With the recent publication of “Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne” in Pediatrics, pediatricians and dermatologists finally have comprehensive guidelines for managing one of the most common skin conditions of childhood and adolescence. One of the most striking things are the recommendations encouraging the use of simple and relatively inexpensive over-the-counter soaps, skin cleansers, and creams.
The guidelines also shatter a few myths:
One common acne myth is that poor hygiene and improper cleansing cause acne. The role of facial cleansing in acne is to remove makeup, dirt, and excess oil. Use of the wrong, too harsh cleanser can disrupt skin barrier, increase transepidermal water loss, encourage bacterial colonization, promote comedones, and cause symptoms of burning and stinging. Typically, twice-daily washing with a gentle soap-free, pH-balanced cleanser is recommended. Antibacterial washes, other than BP [benzoyl peroxide], have not been shown to be useful in the treatment of acne.
Another common acne myth is that use of cosmetics worsens acne. On the contrary, use of concealing oil-free, noncomedogenic makeup can improve patient quality of life and does not worsen the severity of acne. Use of cosmetics in patients with acne has not been shown to delay treatment response either.
And the use of benzoyl peroxide (BP) — a reliable, inexpensive, over-the-counter, oldie-but-a-goodie — tops the list of recommended medications:
BP has been shown to be the most widely studied of OTC products and has shown to be one of the most versatile, safe, inexpensive, and effective acne therapies.
The guidelines go on to describe treating more severe cases of acne with common add-ons to BP that are not terribly expensive: retinoids (like Retin-A) and topical and oral antibiotics. The recommendations are clear, easy to understand, and (unless acne is particularly severe) shouldn’t break-the-bank. So what could be controversial?
When the American Academy of Pediatrics endorsed guidelines recommending expensive prescription drugs to treat childhood acne, it didn’t tell doctors this: 13 of the 15 experts who drafted the guidelines were paid consultants or speakers for companies that market the drugs recommended in the guidelines.
Or this: The organization that developed the guidelines — paid the academy to publish them — received 98% of its 2011 revenue from companies that make acne drugs.
John Fauber questions motives:
In 2012, the top five prescription acne drugs racked-up $1 billion in U.S. sales, according to the drug-market research firm IMS Health.
“Does it make me suspicious?” asked Catherine DeAngelis, MD, a professor of pediatrics at Johns Hopkins School of Medicine and former editor of the Journal of the American Medical Association. “Are you kidding?
“The basis for these guidelines seems to be marketing, not science.”
Fauber has investigated this before:
A December 2012 investigation by the Journal Sentinel/MedPage Todayfound that treatment guidelines related to the nation’s top 25 selling drugs were heavily stacked with doctors who had ties to drug companies and often recommended expensive brand name drugs made by those companies.
The analysis found that of the 16 guideline panels that disclosed conflicts of interest, 164 of 247 doctors — 66% — had financial ties to drug companies.
Which begs the question: How much are doctors really influenced by pharmaceutical companies? Dr. Rahul Parikh emphatically says, a lot:
Early on in the movie “Love and Other Drugs,” newly hired pharmaceutical salesman Jamie Randall (Jake Gyllenhaal) and his more seasoned partner, Bruce Winston (Oliver Platt), stand in a rainstorm outside a doctor’s office. As a physician pulls into the parking lot, Winston gives Randall a pep talk to get out there, meet the guy and most importantly — give him a pen.
“Gifts establish reciprocity!” yells Winston as Randall hustles off, promotional pens in hand.
Reciprocity. I get a drug-branded pen or trinket. In return, I feel obliged to let a drug rep into my office, drop off free samples, listen to a slick sales pitch as I hustle between patients and, ultimately, prescribe their drug.
My wife and I are both physicians, and we joke that we could decorate our whole house with junk collected over the years from drug companies. Pens and sticky notes; stuffed animals to put in our children’s beds; coffee cups, tissue and soap dispensers, paperweights, posters, fridge magnets, mouse pads, clocks — all branded with some drug company’s logo. Giving out these freebies is just one tactic in the larger strategy of “drug detailing.” Does it work? Absolutely.
But Kevin B. O’Reilly says the rules are changing. As a result the Physician Payments Sunshine Act provision of the Affordable Care Act, these perks are coming to an end:
The Centers for Medicare & Medicaid Services estimates that it will cost physician practices and teaching hospitals staff time worth $59 million to review drugmakers’ reports of payments and gifts for accuracy.
Reports of “transfers of value” worth $10 or more to an individual doctor must be tracked, and any doctor who receives $100 or more in a year will see that information publicly reported on a searchable government website starting Sept. 30, 2014. Physicians will have 60 days to review industry reports for accuracy before they are made public.
In reality, health insurance companies have been dictating what pediatricians prescribe more than pharmaceutical companies. Over the years we’ve seen fewer and fewer pharmaceutical reps coming through our doors as they get the message that we won’t prescribe their products if insurance doesn’t pay for them (and they don’t). Sure, these newer products are more expensive for our patients. But it should also be said that for years, physician reimbursements by insurance companies have been tied to prescribing habits: cheap generics, good; expensive brand names, bad.
I think the role that drug reps have in influencing physicians is overblown and diminishing every day. When it comes to what physicians actually prescribe, “Big Insurance” trumps “Big Pharma” every time.