Contents (for this page)

• A Case Study Workshop in Dermatology
• Program Objectives
• Faculty
• Optimal Drug Therapy in Dermatology
• Program Notes

A Case Study Workshop in Dermatology

DEVELOPED BY FAMILY PHYSICIANS

In the primary care setting, dermatological conditions rank as one of the most common disease presentations, alongside GI disorders, respiratory tract infections, and so forth. On a typical day a clinician may see and treat a wide array of skin diseases – ranging from a simple, infected wound to a widespread cellulitis or psoriasis.

But, although they are common, the management of skin conditions is seldom routine; each case can present distinct challenges in terms of diagnosis, treatment and overall patient care. This dermatology workshop sets the scene to address many of these challenges – in light of the types of medical decisions, socioeconomic issues and patient-related concerns that occur in today’s clinical practice.

To set the stage for this practice-based learning session, close attention was paid to the methodology behind the development of the program materials themselves:

• The core of the program – the Case Studies on atopic dermatitis, psoriasis and skin infections – has been developed primarily by family physicians, in order to ensure that the discussions are oriented toward patient profiles and clinical situations that are actually seen in primary care practice.
• Similarly, the Differential Diagnosis Visual Skills Test highlights the types of skin conditions that commonly occur in the primary care setting.
• And finally, the Self-Assessment Quiz focuses on diagnostic and treatment issues in dermatology that are of routine concern to family physicians.

Overall, we hope that you find this to be a fruitful learning experience, and a stimulus for provocative discussions among peers and colleagues.

Elliot Halparin MD, CCFP, FCFP
PROGRAM EDITOR

In this online course, you will find the following components, intended to be utilized in a 2 hour session:

• Differential Diagnosis
  • Visual Skills Test
• Case Study Workbooks on Atopic Dermatitis, Psoriasis & Skin Infections (Inside Back Folder)
• Self-Assessment Quiz
• Treatment algorithms for psoriasis and skin infections (in Case Workbooks).

Program Objectives

This workshop program in dermatology has been designed to improve the skill and knowledge of participants in the following areas:

1. Differential Diagnosis: This is an area that is a constant challenge for clinicians. Skin disorders manifest in countless ways, with a high degree of inter-patient variability. The key to diagnosis is through “pattern recognition,” derived from extensive exposure to a wide variety of different skin conditions.
2. Pharmacologic Management: Recently, a number of clinical prescribing guidelines have been developed to aid physicians in making treatment choices for their patients. Clinicians today need to determine the utility and applicability of these guidelines – which employ the principles of Optimal Drug Therapy (see next page) – in the management of individual patients.
3. Patient Management: In many skin disorders, nonpharmacologic measures are as important as pharmacologic ones. In managing chronic conditions, such as some forms of psoriasis, physicians need to take into account the psychosocial dimension of the disorder, as well as its impact on the patient’s lifestyle.

Faculty

Family Physician Editor

Dermatology Editors

Contributors

Marie-Christine Roy MD FRCP(C)
Clinical Professor
Department of Medicine
Université de Montréal
Dermatologist
Department of Dermatology
Hôtel-Dieu de Montréal
Quebec

Sam Racanelli MD CCFP
Family Physician
Mississauga, Ontario

Suleman Remtulla MD
MSc CCFP
Family Physician
Staff, Credit Valley Hospital
Mississauga, Ontario

Optimal Drug Therapy in Dermatology

THE ROLE OF CONTEMPORARY CLINICAL GUIDELINES

The contemporary emphasis on cost-control has compelled health caregivers – both individually and as professional groups – to re-evaluate their attitudes and practices regarding patient care. Essentially, the current dilemma can be summarized as follows: How do we continue to provide quality care, while keeping costs under control?

The concept of Optimal Drug Therapy is basically a response to this conundrum; under this concept, the efficacy, safety and cost-effectiveness of a particular therapy are carefully weighed and balanced according to each patient and his/her clinical situation. In other words, clinical consideration is given to the needs of society at large (cost-effectiveness), while ministering to the needs of individual patients (efficacy, safety).

Today’s clinical guidelines have crystallized these criteria (efficacy, safety and cost-effectiveness) by formulating algorithms with indications for first-, second- and third-line therapies. Although these indications would appear to be clear-cut, in practice the application of clinical guidelines is often a complex and highly individualized process.

Individualizing Therapy

As an illustration of this individualized process, consider the way “cost-effectiveness” of therapy is assessed.

It is well known that cost of treatment is an important factor for government (formularies), group (insurance companies) and individual (patients) payors. However, it should be noted that the pharmacoeconomics of a drug does not merely take into account its purchase value; of equal importance is its efficacy and safety. In other words, a drug may be inexpensive but:

• Is it effective? (Treatment failures, relapses or recurrences could necessitate further treatment)
• Is it safe? (Adverse effects may necessitate the use of other drugs for symptom control, or may trigger noncompliance)

Thus, cost-effectiveness of therapy can only be determined by weighing its actual cost, along with the other criteria involved – namely efficacy and safety – and assessing their impact on the patient and his/her clinical situation.

Compliance

There is a fourth factor implicit within this Optimal Drug Therapy pyramid: compliance or patient acceptance. Once again, therapeutic compliance is related to all the preceding factors: If a drug is efficacious, safe and affordable, there is a higher likelihood of compliance. On the other hand, if a drug does not satisfactorily meet one or more of these criteria, it needs to be asked: What is the cost of noncompliance?

Emergency room visits, return visits to the physician, new drug prescriptions, and secondary complications may all result from noncompliance with the initial therapy. Apart from the human consequences, the cost of noncompliance from a macroeconomic standpoint ranges from 7 to 9 billion dollars a year, according to recent estimates.*

Applications

In the following program, discussions surrounding Optimal Drug Therapy are aimed chiefly at promoting comprehensive care of our patients – that is, administering the right treatment, with the right dose, for the right amount of time and at the right price.

* Coambs RB, Jensen P, Her MH, et al. Review of the scientific literature on the prevalence, consequences, and health costs of noncompliance & inappropriate use of prescription medication in Canada. Pharmaceutical Manufacturers Association of Canada, Ottawa, Ontario, 1995.

Program Notes

This program has been designed to run for 2 hours; however, it can be adapted to conform to timeframes ranging from 1-3 hours. The following briefly describes the program flow and possible implementation by program moderators:

1. The first section to be covered, entitled Differential Diagnosis Visual Skills Test, is intended as a rapid series of diagnostic “teasers.” After the presentation of each dermatology slide image, participants choose from a number of diagnostic options. Answers and commentary immediately follow.
2. Next, case studies will be presented on various dermatological conditions. Participants may choose (possibly via a pre-workshop questionnaire) the sequence and types of cases to be covered from the three case workbooks on Atopic Dermatitis, Psoriasis and Skin Infections. Under each case, diagnostic and treatment options are provided; participants should attempt to make appropriate choices and provide detailed rationales. Other suggested topics for discussion are also included within each case.
3. Subsequent to the case presentations, a self-assessment quiz will recap some of the educational points from the case studies, and challenge participants on general issues pertaining to diagnosis and therapeutic management.

The suggested timing of the program is roughly as follows (based on a 2-hour session):