, rarely prescribe topical retinoids, only 12.1% of acne visits. Some physicians may be reluctant to prescribe topical retinoids due to the irritating side eects of the rst generation retinoids. Irritation may lead to patient dissatisfaction and poor adherence to treatment. Newer agents, such as adapalene, oer fewer side eects. However, pediatricians are not prescribing adapalene as frequently as other agents, such as benzoyl peroxide, topical antibiotics, and tretinoin. It is unknown why this occurs. Some physicians may not be comfortable with recommending a topical retinoid regimen or may not be aware of the availability of better tolerated topical retinoids. Pediatricians are not the only physicians that are underutilizing topical retinoids. An analysis of NAMCS data from 1990 to 1999 determined that all physicians

Medications listed include all name brand and formulations mentioned in the NAMCS data. Note that NAMCS estimates add up to greater than the total number of acne visits to the dermatologist (18.1 million). This is likely due to the prescribing of more than one medication at some visits. Percents are calculated by taking the number of visits in which that drug was mentioned and dividing by the total number of acne visits to dermatologists.

dermatologists (Table 2) in this population of patients. Percentage acne visits in which a medication was prescribed was calculated by taking the number of acne visits for the medication being prescribed and dividing by the total number of acne visits to that specialty (18.1 million for dermatologists or 4.6 million for pediatricians). The top two medications prescribed by pediatricians were

Figure 2. The prescribing pattern of specic topical retinoids. Data from the NAMCS were analyzed for visits to either the dermatologist or pediatrician in which a topical retinoid was prescribed for adolescents (1018 yrs old) with acne vulgaris, and this subset was further divided into specic topical retinoids. From 1996 to 2005, dermatologists prescribed topical retinoids much more frequently than pediatricians for acne (46.1% of acne visits vs 12.1%, respectively). Dermatologists prescribed more adapalene than tretinoin (24.5% vs 21.6%, respectively). Whereas pediatricians prescribed tretinoin relatively more often than adapalene (7.4% vs 4.7% respectively). Tazarotene was not commonly used by either group of physicians.

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underutilize topical retinoids in the treatment of acne vulgaris (5). The most compelling predictor of the use or nonuse of topical retinoids was physician specialty with nondermatologists signicantly less likely to use topical retinoids than dermatologists (39.4% vs 23%) (5). In our current analysis of acne visits for the years between 1996 and 2005, an even greater discrepancy was identied for the use of topical retinoids by dermatologists and pediatricians (46.1% vs 12.1%). It may be of benet to have increased cross disciplinary education during residency training. In a 2006 publication of Pediatrics, consensus guidelines for the treatment of acne vulgaris were reiterated in a special article, so that pediatricians can be aware of the most recent recommendations (7). These guidelines for acne management were developed in 2003 by an international committee of physicians and researchers (8). The guidelines support a combination approach that targets all three major factors of acne pathogenesis: comedone formation and sebaceous hyperplasia, bacterial colonization, and inammation. The largely evidence-based recommendations advocate that a topical retinoid should be used as the primary treatment for all mild to moderate acne. Oral antibiotics are the drugs of choice for moderate to severe acne, but should be used in combination with topical retinoids. Due to their comedolytic properties, topical retinoids are also essential for maintenance therapy (8). Topical retinoids can clear acne and be used for longterm treatment without the need for an antibiotic. The tendency for development of antibiotic-resistant bacteria has led to a shift towards greater use of nonantibioticbased treatment of acne (6). Nevertheless, the considerable number of visits at which topical clindamycin monotherapy was prescribed suggests there is still opportunity to reduce antibiotic treatment by increasing topical retinoid use. There are several limitations to our analysis of the NAMCS data. It does not provide reasons why prescribing patterns are dierent. Patient population, insurance status, cost of medication, and direct physician marketing may play a role in the dierences seen. Although many severe nodulocystic acne visits were likely excluded with the elimination of isotretinoin, we were not able to accurately determine the severity of acne that patients were being treated for. Therefore, we were unable to correlate the type of acne medications prescribed to the severity of acne. We were also unable to determine whether or not topical retinoids were prescribed rst or after failure of antimicrobial or other therapy. The low frequency of retinoid use by pediatricians limits the reliability of the estimates. However, the consistently low frequency over a period of

10 years demonstrates pediatricians prescribe retinoids uncommonly. Although pediatricians often see patients for other primary care issues, we were able to capture acne as being one of three possible diagnoses, and the probability of missing a large amount of pediatric patients being treated for acne is low. Furthermore, there is a large population of adolescents that are either being referred to the dermatologist or otherwise seeking a dermatologists care for acne management. In the majority of these cases, a specialist is likely not needed. There is an opportunity here for pediatricians to treat more patients with mild to moderate acne, and to alter their prescribing patterns to be in line with the consensus guidelines. If the pediatricians would use more topical retinoids, they would likely increase their successful treatment of these patients, and obviate the need for referral. FUNDING CONFLICTS OF INTEREST The Center for Dermatology Research is supported by an educational grant from Galderma Laboratories, L.P. Dr. Feldman has received research, speaking and or consulting support from Galderma, Abbott Labs, Warner Chilcott, Aventis Pharmaceuticals, 3M, Connetics, Roche, Amgen, Biogen, and Genentech. Dr. Fleischer has received research, speaking and or consulting support from Astellas, Centocor, Amgen, Abbott, Galderma, Stiefel, Medicis, and Intendis. Mrs. Irby and Dr. Yentzer and have no conicts to disclose. REFERENCES
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