PHILADELPHIA – A variety of medications exist to treat acne, from very potent oral drugs to topical medications. But according to a new study from Penn Medicine, patients who are black are far less likely to receive prescriptions for acne medication – especially systemic treatments like antibiotics - than white patients even though black people may often face long-lasting marks from acne.
After looking at the medical records of almost 30,000 people in the United States with acne, researchers from the Perelman School of Medicine at the University of Pennsylvania found that black individuals were 20 percent less likely to be prescribed oral antibiotics for acne than white people. They were also 32 percent less likely to receive the oral medication spironolactone than white people and 61 percent less likely to get the potent treatment isotretinoin (known by brand names like Absorica and Amnesteem). And overall, black people were less likely to be prescribed any acne medication at all. A similar pattern of treatment disparity was also seen among Asian individuals who, compared to white people, were also more likely to receive topical treatments and less likely to receive oral antibiotics in particular. In addition, prescription patterns differed between men and women, especially for isotretinoin. Researchers say the results call for a look into why these variations exist and whether clinician bias is at play. The study was published in the latest edition of JAMA Dermatology.
"Finding that patients across the U.S. are receiving different care for the exact same condition is jarring, especially since there is no evidence that a person's race or gender has any impact on how effective these treatments are," said senior author Junko Takeshita, MD, PhD, MSCE, an assistant professor of Dermatology at Penn. "Our study suggests that disparities involving race/ethnicity, sex, and insurance exist. Now we need additional research to help tell us why."
Acne affects up to 50 million Americans every year, according to the American Academy of Dermatology. Topical retinoids and topical antibiotics are often effective for many people. But sometimes more powerful systemic treatments - oral antibiotics, spironolactone (which regulates hormones), and isotretinoin (a retinoid) – are needed, especially when the condition is severe. While not everyone needs systemic treatments, Takeshita said the findings suggest that white people, men, and people without Medicaid are more likely to receive prescriptions for these stronger treatments than those who aren't white, aren't male, or are on Medicaid, even for the same clinical issue.
While acne affects people across all races, people who are black and have darker skin may experience more severe after-effects of acne, such as skin discoloration, than their peers of other races who have lighter skin, Takeshita said.
"Considering that black individuals may actually have a greater need for those more potent prescription options in order to avoid persistent dark spots down the road, our results have an even more profound implication for this population," she added.
Takeshita and lead author John Barbieri, MD, a research fellow in Dermatology at Penn, said an additional glaring disparity they found, although one that was not incredibly surprising to them, is that men's odds of receiving a prescription for isotretinoin was more than two times higher than women's.
A serious complication from isotretinoin is that it can cause birth defects if taken by a mother during pregnancy. Barbieri has written about the mandatory U.S. Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy program (iPLEDGE) for patients prescribed isotretinoin, which requires registration in the program, monthly pregnancy tests, and commitment to two forms of contraception.
"We suspect that the logistical barriers from iPLEDGE may be dissuading physicians and women from using isotretinoin, potentially resulting in underuse in this population," Barbieri said.
The authors say prescription inequities could exist for a host of other conditions beyond skin diseases, and that more research is needed to illuminate the ways in which clinicians may be driving such variations in prescribing.
"We all have biases. It's important for clinicians to be aware of their own biases that may unintentionally influence their actions in order to avoid treating patients differently based solely on their personal characteristics such as race or gender," Takeshita said.
Additional authors include Penn's Daniel B. Shin and David J. Margolis.
This study was funded in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (1P30AR069589-01, T32-AR-007465, K23-AR068433) and a Pfizer Fellowship in Dermatology Patient Oriented Research grant.
