Commentary
Knowledge
Oral contraceptive pills were endorsed as effective in the treatment of acne in women by 95.4% (124/130) of respondents. Among prescribers of OCPs for acne, 94.2% (65/69) believed OCPs were associated with an increased risk for VTE, no respondents thought OCPs were associated with a decreased VTE risk, 2.9% (2/69) believed OCPs did not affect VTE risk, and 2.9% (2/69) were unsure.
Among prescribers of OCPs for acne, 46.4% (32/69) believed DCOCPs posed a greater VTE risk than other OCPs. Odds of this response did not differ with frequent DCOCP prescribers versus infrequent prescribers (odds ratio, 0.731 [95% confidence interval, 0.272-1.964]; P=.5342). Participant responses on VTE risk and DCOCPs are provided in Table 2.
Dermatologists prescribing OCPs for acne endorsed greater likelihood of doing so in cases of cyclical flares with menstrual cycle (94.2% [65/69]), acne unresponsive to conventional therapy (87.0% [60/69]), acne on the lower half of the face (78.3% [54/69]), diagnosis of polycystic ovary syndrome (PCOS)(76.8% [53/69]), clinical suspicion of PCOS (71.0% [49/69]), concomitant hirsutism (71.0% [49/69]), late- or adult-onset acne (66.7% [46/69]), laboratory evidence of hyperandrogenism (60.9% [42/69]), and concomitant androgenetic alopecia (49.3% [34/69]).
Among dermatologists who prescribed OCPs for acne, CDC-defined absolute contraindications identified correctly were blood pressure of 160/100 mm Hg (59.4% [41/69]) and history of migraine with focal neurologic symptoms (49.3% [34/69]). The CDC-defined relative contraindications identified correctly were history of deep vein thrombosis or pulmonary embolism (1.4% [1/69]), breast cancer history with 5 years of no disease (15.9% [11/69]), hyperlipidemia (42.0% [29/69]), and 36 years or older smoking fewer than 15 cigarettes per day (21.7% [15/69]).
Comfort
Dermatologist self-reported comfort levels in prescribing OCPs for acne are shown in Table 3.
Prescribing Practices
Among all respondents, acne medications prescribed often included oral antibiotics (76.9% [100/130]), isotretinoin (41.5% [54/130]), and spironolactone (40.8% [53/130]).
Overall, 55.4% (72/130) of respondents prescribed OCPs for the following uses: acne (95.8% [69/72]), concomitant treatment with teratogenic medication (48.6% [35/72]), PCOS (34.7% [25/72]), hirsutism (26.4% [19/72]), androgenetic alopecia (19.4% [14/72]), SAHA (seborrhea, acne, hirsutism, alopecia) syndrome (12.5% [9/72]), and HAIR-AN (hyperandrogenism, insulin resistance, acanthosis nigricans) syndrome (11.1% [8/72]). For teratogenic medications, dermatologists prescribing OCPs did so with isotretinoin (77.8% [56/72]), spironolactone (73.6% [53/72]), tetracycline antibiotics (37.5% [27/72]), and other (34.7% [25/72]).
Of dermatologists prescribing OCPs for acne, frequency included often (19% [13/69]), sometimes (45% [31/69]), and rarely (36% [25/69]). The most frequently prescribed OCPs included Ortho Tri-Cyclen (Janssen Pharmaceuticals, Inc)(80% [55/69]), Yaz (Bayer)(64% [44/69]), and Estrostep (Warner Chilcott)(19% [13/69]). Fill-in responses included Desogen (Merck & Co, Inc)(3/69 [4%]), Alesse (Wyeth Pharmaceuticals, Inc)(3/69 [4%]), Lutera (Watson Pharma, Inc)(1/69 [1%]), Loestrin (Warner Chilcott)(1/69 [1%]), and Yasmin (Bayer)(1/69 [1%]).
In univariate regressions, graduation from medical school in 1997 or later (P=.0416), academic practice setting (P=.0130), and low-density practice setting (P=.0034) were significant predictors of prescribing OCPs. In multivariable regression, only academic practice setting (P=.0295) and low-density practice setting (P=.0050) remained significant predictors. Demographic predictors are summarized in Table 1.
Comment
Our results suggest that most dermatologists (95.4%) believe OCPs effectively treat acne; however, only 54% of respondents reported prescribing them. Academic dermatologists were more likely to prescribe OCPs than nonacademic dermatologists, possibly indicating that academic dermatologists are more familiar with the literature on the efficacy and use of OCPs. Nearly half of respondents seeing 25 or more acne patients weekly did not prescribe OCPs, suggesting a notable practice gap. Dermatologists in less dense US regions were more likely to prescribe OCPs, perhaps because dermatologists may be more likely to prescribe OCPs than refer patients in health care access–limited areas, just as primary care providers treat a broader range of conditions in low-density rural areas than urban ones.17 Exploring all dermatologists’ referral patterns for OCPs is warranted.
A strong knowledge area revealed from this study was hormonal treatment of acne in women, a vital area because appropriate patient selection is key to treatment success.8 Weaker knowledge areas included OCP contraindications and differences in VTE risk between formulations containing drospirenone and those not containing drospirenone. Only half the sample identified CDC-defined absolute contraindications, suggesting an education target for dermatologists to ensure patient safety. In contrast, respondents were conservative about relative contraindications, with most identifying deep vein thrombosis or pulmonary embolism, remote breast cancer history, and light smoking at 36 years or older as absolute contraindications. These results could reflect weighing the risk of relative contraindications against the benefit in acne, resulting in appropriately more conservative management than overall guidelines suggest. If so, it may suggest that dermatologists are adapting overall guidelines appropriately for use of OCPs in skin conditions.
Nearly all respondents knew that OCPs are associated with an increased risk for VTE. Approximately half understood that DCOCPs are associated with a greater VTE risk than other OCPs, with no difference between frequent and infrequent prescribers. Comparing these results to the findings on OCP prescribing overall, some dermatologists’ risk-benefit calculation for VTE differs from other specialties because DCOCPs have superior efficacy in acne, whereas DCOCPs have similar contraceptive efficacy to other OCPs.18 The fact that more dermatologists believed VTE to be an absolute contraindication than hypertension suggests dermatologists have a heightened awareness of VTE risk but prescribe DCOCPs for acne despite it.
Most OCP prescribers felt very comfortable selecting good candidates for OCPs (55.5%) and counseling on treatment initiation (45.8%) and side effects (48.6%). Only 22.2%, by contrast, were very comfortable managing side effects. This finding likely reflects the notion that VTEs are not most appropriately managed by a dermatologist. Exploring if a greater comfort level in managing side effects would make dermatologists more likely to prescribe OCPs is worthwhile. Additionally, exploring why many dermatologists do not prescribe OCPs despite believing they are effective for acne is warranted.
Study limitations included the use of convenience sampling. Additionally, our study did not investigate dermatologists’ reasons for not prescribing OCPs.
