Dr. Daniel Butler discusses strategies for diagnosing atypical dermatitis and overcoming medication access issues, including the use of alternative metrics to measure disease severity, practicing physician patience, and learning to navigate the payer system.
Daniel Butler, MD, Associate Professor, University of Arizona College of Medicine, Tucson, Arizona
“The key points that I would want anyone to come away from [this with] is to rethink what we have been taught and how we perceive dermatitis when we’re evaluating a patient,” said Daniel Butler, MD, who presented “Navigating a New Era: A Practical Guide to Itching and Dermatitis” at this year’s Pacific Derm meeting.
“We are so reliant on our physical exam skills [and] appropriately so. That’s the superpower that we’re trained to have.”
However, patients with atypical presentations, including those with primary itch and minimal skin changes, are inadvertently being looked over, said Dr. Butler.
“And so we have to be able to, as dermatologists, still apply a framework to those patients. And luckily with new medications, we’re really able to address that population, but it has to come from a starting point of reevaluating and auditing ourselves and acknowledging that there’s a population that we’re missing that may have an abnormal or atypical presentation.”
Redefining Dermatitis
According to Dr. Butler, rethinking the approach to dermatitis requires using both the eyes and the ears.
“It’s really about quality of life for patients and understanding different outcome measures and how those outcome measures may be more indicative of the severity of the disease than what we’re seeing with our eyes.”
Consider sleep as a measure, he said.
“We use sleep as a crude but very important metric of disease severity and, subsequently, treatment response and so this is our job as researchers and as creative problem solvers in medicine… we have to be able to think about how our treatments are impacting the population. And when previously almost all of our treatments were defined by how much ‘less red’ someone was, or how much ‘less scaly’ they were, we really have to redefine that.”
Other measures include activity level and caregiver burden, said Dr. Butler.
“These are all ones that we’re investigating and I think are really important metrics that should be included in every dermatitis evaluation, as at least a proxy for the disease severity, but possibly as a metric to drive treatment, either escalation or de-escalation.”
Practical Steps
According to Dr. Butler, the practical side of this is learning how to take the necessary steps to recognize these patients.
“My first practical piece of advice is, be patient with yourself as a dermatologist. There’s a lot of pressure when you walk in a room to look at a rash and to tell the patient what they have. And I think we all feel a little sense of disappointment when we’re not able to do that.”
It can be disarming when dermatologists are faced with an uncharacteristic or subtle rash that isn’t immediately recognizable, he said.
“I encourage anybody who sees these patients to take a step back, be patient with yourself, acknowledge that we may not have everything from a visual standpoint or from a serologic standpoint.”
Instead, collect and track data from each office visit to develop a complete picture of what’s going on with these patients, he said.
“You’ll be able to glean a lot as those data points accumulate. So every time you’re seeing them, every time you get a lab test, those are all pieces to the puzzle of this challenging patient population.”
Practical Paths
As the science in the specialty continues to advance, it becomes imperative to address access and systems issues as well, said Dr. Butler.
“What I mean by that is, we’re at a point with a lot of our diseases where we have a ton of medications that can help and yet we are finding restrictions at multiple levels to be able to access those medications.”
Restrictions include differing payer practices, prior authorizations, and cost to the patient, he said.
“But it’s getting to a point where staff, providers, [and] patients are all getting burned out because of the lack of access to these medications or the work or cost to obtain them. And we have to be able to paint clear paths for ourselves, for our staff, and for our patients in order to know which medications we can get.”
Medicare is one example, according to Dr. Butler.
“A lot of patients who have Medicare access can get medications, but they have significant out-of-pocket costs. That is something that we just can’t have happen.”
That makes the “right” treatment for dermatitis (or related conditions) in this population, any one that is accessible, he said.
“And that’s a sad reality because we like to think of ourselves as having first-line, second-line, third-line treatments, but right now, it’s sort of like you send something in, you flip a coin, and hope for the best—hope that the patient’s not going to get charged a ton of money or hope that it’s not going to be three months delayed because of prior authorizations and a ton of paperwork for them to be able to get it.”
According to Dr. Butler, it’s time for a call to action.
“…yes, it’s fun to talk about the science… but we have to be thinking from a practicality standpoint as we’re thinking about pathophysiology.”
Dr. Butler describes the current situation as a complex interplay between science, health care delivery, and payer systems.
“It’s our responsibility to be able to clarify that for our patients and for our teams, and that’s a major undertaking. But I know we can do it. We’ve got to partner with everyone: regulators, patients, payers… We have to do better by our patients to get them medications in a timely and cost-effective way.”
For his part, Dr. Butler is a founding member of an outcomes research group that is working with regulators, payers, and the specialty to increase access to medications for older adults.
“I don’t know what the perfect solution is. And it’s always hard because I feel like a lot of the responsibility gets put on doctors to try to figure everything out. (And certainly this isn’t a ‘woe is us’.) But I would encourage all doctors to think of this as a certain part of their practice. We all have to get creative as far as how to navigate it, because just as important [as], if not more important than, knowing the diagnosis is knowing how to access certain treatments for certain patients.”
