Commentary
The incidence of acne in adult females is rising,1 and treatment with combined oral contraceptive pills (OCPs) is becoming an increasingly important therapy for women with acne. Prior reports have indicated that OCPs were as effective as systemic antibiotics in reducing inflammatory, noninflammatory, and total facial acne lesions after 6 months of treatment.2,3 The acne management guidelines of the American Academy of Dermatology confer OCPs a grade A recommendation based on consistent and good-quality patient-oriented evidence.4
The US Food and Drug Administration (FDA) has approved 3 OCPs for the treatment of acne in adult women: norgestimate–ethinyl estradiol in 1997, norethindrone acetate–ethinyl estradiol in 2001, and drospirenone–ethinyl estradiol in 2007.5 However, the use of these OCPs is poorly understood by many dermatologists. One study showed that dermatologists prescribed OCPs in only 2% of visits with female patients aged 12 to 55 years who presented for acne treatment, which is less often than obstetrician/gynecologists (36%) and internists (11%),6 perhaps due to perceived risks or unfamiliarity with OCP formulations and guidelines among dermatologists.7 Adverse effects of OCPs include venous thromboembolism (VTE), myocardial infarction, and hypertension,8 but they generally are well tolerated.9
Even less is known about dermatologists’ use of drospirenone-containing OCPs (DCOCPs), which contain the only FDA-approved progestin that blocks androgen receptors. In prior studies, treatment with DCOCPs was associated with greater reductions in total lesion count and investigator-graded acne severity compared to early-generation OCPs.10,11 However, DCOCPs have been associated with a greater risk for VTE (4.0–6.3 times higher than OCP nonuse; 1.0–3.3 times higher than levonorgestrel-containing OCPs),12 which may explain the decline in DCOCP prescriptions among gynecologists in Germany from 23.8% of OCP prescriptions in 2007 to 11.4% in 2011.13
In this study, we surveyed US dermatologists about their knowledge, comfort, and prescribing practices pertaining to the use of OCPs. We compare OCP-prescribing to nonprescribing dermatologists, and those frequently prescribing DCOCPs to those who infrequently prescribe DCOCPs.
Methods
Survey Design
We performed a cross-sectional survey study using convenience sampling. The instrument was designed based on primary literature on OCPs in acne treatment and questionnaires assessing the use of OCPs in other specialties. Topics included prescribing practices, contraindications for OCPs defined by the Centers for Disease Control and Prevention (CDC),14 VTE risk, patient selection for hormonal acne therapy, comfort with prescribing OCP therapy, and participant demographics.
Skip logic was employed (ie, subsequent questions depended on prior answers). A pilot study surveyed 9 board-certified dermatologists at our home institution (Weill Cornell Medical College, New York, New York).
Data Collection
Eligible participants were board-certified US dermatologists. Data were collected and managed using an electronic data capture tool through the Weill Cornell Medical College Clinical & Translational Science Center. Surveys were distributed electronically to dermatologic society members, university alumni networks, investigators’ professional contacts, and dermatologists whose contact information was purchased from an email marketing company. Chain-referral sampling (ie, participants’ recruitment among their colleagues) was used. Surveys were distributed at a regional dermatology meeting. Responses were collected from November 2014 to April 2015. This study was approved by the institutional review board.
Statistical Analysis
For the descriptive data, all responses including pilot study participants were analyzed regardless of survey completion and were summarized using frequency counts and percentages (N=130).
For the analysis of OCP prescription predictors, the sample included all respondents answering the demographic questions and indicating if they prescribe OCPs (N=116). One respondent was excluded for answering other for current practice setting. Demographic predictors of OCP prescription were physician characteristics, geographic region, practice location population density, practice attributes, time spent on medical versus pediatric dermatology, number of weekly acne patients, and percentage of total patients who are female. Medical school graduation year was a categorical variable and was categorized as prior to 1997 (when norgestimate–ethinyl estradiol was FDA approved for acne5) versus 1997 or later. Respondents’ practice states were analyzed according to US regions—Northeast, Midwest, South, West/Pacific—and population density (persons per square mile) using US Census Bureau data.15,16
Univariate logistic regressions modeling OCP prescribing probability were performed for each demographic variable; a multivariable logistic model was constructed including all variables significant at α=.20 from univariate modeling.
To compare frequent prescribers versus infrequent prescribers of DCOCPs, we included all respondents answering whether they frequently prescribe DCOCPs and whether they believed the risk for VTE associated with DCOCPs differed from other OCPs (n=68). A univariate logistic regression was performed to model the probability of responding “Yes, they pose a greater risk” versus any of the other 3 responses by whether or not the respondent frequently prescribed DCOCPs for acne, and an unadjusted odds ratio was obtained. All P values were 2-tailed with statistical significance evaluated at α=.05. Ninety-five percent confidence intervals were calculated to assess precision of obtained estimates. Analyses were performed using SAS software version 9.4.
