Reply

Abstract

We appreciate the comments of Dr Peets because they enable us to address and reiterate important issues raised in our article, “Nondermatologists Are More Likely than Dermatologists to Prescribe Antifungal/corticosteroid Products: An Analysis of Office Visits for Cutaneous Fungal Infections, 1990-1994.”1Smith ES Fleischer Jr, AB Feldman SR. Nondermatologists are more likely than dermatologists to prescribe antifungal/corticosteroid products: an analysis of office visits for cutaneous fungal infections, 1990-1994.J Am Acad Dermatol. 1998; 39: 43-47Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar The data clearly documented that nondermatologists prescribe combination corticosteroid/antifungal agent therapy more commonly than do dermatologists. Dr Peets questions an assumption of our analysis, that single agents are more cost-effective than combination products. We must address this point because our conclusion, that dermatologists may be more cost-effective than nondermatologists for simple skin problems, is based on this premise. In addition to the references cited in our article, the citations provided by Dr Peets support our conclusion. In two of the studies, single-drug agents exhibited greater antifungal efficacy than the combination product, and they are of lower cost.2Evans EGV James IGV Seman RAJ Richardson MD. Does naftifine have anti-inflammatory properties? A double-blind comparative study with 1% clotrimazole/l% hydrocortisone in clinically diagnosed fungal infection of the skin.Br J Dermatol. 1993; 129: 437-442Crossref PubMed Scopus (39) Google Scholar, 3Katz HI Bard J Cole GW Fischer S McCormick GE Medansky RS. SCH 370 (clotrimazole-betamethasone diproprionate) cream in patients with tinea cruris or tinea corporis.Cutis. 1984; 34: 183-188PubMed Google Scholar In one of the citations, the mycologic cure rate of betamethasone diproprionate/clotrimazole was only 65%.3Katz HI Bard J Cole GW Fischer S McCormick GE Medansky RS. SCH 370 (clotrimazole-betamethasone diproprionate) cream in patients with tinea cruris or tinea corporis.Cutis. 1984; 34: 183-188PubMed Google Scholar By contrast, monotherapy antifungal agents including topical naftifine, econazole, and terbinafine provide reported cure rates of 80% to 83% for tinea corporis and tinea cruris.4Millikan LE Galen WK Gewirtzman GB Horwitz SN Landow RK Nesbitt Jr, LT et al.Naftifine cream 1% versus econazole cream 1% in the treatment of tinea cruris and tinea corporis.J Am Acad Dermatol. 1988; 18: 52-56Abstract Full Text PDF PubMed Scopus (38) Google Scholar, 5van Heerden JS Vismer HF. Tinea corporis/cruris: new treatment options.Dermatology. 1997; 194: 14-18Crossref PubMed Scopus (13) Google Scholar Aside from clinical trials, we dermatologists regularly see the patients in whom combination products fail as treatment of tinea. We also see patients in whom atrophy develops from inappropriate use of this product.6Fleischer Jr., AB Lotrisone: a negative report.Schoch Lett. 1993; 11Google Scholar These personal experiences are supported by the findings of our study showing that dermatologists choose single agents at 96% of the visits for common fungal infections. Because dermatologists can diagnose common fungal disorders accurately and decisively, they are able to prescribe these cost-effective measures. Because other specialists do not have this special expertise, they must rely on less effective, less safe, and more costly treatment. Dr Peets cites data from a Schering-sponsored study suggesting that “cost savings for follow-up care of patients receiving the combination drug offset the higher initial costs of treatment.” The investigation by Thompson, Schultz, and Oster 7Thompson D Schultz N Oster G. Comparative antifungal therapy: outcomes and costs.J Formulary Management, P and T. 1994; 19: 790-795Google Scholar has several weaknesses. First, the study compares betamethasone diproprionate/clotrimazole primarily to miconazole and clotrimazole, which are not as efficacious as newer antifungal agents. Next, this study did not limit the analysis to the treatment of tinea. Betamethasone diproprionate/clotrimazole is widely used to treat inflammatory conditions. The National Ambulatory Medical Care Survey (1990-1994) estimates that the most common diagnosis treated with Lotrisone (clotrimazole-betamethasone dipropionate) was contact dermatitis, accounting for 798,005 physician visits (12.3% of all use). The next most frequent diagnosis for which this agent was used, tinea corporis, accounted for 388,650 visits (6.0% of total use). Thus, to compare the cost of combination antifungal/corticosteroid treatment with the cost of antifungal monotherapy, without controlling for the diagnoses being treated, is scientific poppycock. Despite its weaknesses, the study of Thompson, Schultz, and Oster advances our thesis that dermatologists are more cost effective because, in addition to our finding that dermatologists prescribe more cost-effective drug therapy, the Thompson group demonstrated fewer required follow-up visits when therapy was initiated by dermatologists. Because dermatologists understand the cost-effectiveness of products for the treatment of tinea, and because they can make the diagnosis of tinea with certainty, they are able to choose the most cost-effective agent. Physicians and the public need to be aware of the special expertise offered by dermatologists, expertise that makes a discernible difference, even for patients with common, “simple” skin disorders.