RESUMO
BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.
Assuntos
Analgésicos Opioides/uso terapêutico , Dermatologia , Prescrições de Medicamentos/normas , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Procedimentos Cirúrgicos Dermatológicos , Feminino , Humanos , Masculino , Guias de Prática Clínica como AssuntoAssuntos
Anestesia Local/métodos , Anestésicos Locais/administração & dosagem , Procedimentos Cirúrgicos Dermatológicos , Lidocaína/administração & dosagem , Dor/prevenção & controle , Procedimentos de Cirurgia Plástica , Anestesia Local/efeitos adversos , Dermatologia/métodos , Calefação , Humanos , Injeções Subcutâneas/efeitos adversos , Dor/etiologiaAssuntos
Cirurgia de Mohs , Neurotecoma/cirurgia , Neoplasias Nasais/cirurgia , Adulto , Feminino , Humanos , Retalhos CirúrgicosAssuntos
Leiomiossarcoma/diagnóstico , Neoplasias Cutâneas/diagnóstico , Amputação Cirúrgica , Tornozelo/patologia , Neoplasias Ósseas/diagnóstico , Neoplasias Ósseas/secundário , Neoplasias Ósseas/cirurgia , Diagnóstico Diferencial , Humanos , Leiomiossarcoma/secundário , Leiomiossarcoma/cirurgia , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/secundário , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Couro Cabeludo/patologia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgiaRESUMO
Cancer affects two major cell types in the human skin: epithelial cells and melanocytes. Aging and a previous history of ultraviolet light exposure are major risk factors for skin cancers, including basal and squamous cell carcinomas and melanomas. However, melanomas, which are the most deadly of the skin tumors, display two intriguing characteristics: The incidence is increased and the prognosis is worse in males over 60 years as compared with females of the same age. This Perspective discusses possible reasons for age and gender as melanoma risk factors, as well as the need for studies aimed at unraveling the molecular mechanism of such puzzling events.
Assuntos
Carcinoma Basocelular/fisiopatologia , Carcinoma de Células Escamosas/fisiopatologia , Melanoma/fisiopatologia , Neoplasias Cutâneas/fisiopatologia , Fatores Etários , Idoso , Carcinoma Basocelular/tratamento farmacológico , Carcinoma de Células Escamosas/etiologia , Dano ao DNA , Reparo do DNA , Feminino , Humanos , Queratinócitos/patologia , Queratinócitos/fisiologia , Masculino , Melanócitos , Melanoma/etiologia , Pessoa de Meia-Idade , Fatores de Risco , Fatores Sexuais , Neoplasias Cutâneas/etiologiaRESUMO
BACKGROUND: Infliximab inhibits T-cell activation by binding tumor necrosis factor-alpha (TNF-alpha). This medication is widely used in the US for treatment of psoriasis as an off-label indication. The durability of its effect is largely unknown. OBJECTIVE: To assess the proportion of patients still on infliximab 12 months after initiation of therapy for psoriasis. METHODS: Retrospective chart review analysis of 73 patients with psoriasis treated with infliximab for at least 12 months or those who experienced treatment failure in less than 12 months. The point where infusions were deemed to no longer be efficacious was determined by physician's global assessment (PGA). RESULTS: Of 73 patients who started infliximab at least 12 months prior to this chart review, 22 (30.1%) had discontinued treatment secondary to loss of efficacy. Thirty seven patients (50.7%) had no loss of efficacy and continued to receive infusions. Two patients (2.7%) discontinued due to loss of efficacy after greater than 12 months. Of the 22 patients who discontinued treatment due to loss of efficacy, 2 were on concomitant methotrexate (5-7.5 mg/wk) therapy. Of the 37 patients still receiving treatment with no loss of efficacy at 12 months, 3 patients were on concomitant methotrexate therapy. Five patients (6.8%) discontinued secondary to minor adverse events: sinus infection (1), acne (1), fever (1), arthralgia (1), and transient rash (1). Three patients (4.1%) discontinued due to major adverse events: reactivation of tuberculosis (1), breast cancer (1), and gastrointestinal bleeding (1). One patient discontinued infliximab secondary to concerns of possible lymphoma risk (though there were no signs of symptoms of disease on examination), and 3 patients discontinued due to insurance concerns. CONCLUSION: Infliximab treatment resulted in significant improvement in psoriasis, with 37 out of 73 patients (50.7%) experiencing no loss of efficacy. This longitudinal retrospective chart review demonstrates continued benefit of infliximab infusions in about half of patients after 1 year, though a notable percentage (30.1%) experienced loss of efficacy as determined by physician's global assessment (PGA) and a number of others discontinued due to adverse events or insurance difficulty.
Assuntos
Anticorpos Monoclonais/uso terapêutico , Psoríase/tratamento farmacológico , Fator de Necrose Tumoral alfa/uso terapêutico , Adolescente , Adulto , Anticorpos Monoclonais/administração & dosagem , Anticorpos Monoclonais/efeitos adversos , Feminino , Humanos , Infliximab , Infusões Intravenosas , Estudos Longitudinais , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Psoríase/epidemiologia , Psoríase/patologia , Estudos Retrospectivos , Texas/epidemiologia , Falha de Tratamento , Recusa do Paciente ao Tratamento , Fator de Necrose Tumoral alfa/administração & dosagem , Fator de Necrose Tumoral alfa/efeitos adversosRESUMO
Atopic dermatitis has been associated with elevated levels of IgE. Omalizumab is a monoclonal anti-IgE antibody currently approved for the treatment of asthma. We report the failure of omalizumab to improve atopic dermatitis in 3 patients when administered for 4 months.