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October 23, 2019

A State-of-the-Art Review Highlighting Medical Overuse in Dermatology, 2017-2018: A Systematic Review

Author Affiliations
  • 1Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
  • 2School of Medicine, University of California, San Francisco
  • 3Department of Dermatology, University of Pennsylvania, Philadelphia
  • 4Division of Dermatology, Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin
JAMA Dermatol. 2019;155(12):1410-1415. doi:10.1001/jamadermatol.2019.3064
Key Points

Question  What recent evidence exists to inform physician practice to decrease medical overuse in dermatology?

Findings  This systematic review of 10 articles identified several practices commonly performed but with limited prognostic value and therapeutic benefit to the patient.

Meaning  This systematic review highlights relevant areas of dermatologic overuse that may signify actionable means by which dermatologists can change practices.


Importance  Emerging efforts to recognize and combat medical overuse are important solutions to mitigate patient morbidity from unnecessary health care interventions.

Objectives  To identify and highlight important original investigations on medical overuse in dermatology from 2017 to 2018.

Evidence Review  The PubMed and Embase databases coupled with articles published in 8 major dermatology and medical journals from January 1, 2017, to December 31, 2018, were searched to identify articles related to medical overuse in dermatology.

Findings  Of 1941 candidate articles identified through the database search and 41 through the manual journal review, 38 were deemed relevant to medical overuse in dermatology by 2 independent reviewers. Twenty-eight of these articles were determined to be high priority based on scoring for quality of methods, magnitude of clinical effect, and number of patients potentially affected. After expert reviewer scoring, 10 articles were selected for analysis based on highest scores and greatest clinical significance. Selected articles covered topics such as dermatology consultation for cellulitis, management of dysplastic nevi, prognostic utility of sentinel lymph node biopsy, laboratory monitoring for terbinafine and isotretinoin, and safe medication prescribing. For cellulitis management, dermatology consultation is important for reducing misdiagnosis, unnecessary hospitalization, and inappropriate use of antibiotics. Findings related to common dermatologic procedures revealed that clinical observation is safe for dysplastic nevi and that sentinel lymph node biopsy may not have prognostic utility over Breslow thickness. In monitoring for terbinafine and isotretinoin, patient education on clinical symptoms is likely more effective than standard laboratory test result monitoring. Finally, dermatologists should reconsider the use of cyclosporine in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis and reevaluate the use of perioperative narcotics for patients.

Conclusions and Relevance  This review notes actionable, evidence-based practices to reduce medical overuse in dermatology. This work may help to facilitate management changes to emphasize high-value care in dermatology while promoting awareness and further evaluation of overuse in medicine.

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