WINSTON-SALEM, N.C.--Should you see a specialist for athlete's foot? You should if you want the infection cleared up faster and at less cost, according to researchers at the Wake Forest University School of Medicine.
Researchers at the school's Department of Dermatology found that family doctors, internists and other non-dermatologists were far more likely than dermatologists to prescribe less-effective yet more costly medications for athlete's foot and other fungal skin disease.
The study has implications not only for the public, but for health maintenance organizations that typically limit access to specialists in the belief that it reduces costs.
The results of the study, funded by Westwood-Squibb Pharmaceuticals, were published today (July 1) in the Journal of the American Academy of Dermatology.
Alan Fleischer, M.D., associate professor of dermatology, and others based their conclusion on an analysis of visits to doctors for fungal skin infections as recorded in the National Ambulatory Medical Care Survey for 1990-1994.
The survey recorded 4.1 million visits to doctors for fungal skin infections during those five years. Of those 4.1 million visits, 82 percent of the visits were to doctors other than dermatologists.
The data showed that 34.1 percent of the non-dermatologists prescribed drugs that combined cortisone with anti-fungal agents, compared with just 4.8 percent of the dermatologists.
This treatment is less effective than the single agents, such as Lotrimin (made by Schering Corp.), Nizoral (Janssen Pharmaceutica Inc), Lamisil (Sandoz Pharmaceuticals Corp.) and Exelderm (Westwood-Squibb), that the overwhelming number of dermatologists prescribed, Fleischer said.
"The cortisone keeps the anti-fungal drug from working as effectively," he said. "It doesn't completely cancel it out but it does, to some degree, cancel it out." Other studies have shown failure rates of 45 percent for combination drugs, compared with just 8 percent for single agents.
The combination drugs cost more, too. Fleischer estimated that the combination drugs cost the nation's health care system $10.3 million to $24.9 million during the five years studied, depending on the drug prescribed. And this conservative estimate does not include the cost of additional office visits and prescriptions that would have been required in cases where the combination agent did not clear up the infection.
Roughly two-thirds of the visits to non-dermatologists were to family or general practitioners. They prescribed combination agents in 29 percent of the visits. Visits to internists accounted for about a sixth of the visits to non-dermatologists. They prescribed combination agents 51 percent of the time.
Fleischer conjectured that the doctors prescribing combination agents may do so because these drugs would seem to fit the symptoms.
"With some fungal infections there is a great amount of inflamation and irritation of the skin, and the patient has itching and burning," Fleischer said. These doctors may prescribe combination agents so that the cortisone can relieve the inflamation, not realizing that it negates the anti-fungal drug.
"The reason there's inflamation," Fleischer said, "is there's an infection, and the best way to treat the infection is to treat the infection, rather than the inflamation that results from the infection."
The study has important implications for HMOs, which, to reduce costs, typically require that patients first be seen by a primary care doctor, Fleischer said.
"What we are interested in are cost-effective outcomes for patients--that is, getting a patient to disease resolution quickly and efficiently.
"It might be assumed that treatment of skin disease is very straightforward, and that there are only two creams and you use Cream A or Cream B. But in fact, the recognition that there may very well be differences between how specialities manage skin diseases is very important. And this is just one piece of the puzzle that helps us understand what some of these differences are."
Contact: Robert Conn or Jim Steele at 336-716-4587
Journal
Journal of the American Academy of Dermatology