Key Points
Question
Do dermatologists and pharmacists differ in their perceptions and counseling practices when instructing patients on topical corticosteroid use?
Findings
In this survey study of 52 dermatologists and 111 pharmacists, discordance in topical corticosteroid beliefs and counseling practices was detected. More pharmacists advised patients to limit the duration of topical corticosteroid use, and differing adverse effects were emphasized in counseling.
Meaning
Further investigation, collaborative education, and improved communication are needed between dermatologists and pharmacists to ensure that patients are receiving accurate and unified topical corticosteroid counseling.
Abstract
Importance
Topical corticosteroids (TCs) are common treatments for many dermatologic conditions. Anecdotal experience and literature suggest that dermatologists and pharmacists differ in their beliefs about TCs and approach to TC counseling, creating the opportunity for patient confusion.
Objective
To examine interprofessional practice gaps between dermatologists and pharmacists with regard to how each group views TCs, counsels patients on TC use, and communicates modifications to TC prescriptions.
Design, Setting, and Participants
An electronic survey was disseminated statewide in Wisconsin to 117 board-certified or eligible dermatologist members of the Wisconsin Dermatological Society and 2954 licensed pharmacists. The survey was performed from October 11, 2017, to January 2, 2018. Survey responses and demographic information were compiled and analyzed for each population.
Exposures
Study participants completed and returned a 17-question survey recalling experiences with TC prescribing from the past year along with self-reported demographic information.
Main Outcomes and Measures
Dermatologists’ and pharmacists’ self-reported counseling of patients regarding TC application, duration of use, and adverse effects; frequency of communication of changes to TC prescriptions and instructions; and demographic data were tabulated and compared.
Results
Of the 117 dermatologists, 52 (44.4%) completed and returned the survey; of the 2954 pharmacists, 111 (3.8%) returned the survey. Those no longer in active practice (3 dermatologists, 1 pharmacist) were excluded from analysis. A substantial proportion of pharmacists (51 [46.4%]) advised patients to limit TC use to 2 weeks or less, which was an uncommon strategy among dermatologists (3 [6.1%]) (P < .001). Discordance also was noted in the adverse effects that are emphasized in counseling, pharmacist-perceived and dermatologist-observed adverse effects in patients, and resources that inform counseling content. Only 8 (16.3%) dermatologists perceived that pharmacists made no unauthorized modifications to their TC prescriptions or instructions; however, 77 (70.0%) pharmacists reported not doing so (P < .001).
Conclusions and Relevance
An interprofessional practice gap appears to exist between dermatologists and pharmacists in Wisconsin regarding TC beliefs and counseling strategies. Collaborative education and improved communication between the 2 groups may be necessary to ensure that patients receive a unified, clear message about TC application and adverse effects. Larger studies are needed to further investigate this potential practice gap.
This survey study compares the practices of dermatologists and pharmacists in counseling patients regarding the use of topical corticosteroids.
Introduction
Topical corticosteroids (TCs) are frequently prescribed in dermatology.1 Dermatologists commonly instruct patients to continue TC application to areas of active skin disease and monitor for adverse effects, including skin atrophy. In our experience, patients report receiving TC prescriptions or counseling from pharmacists that conflict with our communicated plan, suggesting a practice gap in interprofessional collaboration between dermatologists and pharmacists. Discrepant instructions can lead to patient confusion, unnecessary fear of TCs, and delays in onset and premature discontinuation of therapy.
The literature highlights that dermatologists identify pharmacists to be a source of misinformation contributing to TC phobia2 and misuse,3 and that most pharmacists occasionally or frequently adjust TC prescriptions, including decreasing duration of use to less than 2 weeks.4,5 Although interprofessional relations between dermatologists and pharmacists have been studied6 and beliefs regarding TC use have been examined within populations of physicians, pharmacists, patients, and caregivers,2,3,4,5,7,8,9,10,11,12,13 the purpose of our study is to directly contrast dermatologists’ and pharmacists’ perceptions of TCs, counseling strategies, and experiences.
Methods
Participant Recruitment
Seventeen-question surveys were distributed via email to 117 board-certified or -eligible dermatologist members of the Wisconsin Dermatological Society and 2954 licensed pharmacists from the Pharmacy Society of Wisconsin and Wisconsin Department of Safety and Professional Services. The survey was performed from October 11, 2017, to January 2, 2018. The study was approved by the Marshfield Clinic Health System Institutional Review Board. Investigators were blinded to respondents’ identifying information. Respondents provided informed consent; there was no financial compensation.
Survey Instrument
Self-reported demographic data were collected. Dermatologists and pharmacists selected how they counsel patients on TC application, duration, adverse effects, and resources used to inform counseling content. Reported pharmacist modifications to TC prescriptions and counseling over the past 12 months were compared.
Statistical Analysis
For survey questions relevant to dermatologists and pharmacists, response frequencies were summarized. The 2 groups were compared using the Fisher exact test. P values determined with 2-tailed, unpaired testing are presented after correction for multiple comparisons within each group of outcomes using the Hochberg sequential test procedure; results were deemed statistically significant at the 5% level (adjusted P < .05). All analyses were completed using SAS, version 9.4 (SAS Institute).
Results
Demographics
Fifty-two dermatologist (44.4%) and 111 pharmacist (3.8%) responses were received. Table 1 reports demographic results. Dermatologist and pharmacist respondents were similar in active practice status (49 [94.2%] vs 110 [99.1%]; P = .19) and years since training (eg, 0-5 years: 12 [24.5%] vs 27 [24.5%]; P = .99). Respondents who were no longer in active practice were excluded from further analysis (3 dermatologists, 1 pharmacist). Dermatologists were more likely practicing in urban areas (65.3% vs 36.4%; P = .01) (Table 1). The greatest number of dermatologists (22 [44.9%]) reported writing or refilling 501 to 1500 TC prescriptions per year, whereas the highest number of pharmacists (42 [38.2%]) reported counseling on 51 to 250 prescriptions (P < .001) (Table 1).
Table 1. Demographics and Adverse Effect Perceptions of Dermatologists and Pharmacistsa.
| Question Summary | Response Options | No. (%)b | P Valuec | |
|---|---|---|---|---|
| Dermatologists (n = 52) | Pharmacists (n = 111) | |||
| Respondent Demographics | ||||
| Years since completing dermatology residency/pharmacy school | 0-5 | 12 (24.5) | 27 (24.5) | .99 |
| 6-10 | 10 (20.4) | 23 (20.9) | ||
| 11-15 | 7 (14.3) | 16 (14.5) | ||
| 16-20 | 3 (6.1) | 9 (8.2) | ||
| 21-25 | 6 (12.2) | 14 (12.7) | ||
| 26-30 | 4 (8.2) | 8 (7.3) | ||
| >30 | 7 (14.3) | 13 (11.8) | ||
| Location of primary workplace | Rurald | 2 (4.1) | 18 (16.4) | .01 |
| Urban cluster | 13 (26.5) | 48 (43.6) | ||
| Urban | 32 (65.3) | 40 (36.4) | ||
| >1 of these | 2 (4.1) | 4 (3.6) | ||
| Topical corticosteroid prescriptions newly written or refilled/counseled on in the past 12 mo | 0 | 0 | 9 (8.2) | <.001 |
| 1-50 | 2 (4.1) | 26 (23.6) | ||
| 51-250 | 8 (16.3) | 42 (38.2) | ||
| 251-500 | 9 (18.4) | 17 (15.5) | ||
| 501-1500 | 22 (44.9) | 15 (13.6) | ||
| >1500 | 8 (16.3) | 1 (0.9) | ||
| Adverse Effect Perceptions and Dermatologist-Observed Event Rates | ||||
| No. of unique patients you encountered describing or presenting with signs of atrophy from dermatologist-prescribed topical steroid/No. of times you estimate the average Wisconsin dermatologist encountered atrophy in the past 12 mo | 0-1 | 31 (63.3) | 22 (20.0) | <.001 |
| 2-5 | 16 (32.7) | 42 (38.2) | ||
| ≥6 | 2 (4.1) | 46 (41.8) | ||
| No. of unique patients you encountered presenting with any adverse effect from dermatologist-prescribed topical corticosteroid/No. of times you estimate the average Wisconsin dermatologist encountered any adverse effect in the past 12 mo | 0 | 12 (25.0) | 4 (3.6) | <.001 |
| 1-5 | 26 (54.2) | 28 (25.5) | ||
| 6-10 | 8 (16.7) | 45 (40.9) | ||
| ≥11 | 2 (4.1) | 33 (30.0) | ||
| No. of unique patients encountered presenting to you with any adverse effect from dermatologist-prescribed topical corticosteroid (same asked of both groups) | 0 | 12 (25.0) | 57 (51.8) | .004 |
| 1-5 | 26 (54.2) | 44 (40.0) | ||
| 6-10 | 8 (16.7) | 8 (7.3) | ||
| ≥11 | 2 (4.1) | 1 (0.9) | ||
Question stems and response categories are nearly identical to those on the survey instruments.
Not all respondents answered all questions.
Adjusted for multiple comparisons using the Hochberg procedure.
2010 US Census Bureau definitions.14
TC Counseling Practices
Dermatologists and pharmacists differed in TC counseling strategies (Table 2). A substantial proportion of pharmacists advised patients to limit TC use to 2 weeks or less, an uncommon strategy among dermatologists (51 [46.4%] vs 3 [6.1%]; P < .001).
Table 2. Dermatologist and Pharmacist Counseling Strategies on Topical Corticosteroidsa.
| Question Summary | Response Options | No. (%)b | P Valuec | |
|---|---|---|---|---|
| Dermatologists (n = 52) | Pharmacists (n = 111) | |||
| The amount of topical corticosteroid you instruct patients to apply to acute or chronic skin conditions | Do not specifically counsel on the amount to apply | 4 (8.2) | 1 (1.1) | <.001 |
| Thin layer of medication | 32 (65.3) | 82 (87.2) | ||
| Liberally to affected area | 5 (10.2) | 0 | ||
| By No. of grams or ounces used | 1 (2.0) | 0 | ||
| By how long a container should last | 1 (2.0) | 0 | ||
| By fingertip units | 0 | 7 (7.5) | ||
| Other | 6 (12.2) | 4 (4.3) | ||
| Limit topical corticosteroid application to ≤2 wk | No | 46 (93.9) | 59 (53.6) | <.001 |
| Yes | 3 (6.1) | 51 (46.4) | ||
| Adverse effects emphasized in counseling | Do not specifically counsel on adverse effects | 1 (2.0) | 16 (14.5) | .16 |
| Atrophic changes | 47 (95.9) | 84 (76.4) | .02 | |
| Acneiform eruption | 23 (46.9) | 12 (10.9) | <.001 | |
| Masking or worsening of superficial infections | 11 (22.4) | 27 (24.5) | >.99 | |
| Corticosteroid addiction | 18 (36.7) | 9 (8.2) | <.001 | |
| Loss of effect with ongoing use | 21 (42.9) | 16 (14.5) | .002 | |
| Systemic effects | 3 (6.1) | 13 (11.8) | >.99 | |
| Other | 2 (4.1) | 4 (3.6) | >.99 | |
| Resources that inform your topical corticosteroid counseling | First-choice comparison | |||
| Previous patient care experience | 22 (44.9) | 17 (15.5) | <.001 | |
| Formal educational training | 17 (34.7) | 41 (37.3) | ||
| Drug reference textbooks/websites | 1 (2.0) | 35 (31.8) | ||
| Medication package inserts | 0 | 7 (6.4) | ||
| Current research | 9 (18.4) | 10 (9.1) | ||
| Any choice comparison (select up to 3) | ||||
| Previous patient care experience | 48 (98.0) | 69 (62.7) | <.001 | |
| Formal educational training | 43 (87.8) | 78 (70.9) | .16 | |
| Drug reference textbooks/websites | 17 (34.7) | 87 (79.1) | <.001 | |
| Medication package inserts | 2 (4.1) | 49 (44.5) | <.001 | |
| Current research | 26 (53.1) | 32 (29.1) | .04 | |
| Other | 3 (6.1) | 1 (0.9) | .44 | |
| None of these | 2 (4.1) | 1 (0.9) | .90 | |
Question stems and response categories are nearly identical to those on the survey instruments.
Not all respondents answered all questions.
Adjusted for multiple comparisons using the Hochberg procedure.
Dermatologists were more likely to emphasize the risk of atrophic changes (47 [95.9%] vs 84 [76.4%]; P = .02), acneiform eruption (23 [46.9%] vs 12 [10.9%]; P < .001), corticosteroid addiction (18 [36.7%] vs 9 [8.2%]; P < .001), and tachyphylaxis (21 [42.9%] vs 16 [14.5%]; P = .002). Dermatologists’ and pharmacists’ rates of counseling on overall TC adverse effects (48 [98.0%] vs 94 [85.5%]; P = .16), masking superficial infections (11 [22.4%] vs 27 [24.5%]; P > .99), and systemic adverse effects (3 [6.1%] vs 13 [11.8%]; P > .99) were similar.
Dermatologists were more likely than pharmacists to use previous patient care experience (48 [98.0%] vs 69 [62.7%]; P < .001) and current research (26 [53.1%] vs 32 [29.1%]; P = .04) as the basis of patient counseling. Pharmacists more often used drug reference textbooks and websites (87 [79.1%] vs 17 [34.7%]; P < .001) as well as medication package inserts (49 [44.5%] vs 2 [4.1%]; P < .001) among their top resources.
Modification of TC Prescriptions and Instructions
The predominant dermatologist perception was that pharmacists modified TC prescriptions or instructions without communication within the past year, but a smaller fraction of pharmacists reported making such modifications (41 [83.7%] vs 33 [30.0%]; P < .001) (Table 3). When identifying the most frequently encountered prescription modifications, most dermatologists reported that pharmacists advised patients to prematurely discontinue TCs at 2 weeks (37 [75.5%]) and stressed rare adverse effects (30 [61.2%]), but pharmacists reported doing this at lower rates (7 [6.4%] and 12 [10.9%], respectively; P < .001 for both). Pharmacists reported that their top modification of dermatologists’ prescriptions or instructions was dispensing less medication than was prescribed (34 [30.9%]; P < .001).
Table 3. Modifications Observed by Dermatologists and Reported by Pharmacists to Topical Corticosteroid Prescriptions/Instructionsa.
| Question Summary | Response Options | No. (%)b | P Valuec | |
|---|---|---|---|---|
| Dermatologists (n = 52) | Pharmacists (n = 111) | |||
| In the last 12 mo, how did pharmacists modify your topical corticosteroid prescriptions or instructions?/In which ways have you modified prescriptions or instructions? | Pharmacists did not modify prescriptions without discussion | 8 (16.3) | 77 (70.0) | <.001 |
| Dispensed less than the amount prescribed | 16 (32.6) | 39 (35.4) | >.99 | |
| Dispensed more than the amount prescribed | 0 | 20 (18.2) | .004 | |
| Instructed patient to halt use after 2 wk | 37 (75.5) | 7 (6.4) | <.001 | |
| Instructed patient to continue longer than prescribed | 0 | 0 | NA | |
| Stressed side effects that are rare/not emphasized by prescriber | 30 (61.2) | 12 (10.9) | <.001 | |
| Other | 4 (8.2) | 14 (12.7) | >.99 | |
| Which was the most common pharmacist modification of your prescriptions or instructions?/Which was the most common way you modified prescriptions or instructions? | Pharmacists did not modify prescriptions without discussion | 8 (16.3) | 66 (60.0) | <.001 |
| Dispensed less than the amount prescribed | 2 (4.1) | 34 (30.9) | <.001 | |
| Dispensed more than the amount prescribed | 0 | 13 (11.8) | .07 | |
| Instructed patient to halt use after 2 wk | 27 (55.1) | 6 (5.4) | <.001 | |
| Instructed patient to continue longer than prescribed | 0 | 0 | NA | |
| Stressed side effects that are rare/not emphasized by prescriber | 9 (18.4) | 8 (7.3) | .30 | |
| Other | 3 (6.1) | 10 (9.1) | >.99 | |
| How often do you communicate with pharmacists about prescription or instruction changes that you encounter?/How likely are you to communicate with prescribers when you feel topical corticosteroids are prescribed incorrectly? | Never | 28 (57.1) | 3 (2.7) | <.001 |
| Rarely/occasionally | 14 (28.6) | 38 (34.6) | ||
| Usually/always | 7 (14.3) | 69 (62.7) | ||
Abbreviation: NA, not applicable.
Question stems and response categories are nearly identical to those on the survey instruments.
Not all respondents answered all questions.
Adjusted for multiple comparisons using the Hochberg procedure.
When pharmacists perceived that TCs were prescribed incorrectly (eg, wrong strength for body site, inappropriate length of use), 69 (62.7%) reported usually or always communicating with the prescribing dermatologist. In contrast, 28 (57.1%) dermatologists indicated that they never communicate with pharmacists when changes to prescriptions or instructions occur (P < .001) (Table 3).
Adverse Effects of TCs
Pharmacists believed that dermatologists see TC adverse effects frequently in practice, including skin atrophy, but dermatologists reported that they do not. Many pharmacists (46 [41.8%]) believed that the typical Wisconsin dermatologist sees topical corticosteroid-related atrophy 6 or more times yearly. In contrast, 31 (63.3%) dermatologists reported seeing atrophy never or once in the past year (P < .001). Pharmacists estimated that dermatologists encounter overall TC adverse effects frequently (≥11 events per year), but dermatologists reported they do not (33 [30.0%] vs 2 [4.1%]; P < .001) (Table 1).
Discussion
Results of this study suggest that dermatologists and pharmacists in Wisconsin differ in their TC beliefs, counseling, and communication about prescription modifications. Pharmacists estimated greater adverse effect rates, including atrophy, than dermatologists observed in practice, which may be associated with counseling practices. Almost half of pharmacists instructed patients to limit TC use to 2 weeks or less, which was uncommon among dermatologists. Dermatologists perceived that pharmacists instructed patients to limit the duration of TC use and stressed rare adverse effects. Although dermatologists reported unauthorized pharmacist modifications to TC prescriptions or instructions in the past year, most pharmacists indicated that they never made unauthorized changes. Most pharmacists reported usually or always communicating the need to make modifications with dermatologists, yet, most dermatologists reported never communicating with pharmacists when unauthorized changes were discovered.
Use of TCs of appropriate strength, quantity, and duration is integral to the improvement of acute and chronic skin diseases. This study’s findings may suggest that patients may be receiving contradictory instructions from dermatologists and pharmacists, creating potential confusion. Unclear and discrepant information on TCs from physicians and pharmacists has been correlated with “topical steroid phobia.”7 Understanding the perspectives of dermatologists and pharmacists surrounding TCs is critical for delivering effective patient care.
Interprofessional conferences that align counseling strategies might improve dialogue and collaboration, including dispelling myths about the likelihood of patients experiencing clinically relevant adverse effects, such as cutaneous atrophy. Although it is possible that dermatologists are underreporting adverse effects, the literature suggests that atrophy rates are low when TCs are used as prescribed on inflamed skin.15
Limitations
Limitations include this study’s survey-based nature with the potential for recall, representational, and other biases inherent in self-reported data. Some survey questions were based on perceptions and not necessarily actual communication events. Surveys were distributed within Wisconsin, so the results may be of limited generalizability to other regions. Dermatologists and pharmacists differed in practice location. This study did not examine whether this variation in setting represents the population-based distribution of dermatologists and pharmacists. The pharmacist response rate was low, and it is possible that the respondents differ in important ways from Wisconsin pharmacists as a whole. The low response may be explained, in part, by the means of survey distribution to the pharmacists (ie, a link in an electronic newsletter rather than a direct email, or an email to a pharmacy group or manager rather than an individual), but the significant differences that we observed might reflect true differences between the populations.
Conclusions
Wisconsin dermatologists and pharmacists appear to differ in their TC perceptions, counseling, and communication practices. This finding represents an interprofessional practice gap and highlights the need for additional collaborative education and improved communication to minimize patient confusion. This issue merits further investigation in a larger study.
References
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