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    Balancing ethics, finances, morals and patient preference in actinic keratosis follow-up

    Dermatologists who suggest low-risk actinic keratosis patients come back annually for disease management might experience kickback from patients, who fear they need more frequent care for their precancerous skin condition. 

    So, what’s a dermatologist to do?

    Authors tackled the topic in the paper “Frequent skin examinations in patients with actinic keratoses: Ethical, financial, and moral implications,” published November in the Journal of the American Academy of Dermatology. 

    Understanding how to best strike a balance between physician judgement and knowledge and patient preference and emotions when determining actinic keratosis follow-up is not only a quality of care issue.

    “This is important because access to dermatology care is often limited or fraught with long wait times; yet, we want to make sure our established patients feel well cared for, and that we are responding to their needs,” says the paper’s senior author Jess Kaffenberger, M.D., a dermatologist with The Ohio State University Wexner Medical Center, Gahanna, Ohio. 

    Dermatologists and other providers don’t have the benefit of universally-accepted actinic keratosis guidelines on which to base their recommendations. Their decisions on optimal intervals for actinic keratosis follow-up might rest, rather, on experience, medical judgement and available studies. 

    Researchers found in a recent study that most dermatologists do total body skin screenings on low-risk actinic keratosis patients every two to three years, and at least once a year on high-risk actinic keratosis patients.

    Without established guidelines, however, dermatologists should consider patient preference, emotional needs, practicality and other potential skin cancer risk factors when determining individual actinic keratosis patients’ follow-up care. 

    The authors use the example of a busy dermatologist in rural America, who sees a 65-year-old woman who is concerned about scaly spots on her forearm. She has no personal or family history of skin cancer and reports mild sun exposure in her youth. The dermatologist examines her to find a few facial lentigines and two thin actinic keratoses on her forearm. He performs cryotherapy on the lesions and educates the patient about sun protection, recommending that she follow up in a year for another skin examination. 

    The patient voices her concern that her pervious dermatologist saw her every three months to monitor for skin cancer and wants to continue the frequent visits, despite the current dermatologist’s explanation that more frequent monitoring is not necessary in her case. 

    While the dermatologist’s choices range from doing what the patient wants to referring her to another dermatologist because of the disagreement, the authors suggest that somewhere in the middle is the optimal decision. 

    “In this instance, compromise, while not perfectly meeting each party’s needs, can ultimately lead to the most ethically satisfactory outcome,” they write. 

    A twice-a-year schedule for follow-up, for example, costs the healthcare system less and is not as great a barrier to other patients’ access to a busy dermatologist as making visits four times a year. It also might be a more acceptable option to the patient and takes the patient’s needs into consideration in the doctor-patient relationship. 

    Overall, guidelines are needed and should help lower costs and complications related to actinic keratosis care, while improving outcomes and streamlining healthcare delivery, according to the authors. 



    Milam P, Korman A, Kaffenberger J. "Frequent skin examinations in patients with actinic keratoses: Ethical, financial, and moral implications," Journal of the American Academy of Dermatology. November 2017. doi: 10.1016/j.jaad.2017.03.005. 

    Stevenson ML, Glazer AM, Cohen DE, et al. "Frequency of total body skin examinations among US dermatologists," J Am Acad Dermatol. 2017 Feb. doi: 10.1016/j.jaad.2016.09.017. 

    Lisette Hilton
    Lisette Hilton, president of Words Come Alive, has written about health care, the science and business of medicine, fitness and wellness ...


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