To the Editor Using treatments without a clear preponderance of evidence should be considered distinct from medical overuse when consensus guidelines or data-driven alternatives are lacking. In their recent systematic review, Pournamdari et al1 highlight actionable examples in which dermatologists can be more data driven in their treatment of patients, taking into account the information available about effectiveness, adverse effects, and cost. These points are well taken, but there are inherent limitations to current dermatologic research. These include the treatment of rare diseases, for which there is often less available evidence, conflicting results, or no expert consensus. Several previous studies, including 2 systematic reviews,2,3 have found cyclosporine to be safe and likely effective in the treatment of Stevens-Johnson syndrome/toxic epidermal necrolysis in selected patients at low risk for renal failure. Although Pournamdari and colleagues highlight a study that was unable to show a benefit of cyclosporine, it may be premature to deem its utility in that disease as medical overuse on the basis of 1 single-center, retrospective cohort study that the authors acknowledge is discordant with previously published data. Multi-institution prospective trials are needed to make any definitive conclusions. In the absence of these data, the decision to discuss and offer potentially beneficial treatments is what makes medicine an art as much as it is a science.
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O’Connor DM, Nathan NR, Kroshinsky DD. Evaluation of the Merits and Limitations of Evidence-Based Medicine. JAMA Dermatol. Published online June 24, 2020. doi:10.1001/jamadermatol.2020.1943
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