2023 Top Story in Dermatology: Chronic Use of Hydrochlorothiazide and Risk of Skin Cancer in Caucasian Adults
Chronic Use of Hydrochlorothiazide and Risk of Skin Cancer in Caucasian Adults | PracticeUpdate
I chose the article by Haisma et al, "Chronic Use of Hydrochlorothiazide and Risk of Skin Cancer in Caucasian Adults: A PharmLines Initiative Inception Cohort Study," as my top story of the year.1 Although hydrochlorothiazide (HCTZ) is known to have photosensitizing properties, there have been conflicting findings about the possibility that it might be associated with an increased risk of skin cancer. This excellent retrospective study compared patients taking HCTZ with a comparator group taking non-antihypertensive long-term medications and a group taking other antihypertensive medications. It improved on previous studies by assessing dose–response and correcting for a number of possible confounders. Cox regression analysis was performed to derive adjusted hazard ratios, and a significant association was found between patients taking a high cumulative dose of HCTZ and the risk of skin cancer, including keratinocyte carcinoma, basal cell carcinoma, and squamous cell carcinoma. There is likely not going to be a prospective, randomized, double-blinded study with sunscreen use compared with a control group of patients taking long-term HCTZ in a large number of patients. This article may well report the best study that can be done to guide our actions!
I am ready to begin recommending routine use of sunscreen, hats, and sun-avoidance measures to my patients taking HCTZ, which, by the way, is the most prescribed antihypertensive in most Western countries. Targeting education programs to specific groups of patients with an increased risk of skin cancer is a more effective way to decrease skin cancer in a population. Of course, the programs each of us design for our patients may be quite different from one another. I know that all patients will not adhere to my advice; however, it is my job as a physician to provide my opinion to make sure that each patient taking HCTZ understands that if he or she does not act, the risk is increased of developing pre-cancers and skin cancers.
It would be nice to know whether the plan I design in my office is making a difference with regard to the intended outcome. What percentage of my patients on HCTZ have been instructed to use sunscreen in my practice in past years? Can I develop a program to impact this process measure? In fact, it is possible to assess changes in my practice and compare my efforts with that of like-minded dermatologists and then assess my practice habits over time. Some 4000 American dermatologists, all of whom utilize an electronic health record (EHR), are connected to the AAD DataDerm system, and I am going to request that the DataDerm registry add a measure assessing the number of patients with HCTZ on their medication list (denominator) and a mention of sunscreen or sun protection in the corresponding progress note. Whatever this percentage might be, I know I could do better by establishing a reminder system. I will certainly be able to see if my system is impacting my practice. Then, just perhaps, in 10 to 20 years, my patients will develop fewer skin cancers, and it may even be possible that DataDerm could be used to quantify the real outcome I desire, the development of fewer skin cancers.
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