I S S U E

21SEPTEMBER

2017

I N T H I S I S S U E

Corticosteroids: A Two-Edged Sword ....................................................................... p1

Using Social Media to Help Build Your Practice ............................................................... p4

Corticosteroids: A Two-Edged Sword

Corticosteroids are the primary (symptomatic) treatment for inflammatory skin diseases. Unfortunately, corticosteroids, which can be administered in creams,

gels, lotions, ointments, suppositories, intramuscular or intravenous solutions, or orally, really are a two-edged sword because they are also sensitizing substances. The most common reaction to corticosteroids is delayed type IV hypersensitivity, but type I allergic reactions have also been reported. Because patients are often prescribed corticosteroids to treat a variety of dermatitic conditions, diagnosing allergic contact dermatitis to the medicine itself can be challenging. In a recent retrospective analysis of almost 18,000 patients conducted by the North American Contact Dermatitis Group (NACDG), the overall prevalence of sensitivity to corticosteroids was 4.1%, which is consistent with earlier international reports. Given the widespread therapeutic use of corticosteroids, the American Contact Dermatitis Society recognized this group of drugs as the Allergen of the Year in 2005.

In 1989 Coopman and coworkers classified corticosteroids into 4 groups (A, B, C, and D) that reflect structural distinctions between groups and highly homogenous molecular structures of the substances within a group (Table 1). Later, Group D was divided into subgroups D1 (stable esters) and D2 (labile esters) based on chemical substitutions on the corticosteroid backbone. In 2011 Baeck and coworkers introduced a new class-ification system that condensed corticosteroids into three clusters (Table 1). Their simplification was based on identification of two patient profiles: those who reacted to corticosteroids from only one group and those likely to react to the entire spectrum of cortico- steroids. Hence, nonmethylated, nonhalogenated allergic corticosteroids were classified as Group 1(i.e., Coopman Groups A and D2 and the S isomerof budesonide). Group 2 was defined as halogen-ated corticosteroids with a carbon (C)16/C17 cis-ketal diol structure (i.e., acetonides from Coopman Group B) while Group 3 included those halogenated and methylated on C16 (i.e., Coopman Groups C and D1). The poten-cy of corticosteroid patch test substances has also been ranked from superpotent (Class 1) to least potent (Class 7).

Why do such classification systems matter? Conceptualizing corticosteroids in these

Continued on next page

Dear Readers,

In the 2017 Winter and Spring issues of this newsletter, we shared tactics for re-taining and building your patient base. We introduced the concept of the net promotor score for gauging your pa-tients’ satisfaction with your practice and discussed the importance of devel-oping a website as part of that strategy. This series now closes with a final article that explores additional options for en-gaging current and future patients using tools such as Google Places and social media. We hope these articles have enhanced your appreciation of what it takes to become and remain a success-ful practice in today’s ever-changing en-vironment.

Even as one series ends, another begins. This time the topic is motivated by the many questions we receive on the topic of corticosteroids—a group of allergens far too complex to discuss in a single ar-ticle. In this issue you will find an over-view of corticosteroids: how they are classified and the underlying clinical im-plications for diagnostic patch testing. Future articles will offer a more in-depth look at the specific markers that are available commercially for the diagno-sis of corticosteroid allergies. Of course, don’t wait if you have unanswered ques-tions. Always feel welcome to contact us because helping you help your patients obtain a diagnosis is the heart of our mission.

Kind Regards,

Dr. Curt Hamann President & CEO, SmartPractice

all things contact dermatitis N E W S & N O T E S

™

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hypothetical classifications has helpful clinical ramifications. The Coop-

man system established that allergenicity differs across the groups: Compounds in Groups A, B, D2 are thought to be more highly allergen-ic than those in Groups C and D1. Furthermore, drugs within a group are more likely to elicit cross reactions

than those in different group; however, cross reactions between corticosteroids in differ-ent groups (i.e., between budesonide (Group B) and Group D2 substances have also been reported. The identification of potential cross-reacting substances is a crucial step in deter-mining alternative products that a patient can use safely (Ta-ble 1) even though it can be challenging to ascertain whether reactions to more than one compound represent true cross reactions. In general, Group A corticosteroids are considered to have the potential to cause cross reactions with members of Group D2 and with the S isomer of budesonide and vice versa. In the Baeck system, patients who react to Groups 2 and 3 are also likely to react to Group 1. The reverse, how-ever, does not hold true.

What are the important points to remember when patch test-ing patients with corticosteroids? First, patients with chronic dermatitis that fails to improve after prolonged treatment with corticosteroids are prime candidates for diagnostic patch testing, especially if their dermatitis deteriorates or spreads. Markers used by the NACDG for testing are tixocortol piva-late for Group A, budesonide for Group B, desoximetasone for Group C, clobetasol-17-propionate for Group D1, and hy-drocortisone-17-butyrate for Group D2, all of which are com-mercially available in petrolatum (or ethanol). The ready-to-use patch test product includes markers for all groups except the less allergenic Coopman Group C.

The concentration of a corticosteroid used for patch testing is important, but the findings may seem counterintuitive: lower doses are associated with a higher frequency of positive reac-tions than higher doses. This tendency is interpreted to indi-cate that the anti-inflammatory action of the steroid itself sup-presses an allergic reaction, thereby yielding a false-negative reaction. When a patient’s personal corticosteroid product is used for patch testing, it should be remembered that the po-tency of a corticosteroid can vary depending on its formula-tion. In other words, the same active ingredient may be more potent in an ointment than in a cream because of differences in the rate of penetration.

Doses that are too high have also been associated with the “edge” effect—an apparent positive reaction confined to the ring of a round patch test chamber at early readings. Although

Corticosteroids: A Two-Edged Sword…continued

Table 1 Corticosteroid drugs classified by group

Coopman Group (Structure) Examples Baeck Group

(Structure)

A(Short-chain esters at C21 are only substitution in D ring)

Cloprednol 1(Mostly no C16 methyl or halogen substitution)

Cortisone acetateDichlorisone acetateFludrocortisone acetateFluorometholone acetateFluprednisolone acetateHydrocortisone*Isofluprednone acetateMazipredoneMedrysoneMethylprednisone*Prednisolone*PrednisoneTixocortol pivalate

B(C16/C17-cis-diol or -ketal)

Amcinonide

2(C16/C17-cis-diol or -ketal Halogen substitution**)

Budesonide 1Desonide 2FluchloronideFlumoxonideFlunisolideFluocinolone acetonideFluocinonideHalcinonideTriamcinolone 1Triamcinolone salts (various) 2

C(C16 methyl substitution)

Betamethasone 3(C16 and halogen substitution)

DesoxymethasoneDexamethasone*Diflucortolone valerateFlumethasone pivalateFluocortin butylFluocortolone*Fluprednidene acetateHalomethasoneMeprednisone

D1(C16 methyl substitution C17/C21 long chain ester)

Alclomethasone dipropionate

3(C16 and halogen substitution)Beclomethasone dipropionate

Betamethasone dipropionateClobetasol propionateClobetasone butyrateDiflorasone diacetateFluticasone propionateMometasone furoate

D2(No methylation or haloge-nation at C16 C17 long chain ester C21 possible side chain)

Difluprednate 1Hydrocortisone*

Methylprednisolone aceponate

*Including various salt forms. **Group 2 exceptions to halogen substitution are desonide and halcinonide.

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Corticosteroids: A Two-Edged Sword…continued

an edge effect is considered a negative reaction by strict reading criteria, later readings (day 6 or 7) may show a clear positive reaction at the same site(s). Testing with a lower dose may eliminate the edge effect and yield an early positive reaction. Because of the intrinsic anti-inflammatory effect of corticosteroids, late readings are always advisable. In a Swedish study, for example, the rate of false-negative reactions would have been as high as 30% without late readings.

Patients who are suspected of reacting to a corticosteroid should first undergo patch testing with a baseline screening series. Testing with a marker from all groups may help identify an alternative active ingredient that patients can use safely if they fall into the monosensitization profile, as did almost 71% of patients in the NACDG study. A patient’s personal product can be tested, but it is important to be aware that reactions have been reported to the vehicle in which some medicinal corticosteroids are formulated. Positive patch test reactions may warrant further investigation by patch testing with an extended series. Despite the relatively low overall prevalence of sensitization to corticosteroids, the relevance of positive patch test reactions is reassuringly high—almost 80% in the recent NACDG study.

Corticosteroids are a complicated set of allergens—far too complex to cover adequately in one brief article. So be sure to check out upcoming issues of this newsletter to learn more about the specific markers used for patch testing. And remember only a phone call is needed to receive the support you may need for patch testing with this important group of anti-inflammatory drugs.

Suggested Readings

Baeck M, Chemelle JA, Goossens A, et al. Corticosteroid cross-reactivity: clinical and molecular modeling. Allergy 2011;66:1367-1374

Coopman S, Degreef H, Dooms-Goossens A. Identification of cross-reaction patterns in allergic contact dermatitis from topical corticosteroids. Br J Dermatol 1989;121:27-34

Isaksson M. Corticosteroids. Dermatologic Therapy 2004;17:314-320

Isaksson M, Andersen KE, Brandao FM, et al. Patch testing with corticosteroid mixes in Europe. A multicenter study of the EECDRG. Contact Dermatitis 2000;42:27-35

Isaksson M, Andersen KE, Brandao FM, et al. Patch testing with budesonide in serial dilutions: the significance of dose, occlusion time and reading time. Contact Dermatitis 1989;21:538-543

Isaksson M, Bruze M. Corticosteroids. Dermatitis 2005;16:3-5

Jacob SE, Steel T. Corticosteroid classes: a quick reference guide including patch test substances and cross-reactivity. J Am Acad Dermatol 2006:54:723-727

Pratt MD, Mufti A, Lipson J, et al. Patch test reactions to corticosteroids: Retrospective analysis from the North American Contact Dermatitis Group 2007-2014. Dermatitis 2017;28:58-63

Wilkinson SM, Hollis S, Beck MH. Reactions to other corticosteroids in patients with allergic contact dermatitis from hydrocortisone. Brit J Dermatol 1995;132:766-771

Wilkinson M, Hollis S, Beck M. Reactions to other corticosteroids in patients with positive patch test reactions to budesonide. J Am Acad Dermatol 1995:33:963-968

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IMPORTANT SAFETY INFORMATION

INDICATIONS AND USAGE:T.R.U.E. TEST is an epicutaneous patch test indicated for use as an aid in the diagnosis of allergic contact dermatitis in persons 6 years of age and older whose history suggests sensitivity to one or more of the 35 substances included on the T.R.U.E. TEST panels.

CONTRAINDICATIONS• Do not apply to skin of patients with a history of severe al-

lergic reaction (systemic and/ or local) to any of the allergen components or inactive substances of T.R.U.E. TEST.

• Do not apply to skin that is injured or inflamed.

WARNINGS AND PRECAUTIONS• Acute allergic reactions, including anaphylaxis, may occur.• Sensitization to one or more of the allergens may occur

with initial or repeat testing.• Extreme positive reactions, excited skin syndrome, tape

reactions, irritant contact dermatitis, persistent reactions, and late reactions at the test site may occur.

ADVERSE REACTIONS• The most common adverse reactions (occurring in more

than 1% of the study population) were burning, tape irritation, persistent reactions, erythema, and hyper/ hypo pigmentation.

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Besides developing and maintaining a website as discussed in the previous issue of this newsletter, other tactics are available to help you build your patient base. Digital options include listing your practice on Google Places and taking advantage of social

media to reach potential patients directly. Although 57% of the respondents at our 2017 Patch Test Workshop indicated that they had a website, only 30% said that that they used both a website and Google Places. What is Google Places and why weren’t more respondents using this free tool? Answers to that question ranged from not knowing about it, not knowing how to use it, too busy, or too complicated or confusing. If you fall into one of those categories, this quick primer is for you!

A listing with Google Places is indispensable in helping you to attract new customers. When potential patients search for a practice similar to yours on Google Search or Google Maps, your listing pops up! Your listing can include your practice name, address, hours, phone number, website link, and directions to your clinic. Your information can be updated at any time (do your hours change over a holiday?) or to freshen the look (have you hired new professional staff? Photographs are important!) from your phone, tablet, or computer. Be aware, however, that patients can post reviews about their experience in your clinic. Good reviews can be a powerful source of referrals so make sure that you not only earn good reviews but also ask satisfied patients to write them. Reviews also represent an opportunity to interact directly with a respondent and to foster loyalty by engaging in a conversation. You can gain useful insights into how patients find your practice—do they engage in direct searches of your practice name or did they discover your practice by searching on a related service? How many have visited your website? These are just a few of the data that Google Places can provide to help you improve your understanding of your patient community and how your practice compares to others.

Social media represents another cost-effective opportunity (it’s free!) to engage with current and prospective patients. You can communicate more frequently with patients and even connect on a deeper level. Do you have good news about your clinic to share—are you expanding, renovating, improving parking, offering a new service? Social media outlets can help you spread the word.

But which social media is right for you? Facebook likely remains the most widely used of the social media. Besides familiarity, Facebook offer two other major advantages: You can control posts to your practice timeline, and there’s an excellent chance that someone in your clinic already knows how to use it. Twitter is another option—it can reduce response times to minutes—but responses can be no longer than 140 characters. Careful crafting of messages is crucial. If you are not on Twitter, you miss the opportunity for your practice to get “tagged” (@yourclinic name). On the other hand, Twitter is routinely used by clients to hold businesses accountable for providing services that meet their expectations, and users expect immediate responses. The level of engagement required by Twitter can be off-putting to clinics, but the benefits can be great when accounts are managed wisely. Another popular social networking site is Yelp, which functions like word-of-mouth in the digital arena. It serves as an online business directory like Yellow Pages, but individuals can leave feedback about their experiences. While anyone can write a review or post photos on Yelp, you

must claim your business to respond to a review. Much like Twitter, Yelp is an opportunity that must be managed carefully because negative posts can be viewed widely. In fact, all social media can be time consuming to manage, an important point to consider before you engage with too many outlets. And it must be remembered that a stagnant page can be worse than no page at all.

There are other more traditional approaches to building your patient base. Referrals can be bolstered by actively seeking professional referrals from colleagues in other medical specialties and from insurance company physician networks. Fortunately, for patch testing clinicians, the potential pool for professional referrals is wide. Primary care physicians (family medicine, internal medicine, and pediatricians) are a good place to start because they may see patients with all types of dermatological issues in need of specialized diagnoses and care. You should network and build those relationships, but don’t limit yourself there. Another valuable source of referrals for clinicians who patch test could be specialists such as orthopedists, cardiologists, and dentists who treat patients with preexisting skin conditions or patients who receive a metal implant and later develop skin reactions related to metal or to rubber, disinfectants, or many other

Using Social Media to Help Build Your Practice

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800.878.3837 l smartpractice.com/dermatology84971-A_0917 © 2017 SmartPractice • All rights reserved

Using Social Media to Help Build Your Practice…continued

potentially allergenic materials found in a variety of clinical settings. Don’t overlook occupational medicine professionals who may encounter patients working in fields associated with a high prevalence of contact allergies, for example, health care workers, machinists, hairdressers, and tattoo artists (and their clients). We’ve made it easy for you to seek referrals—click here to download letters you can customize to your practice and then share with your colleagues.

What should you do to get started on maintaining and building your patient base? Consider your available resources—personnel, time, and money—and prioritize your efforts accordingly. Create a plan and start implementing it with easy wins. Set up Google Alerts for your practice so that you automatically receive notifications of online mentions of you or your practice. Begin to track your efforts and measure your results, but be patient enough to establish a baseline so that you can draw meaningful comparisons in the future.

Finally, remember that marketing—putting your best foot forward—is never “done.” At minimum, add new to content to your website quarterly, celebrate your patients and thank referring clinicians monthly, and post weekly if you opt for social media. If you are still feeling unsure of how to proceed, call us at 1-800-878-3838 for help with all your practice management needs.

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