Did you know that drug shortages are a common occurrence in the United States. At any time of the year the FDA reports multiple medications that are out of stock. This becomes troubling for people with specific diagnoses who require treatment that doesn’t have alternatives.
However, we are now in a crisis where the supply of an entire class of medications has been disrupted and millions of patients have/will be affected. Local Anesthetics.
Dermatology practices like ours have been struggling to get local anesthetics like lidocaine. These anesthetics are used for hundreds of procedures that are done in our offices each week. We use lidocaine to biopsy lesions suspicious of cancer and to perform surgical procedures to remove malignant and nonmalignant, but sometimes critical, lesions.
This is frustrating for both our patients and our providers. We are dependent on the suppliers of these medications to have them readily available for our use. It’s surprising that our government hasn’t done much to prevent these drug shortages since the first FDA drug shortage report to congress in 2013.
Please consider sending your representative a letter regarding your concern.
Dear [Congressional Member]:
I am writing to you as your constituent to discuss an issue of great concern—the national drug shortage. It is troubling that commonplace medications that are used in physicians’ offices every day are not available in the United States, and that their unavailability places America’s patients, including your constituents, at risk.
The issue of drug shortages in the United States is an escalating problem that began nearly a decade ago when limited production capacity and lack of competition in the pharmaceutical industry led to a shortage of generic injectable medications, including lidocaine and lidocaine with epinephrine. Since then, medical organizations, like the American Academy of Dermatology Association, have actively lobbied Congress and federal agencies, including the Federal Drug Administration, to address the concern. I fear that those efforts have not fixed the problem. Therefore, I am writing to you as a patient and your constituent to let you know how this shortage affects us.
Lidocaine is a local anesthetic frequently used for common dermatologic procedures, and lidocaine with epinephrine is essential to control bleeding during these surgical procedures. However, lidocaine with epinephrine is only available in limited quantities and in some cases has been on back order for months. The impact on this shortage is most acutely felt among solo and small practitioners where the predominant outpatient care is provided.
This is what the national shortage of lidocaine means to me and millions of other patients across the United States:
- A patient (especially one taking a blood thinner) may not be able to have a biopsy of a suspicious skin lesion simply because the risk of bleeding is too high.
- A patient’s skin cancer surgery may be delayed indefinitely simply because the physician cannot control the pain and bleeding inherent in the surgical procedure, which could lead to intraoperative complications.
- A physician may have to find unconventional alternatives to anesthetizing me, thus increasing the risks associated with my procedure.
Please put an end to our nation’s drug shortage by working with the pharmaceutical industry, federal agencies and our national medical organizations to rapidly identify feasible solutions to this national crisis.
Yours most sincerely:
[Patient Name and Contact Information]
Sunscreens have not required the same scientific studies to be done that medicines require.
Recent studies made by Wp Health Care News have been conducted that now show that when using lots of sunscreen, those chemicals are absorbed systemically and can be found in your blood stream. Additionally some of these chemicals may not be safe.
So… now the FDA is going to require that safety studies be done on sunscreens to make sure the chemicals that are absorbed are safe.
Until these studies are done, it is still recommended to use sunscreens to prevent UV damage to the skin which is a known cause of skin cancer.
If you are suffering with damaged skin then also have a look at this skin repair cream for damaged skin made by CHOLLEY as we have seen amazing results so far.
This often brings up the question about using natural sunscreens that don’t contain these chemicals. However, it is these chemicals that make sunscreens effective at preventing UV damage.
Optima Medical Casa Grande made a gift to the American Academy of Dermatology’s Camp Discovery to help send 350 kids with skin diseases to camp this summer.
About Camp Discovery
“Under the expert care of dermatologists and nurses, Camp Discovery offers campers the opportunity to spend a week among other young people who have similar skin conditions. Many of the counselors have chronic skin conditions as well, and can provide support and advice to campers.”
Dr. Geisse was awarded the Patients’ Choice Award!
The Patients’ Choice award is bestowed upon physicians based on your patients’ appreciation and praise for the quality of care and service you provide.
Every month, more than 200,000 patients across the U.S. provide online feedback about their doctor experiences. They rate various components of the care they receive, such as bedside manner, doctor-patient face time, follow-up care, ease of appointment setting and courtesy of office staff. They also share their overall opinions.
Over the course of 2013, hundreds of thousands of patient reviews were written and shared. While physicians generally receive positive feedback from their patients, only physicians like you – with near perfect scores – have been voted by their patients for this honor.
In fact, of the nation’s 870,000 active physicians, only 5 percent were accorded this honor by their patients in 2013.
Congratulations Dr. Geisse!
Squamous cell carcinoma is the second most common skin cancer and is increasing at an alarming rate, particularly in the elderly. Squamous cell carcinoma without question is related directly to sun exposure and also to age. The more sun and sunburns you have had and the longer you live the higher your risk of developing squamous cell carcinoma. They often come from precancerous lesions called actinic or solar keratoses which fair-haired, fair-eyed patients suffer from who have had sunburns as a child and have had chronic sun exposure. These red, raw, itchy, sometimes tender scaly spots on the scalp, face, ears, back of the hands and arms can convert to squamous cell carcinoma. Squamous cell carcinoma can also develop on its own and grow rapidly often fooling patients thinking they are bug bites, boils or infected hairs. These types of squamous cell carcinomas can be dangerous; they present as a nodule that hurts, grow rapidly and have between a 5%-25% risk of spreading or becoming metastatic depending on their depth of invasion and location.
Metastatic squamous cell carcinoma can be lethal and requires aggressive surgery by our head and neck surgical colleagues. This most often happens when squamous cell carcinoma occurs on the scalp, ears, or lips. Squamous cell carcinoma in these areas would usually spread first to the lymph nodes of the neck or in front of or behind the ear. The goal in treating all skin cancers is to treat them early before they become dangerous and that is particularly true of squamous cell carcinoma because if they are not very deeply invasive the risk of them spreading is probably close to zero.
There are superficial forms of squamous cell carcinoma which are called in situ or Bowen’s disease (SCC in situ). There is a specialized form of squamous cell carcinoma in situ that can occur on the genitalia called Bowenoid papulosis which is induced by the wart virus, not by sun exposure. Just as in superficial forms of basal cell carcinoma, superficial squamous cell carcinoma can be treated with the scraping and burning procedure (curettage and electrodesiccation), excision or sometimes Aldara or imiquimod. Aldara or imiquimod has not been studied nearly as thoroughly for superficial squamous cell carcinoma as it has for basal cell carcinoma. Aldara’s cure rates for SCC in situ are supposed to be 80% based upon less reliable studies. We have seen a number of cases of squamous cell carcinoma in situ that have failed rather spectacularly from superficial treatment with Aldara or Efudex, which is called 5-fluorouracil. Solano Dermatology Associates does not recommend Efudex or 5-fluorouracil for cancers, only for the precancerous lesions called actinic keratoses despite its use by other practices for cancer. We do not recommend Efudex because its use is actually quite weak when compared to even the limited research done using Aldara for skin cancer. Aldara for squamous cell carcinoma in situ causes a severe reaction and it needs to be continued for ten weeks thus it is, just as is with basal cell carcinoma, infrequently used. For very large areas that have been resistant to superficial forms of treatment we will perform wide excision or Mohs micrographic surgery. This superficial form of squamous cell carcinoma is becoming alarmingly common and is actually difficult to treat adequately without significant surgery, particularly in hair bearing skin. It is always problematic to recommend aggressive surgery for a non-invasive, not very dangerous cancer but these can become very large and eventually invasive and need to be treated properly to avoid a much worse procedure down the road when it can become many times the size it was early on.
Invasive squamous cell carcinoma can be quite dangerous particularly if it is over 2 mm in depth or involves the muscle, the lip, the cartilage of the ear, or down to the bone of the scalp. Patients who have suppressed immune systems, such as transplant patients on drugs to keep their transplant healthy, patients with leukemias and lymphomas, and HIV infected patients who are immunosuppressed can get virulent forms of squamous cell carcinoma that can become metastatic and are often difficult to manage. These patients who have problems with their immune systems need to have their squamous cell carcinomas managed promptly and completely.
For squamous cell carcinomas of the face, full-thickness excision down to the fat and a layered closure is the treatment of choice. Mohs micrographic surgery can be used for squamous cell carcinomas of the central face, scalp or on the shins where they are increasingly common. Mohs is quite useful on areas like the shins and scalp because we can keep the wound smaller and allow a direct or primary closure as opposed to taking skin in from somewhere else as a skin graft, which is frequently needed for regular surgery in these areas because regular surgery takes larger margins. We try to avoid skin grafts which create a second wound and take a long time to heal particularly when over bone of the skull or over the tight, often swollen skin of the shins.
There is some evidence that Vitamin D3 deficiency might accelerate the growth of squamous cell carcinoma which might explain partly why elderly patients, even those in nursing homes who are getting no sun exposure, are developing these cancers at an alarming rate and are sometimes not being managed until they are quite aggressive. Any patient who has skin cancer, who then stays out of the direct sunlight as much as possible with hats, clothing and sunscreen should be taking Vitamin D3. We recommend 4,000-5,000 unites per day. If you have Vitamin D deficiency and are followed by your regular doctor then he or she should manage your Vitamin D dosage.
Basal cell carcinoma is the most common skin cancer. There are millions of these every year in this country alone, much less worldwide. They are usually not very dangerous although they can be quite invasive, destructive and disfiguring. Most of these occur on the face but they can occur anywhere, even in areas where the sun does not shine. Most patients who get basal cell carcinoma have had sunburns, but they also have a genetic predisposition. There may be other co-factors that are not well understood at this time that are contributing to the epidemic of skin cancer.
The treatment of basal cell carcinoma partly hinges upon the pathology. Basal cell carcinoma has different pathologic subtypes grouped into non-aggressive and aggressive forms.
Non-aggressive or circumscribed basal cell carcinoma includes the nodular and superficial types. These can occur anywhere but they are common on the trunk.
The most common treatment for these low-risk, less aggressive basal cell carcinomas is an ablative procedure call curettage and electrodessication. Non-aggressive basal cell cancers are soft and mushy compared to normal skin. An experienced clinician can use a semi-sharp circular spoon-like tool called a curette to scoop out the obvious cancer, leaving behind normal skin. This is often, but not always, followed by a burning procedure called electrodessication to obtain an extra margin of safety. For the worst types of non-aggressive basal cell carcinomas the curettage followed by electrodesiccation is done three times. For the least aggressive types, such as superficial basal cell carcinoma on the trunk, sometimes curettage alone is adequate without using the burning which allows these to heal with better scars. These can also be removed with excisional surgery where the affected areas are cut out and then sewn in a layered fashion with absorbable sutures underneath the skin and some sort of stitching in the skin.
There are some non-surgical treatments for these non-aggressive basal cell carcinomas, primarily Aldara or imiquimod cream. Dr. Geisse authored the two major papers that led to the approval of Aldara or imiquimod cream to treat basal cell carcinomas in the United States. He was the principal investigator for 3M Pharmaceuticals who at that time owned the drug and sponsored the large double blind placebo controlled studies to get it approved. Drs. Beutner and Geisse did the very first study proving that this cream would work for basal cell carcinoma, which led to the larger studies, mentioned above. Despite Solano Dermatology Associates’ long history with Aldara or imiquimod, it is in fact rarely used for basal cell carcinoma. It is costly and creates a significant rash and has to be used for six weeks and only yields an 80% cure rate for small superficial basal cell carcinomas of the trunk. That compares to 90% cure rates for curettage and electrodesiccation or excision and thus, unless there is an extremely apprehensive patient who does not want surgery or the cancer is in an area where any scar would be emotionally devastating (such as on the central chest in a young woman), Aldara is not often used to treat basal cell carcinoma.
Mohs micrographic surgery is the treatment of choice for central facial tumors including so-called non-aggressive or circumscribed tumors. Mohs micrographic surgery, explained elsewhere, provides 98-99% certainly of removal; thus if the cancers are located on the nose, ears, lips or close to the eyes using lesser forms of surgery would not be in the patient’s best interest. The worst cases the Mohs surgeon sees are often the ones that have been previously incompletely removed by lesser forms of treatment. Sometimes many years can go by before incompletely treated basal cell carcinomas show up around or underneath the scar. By that time patients can lose their entire noses, eyelids and ears to this sometimes-destructive cancer.
Aggressive or non-circumscribed forms of basal cell carcinoma include infiltrative, micronodular and sclerosing or morpheaform basal cell carcinomas.
These variants of basal cell carcinoma are usually on the central face and can be much larger than they appear from the surface. They often have what is called “subclinical extension”. What that means is that the cancer has branches and roots that go out well beyond the small area that may be visible on the surface. These cancers are often incompletely removed by regular forms of surgery, thus Mohs micrographic surgery is the treatment of choice for these more aggressive cancers, particularly on that face. Wide and aggressive excision can be done on the trunk for aggressive basal cell carcinoma without doing Mohs since the scar is not as noticeable or as concerning to the patient and there is usually enough extra skin to close even large wounds.
Radiation therapy is rarely used for the treatment of basal cell carcinoma. It is expensive, requires multiple trips to the radiation oncologist and has some significant short term and more importantly long term side effects. The side effects include short term redness, swelling and sometimes bleeding and open areas of skin in the area that has been treated with radiation. Long term scarring and dilated blood vessels can occur and rarely second malignancies can occur in irradiated skin many years later. Around the eyes, nose or the glands of the face radiation can cause quite severe side effects such as dryness of the nose, bloody noses, dry eyes, loss of vision and loss of saliva formation from the parotid gland, which is the major gland in the cheek that forms saliva.
Solano Dermatology Associates rarely recommends radiation therapy and usually only for terrible cases where the surgery would be disfiguring in an elderly patient as a form of palliation, which means we shrink the tumor and keep it from bleeding or leaking on their beds, but do not necessarily cure it since these are slow growing cancers as a rule. Rarely, when basal cell cancers are deeply invasive or involve nerves, we use radiation after Mohs surgery to help ensure it does not return. If these cancers are large and deep on the face and involve the nerves of the face and if they are not completely removed they can lead to invasion of the brain through the cranial nerves. Radiation therapy as primary treatment of basal cell carcinoma providers somewhat over 90% cure rates, based upon fairly limited studies when compared to Mohs micrographic surgery which has a great deal of data to support its use and confirm its much higher cure rate.