Choosing Wisely | aad.org

Choosing Wisely

More than 80 medical societies have joined the ABIM Foundation's Choosing Wisely® campaign, which is focused on encouraging physicians and patients to talk about medical tests and procedures that may be unnecessary, and, in some instances, can cause harm. To join, a medical society must provide expert guidance on five medical tests or treatments commonly used in its field.

The Academy has identified five recommendations that can support conversations between patients and dermatologists about treatments, tests, and procedures that may not be needed.

Choosing Wisely video

AAD President-Elect Brett Coldiron, MD, provides a brief overview of the five recommendations of Choosing Wisely® for dermatology.

1. Don’t prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection

Rationale:

About half of nails with suspected fungus do not have a fungal infection. Because other nail conditions, such as nail dystrophies, may look similar in appearance, it is important to ensure accurate diagnosis of nail disease before beginning treatment. By confirming a fungal infection, patients are not inappropriately at risk for the side-effects of antifungal therapy, and nail disease is correctly treated.

References:

Roberts DT, Taylor WD, Boyle J; British Association of Dermatologists. Guidelines for treatment of onychomycosis. Br J Dermatol. 2003 Mar;148(3):402–10. 

Mehregan DR, Gee SL. The cost effectiveness of testing for onychomycosis versus empiric treatment of onychodystrophies with oral antifungal agents. Cutis. 1999 Dec;64(6):407–10.

2. Don’t perform sentinel lymph node biopsy or other diagnostic tests for the evaluation of early, thin melanoma because they do not improve survival

Rationale:

Patients with early, thin melanoma, such as melanoma in situ, T1a melanoma, or T1b melanoma ≤ 0.5mm, have a very low risk of the cancer spreading to the lymph nodes or other parts of the body. Further, patients with early, thin melanoma have a 97 percent five-year survival rate, which also indicates a low risk of the cancer spreading to other parts of the body. As such, the performance of sentinel lymph node biopsy is unnecessary.

Additionally, baseline blood tests and radiographic studies (e.g, chest radiographs, CT scans, and PET scans) are not the most accurate tests for the detection of cancer that is spreading because they have high false-positive rates. These tests have only shown benefit when performed as indicated for suspicious signs and symptoms based on the patient’s history and physical exam.

References:

Bichakjian CK, Halpern AC, Johnson TM, Foote Hood A, Grichnik JM, Swetter SM, Tsao H,  VH, Chuang TY, Duvic M, Ho VC, Sober AJ, Beutner KR, Bhushan R, Smith Begolka W; American Academy of Dermatology. Guidelines of care for the management of primary cutaneous melanoma. American Academy of Dermatology. J Am Acad Dermatol. 2011 Nov;65(5):1032–47. 

American Joint Committee on Cancer. AJCC cancer staging manual. 7th ed. New York: Springer; 2010. 

National Comprehensive Cancer Network. National Comprehensive Cancer Network clinical practice guidelines in oncology (NCCN Guidelines®): melanoma. Revised 2012. Fort Washington (PA): NCCN;2012.

3. Don’t treat uncomplicated, non-melanoma skin cancer less than 1 centimeter in size on the trunk and extremities with Mohs micrographic surgery

Rationale:

In healthy individuals, the use of Mohs micrographic surgery for low-risk, small (< 1cm), superficial or non-aggressive (based on appearance under a microscope) squamous cell carcinomas and basal cell carcinomas is inappropriate for skin cancers on the trunk and extremities. In these areas of the body, the clinical benefits of this specialized surgical procedure do not exceed the potential risks. It is important to note that Mohs micrographic surgery may be considered for skin cancers that appear on the hands, feet, ankles, shins, nipples, or genitals because they have been shown to have a higher risk for recurrence or require additional surgical considerations.

References:

Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, Zalla MJ, Brewer JD, Smith Begolka W; Ratings Panel, Berger TG, Bigby M, Bolognia JL, Brodland DG, Collins S, Cronin TA Jr, Dahl MV, Grant-Kels JM, Hanke CW, Hruza GJ, James WD, Lober CW, McBurney EI, Norton SA, Roenigk RK, Wheeland RG, Wisco OJ. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012 67(4):531–50.

National Comprehensive Cancer Network. National Comprehensive Cancer Network clinical practice guidelines in oncology (NCCN Guidelines®): Basal cell and squamous cell skin cancers. Revised 2011 February. Fort Washington (PA): NCCN;2011.

4. Don’t use oral antibiotics for treatment of atopic dermatitis unless there is clinical evidence of infection

Rationale:

The presence of high numbers of the staphylococcus aureus (staph) bacteria on the skin of children and adults with atopic dermatitis (AD) is common. It is widely believed that staph bacteria may play a role in causing skin inflammation, but the routine use of oral antibiotic therapy to decrease the amount of bacteria on the skin has not been definitively shown to reduce the signs, symptoms (e.g, redness, itch), or severity of atopic dermatitis. In addition, if oral antibiotics are used when there is not an infection, it may lead to the development of antibiotic resistance. The use of oral antibiotics also can cause side effects, including hypersensitivity reactions, including exaggerated immune responses such as allergic reactions. Although it can be difficult to determine the presence of a skin infection in atopic dermatitis patients, oral antibiotics should only be used to treat patients with evidence of bacterial infection in conjunction with other standard and appropriate treatments for atopic dermatitis.

References:

Bath-Hextall JF, Birnie AJ, Ravenscroft JC, Williams JC. Interventions to reduce Staphylococcus aureus in the management of atopic eczema: an updated Cochrane review. Br J Dermatol. 2010; 163:12–26.

5. Don’t routinely use topical antibiotics on a surgical wound

Rationale:

The use of topical antibiotics on clean surgical wounds has not been shown to reduce the rate of infection compared to the use of non-antibiotic ointment or no ointment. Topical antibiotics can aggravate open wounds, hindering the normal wound-healing process. When topical antibiotics are used in this setting, there is a significant risk of developing contact dermatitis, a condition in which the skin becomes red, sore, or inflamed after direct contact with a substance, along with the potential for developing antibiotic resistance. Only wounds that show symptoms of infection should receive appropriate antibiotic treatment.

References:

Dixon AJ, Dixon MP, Dixon JB. Randomized clinical trial of the effect of applying ointment to surgical wounds before occlusive dressing. Br J Surg. 2006 Aug;93(8):937–43.

Smack DP, Harrington AC, Dunn C, Howard RS, Szkutnik AJ, Krivda SJ, Caldwell JB, James WD. Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial. JAMA. 1996 Sep 25;276(12):972–7.

Campbell RM, Perlis CS, Fisher E, Gloster HM Jr. Gentamicin ointment versus petrolatum for management of auricular wounds. Dermatol Surg. 2005 Jun;31(6):664–9. 

Sheth VM, Weitzul S. Postoperative topical antimicrobial use. Dermatitis. 2008 Jul-Aug;19(4):181–9.

Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: epidemiology, responsible allergens, and management. J Am Acad Dermatol. 2008 Jan;58(1):1–21. 

The Academy is providing information for its members and the public to enable you to have candid conversations with your patients about treatments and procedures related to skin health and care that are not always necessary.

There are times when the items on the Choosing Wisely® list will be appropriate, and it’s up to physicians and patients to have conversations about doing the right thing, at the right time, for the right patient. In doing so, patients and physicians can be assured they are focusing on improving the quality of health care, avoiding harm, and eliminating waste.

Choosing Wisely Workgroup

The Academy’s Choosing Wisely® Workgroup identified areas to be include on the Academy’s list based on the greatest potential for overuse or misuse, a need for improvement, and availability of strong, evidence-based research as defined by the criteria listed below:  
  • Supported by available scientific evidence (e.g., existing AAD clinical guidelines and/or existing AAD appropriate use criteria).
  • Strongest consensus inappropriate score from the AAD appropriate use criteria.
  • Strong wording and/or level of evidence recommendations from the guidelines about discouraged practices.
  • Greatest potential for improvement in outcomes for patients.
  • Greatest potential for overuse/misuse by physicians.

The AAD Council on Science and Research and the AAD Board of Directors reviewed and approved the recommended list. 

This Choosing Wisely® list was created by dermatologists who are members of the Academy’s Board of Directors; Council on Science and Research; Council on Government Affairs, Health Policy and Practice; Research Agenda Committee; Clinical Guidelines Committee; Access to Dermatology Care Committee; Patient Safety and Quality Committee; Resource-Based Relative Value Scale Committee; and the Workgroup on Innovative Payment Delivery. 

Members of the Choosing Wisely® Workgroup include:
  • Mary-Margaret Chren, MD
  • Brett M. Coldiron, MD
  • Henry W. Lim, MD
  • Jack S. Resneck Jr., MD
  • Kathryn Schwarzenberger, MD
  • Alice J. Watson, MD

For more information about Choosing Wisely®, email Kevin Boyer, manager, clinical practice guideline and application, at kboyer@aad.org.