Contact Dermatitis: Clinical Pearls

Matthew J. Zirwas, MD

What do you need to know about contact dermatitis?

  • Add 10 allergens to the TRUE Test to dramatically improve diagnostic accuracy
  • Lip dermatitis is much more likely to be contact dermatitis if it extends beyond the vermillion border
  • Shampoo and conditioner are a very common cause of eyelid dermatitis
  • You can prepare allergens for patch testing 24 hours ahead of time, except two types: fragrance and acrylates
  • You can patch test patients on prednisone
  • Giving too much information about allergens is as bad as not giving enough
  • Use videos to make patient education easier, faster, and more effective

TNF-a Inhibition and the Treatment of Hidradenitis Suppurativa: Clinical Pearls

Bruce Strober, MD, PhD

What’s new with the treatment of hidradenitis suppurativa and TNF-a inhibition? Dr Strober provides us with his clinical pearls…

  • Both adalimumab and infliximab effectively treat many features of hidradenitis suppurativa.
  • Adalimumab has been evaluated in the most rigorous studies ever conducted on a potential treatment for hidradenitis suppurativa.
  • Adalimumab requires weekly dosing at 40 mg to be consistently effective.
  • TNF-a levels are elevated in lesional and perilesional skin from patients with hidradenitis suppurativa.
  • TNF-a inhibitors such as adalimumab and infliximab reduce not only lesion counts but also pain.
  • AbbVie will seek FDA-approval for the treatment of hidradenitis suppurativa with adalimumab.
  • Etanercept is not effective for the treatment of hidradenitis suppurativa.

The Aesthetic Consult: Clinical Pearls

B. Kent Remington, MD

What is the “real reason” our patients want to look better? Dr Remington provides key takeaway points on his aesthetic consult…

  • Aesthetic physicians are essentially “Image Enhancers” as the patients self image, self esteem and self concept have a direct impact on how they feel about themselves. A youthful appearance is the best thing you can wear. It is therefore paramount at some time in the consult to find and point out the patients positive facial features.
  • The main purpose of all Facial Aesthetic consults is to find the “Real Reason” why your patient wants to look better – it is almost always very little to do with the initial stated reason.
  • It is important to focus on the aesthetic patient that has a great interest and desire to look more youthful. This patient may not have the winning ticket for the best genetic lottery pool or be on a unlimited budget. It’s not their hormone level or the size of their wallet. It’s the wiring of their DNA some patients are just wired for aesthetics.
  • We –like are patients look with our eyes, but we see with our brains. The eye also sees what it wants to see. Most patients have severe selective monofocus. The patient’s perception of reality and reality are often not the same. Our focus is the whole face and converting patients to looking at the whole face and starting a renovation project is like restoring a painting – step at a time.
  • Aging and getting older is not a choice – looking younger is a choice – doing nothing is also a choice,
  • Faces are all about genetics, genetics are all about biology, biology is about physiology, physiology is about physics, physics is all about mathematics – therefore faces are all about Math — this is not left brain math but right brain math. Creating the extraordinary out of the ordinary are all fruits of good mathematics combined with art.
  • Aesthetic clues are like fish in the water – the fish are not aware of the water – they don’t see it or feel it. This is the same with many Aesthetic Physicians during the consult they do not connect with the patient and engage the patient – two essentials to a high consult to treatment percentage.
  • Photography – if possible a dedicated room with the same consistent light and background and camera settings. It cannot be understated the importance of a “baseline pretreatment” photos front view – ¾ views and profiles repose and animated.
  • Have all your aesthetic consults being in a good resolution facial photo in their 20’s to scan with their current photos taken in your clinic– not trying to make them look 20, but the importance of comparing past balance proportion harmony and symmetry to the present– or lack of. This whole exercise helps patients understand why we look at and treat the whole face.

Genetics: Clinical Pearls

James Treat, MD

  • Accurately describing skin disease can help diagnose Genetic diseases
  • There are fantastic searchable resources available to aid in diagnose
  • Capillary malformations can be associated with CNS arteriovenous malformations

Atopic Dermatitis

James Treat, MD

Clinical Pearls from Dr Treat..

  • Atopic dermatitis is caused in part by a defective skin barrier
  • Inmunodeficiency, nutritional deficiency, environmental and food allergies also play a role
  • Look for patterns of atopic dermatitis to help you differentiate.
  • There are multiple systemic agents that have shown efficacy in atopic dermatitis

Chronic Itch: Clinical Pearls

Gil Yosipovitch, MD

Dr Yosipovitch provides us with key takeaway points for managing patients with chronic itch…

  • Chronic itch is a disease on its own right and requires adequate treatment.
  • Anti histamines in most cases do not work for chronic itch
  • There are different types of chronic itch that include dermatologic, neuropathic systemic and psychogenic that require different treatment approaches.
  • Chronic itch is associated with peripheral and central nerve sensitization.
  • There is an imbalance of Mu opioids that over expressed versus kappa opioids in chronic itch and therefore drugs that are kappa opioid agonists and mu antagonists are effective for severe cases of itch.
  • Drugs that reduce nerve fiber sensitization such as gabapentin and pregablin and Selective serotonin and neuroepinephrine re- uptake inhibitors are effective for treatment of chronic itch.
  • Stress aggravates chronic itch and treatments that reduce stress including holistic approaches are important adjunct therapies for chronic itch.

More Clinical Pearls on Psoriasis

Joel Gelfand, MD

What about common comorbidities associated with psoriasis? Dr Gelfand highlights important clinical pearls…

  • The risk of comorbidities generally increases with the severity of psoriasis, patients with more severe disease have a 5 year reduction in life expectancy
  • Well established comorbidities associated with psoriasis include Heart Attack, Stroke, CV death, Metabolic syndrome, Diabetes, Psoriatic arthritis, Mood Disorders (anxiety, depression, suicide), Crohn’s Disease, and T cell lymphoma (rare)
  • Emerging comorbidities associated with psoriasis include Sleep apnea, Nonalcoholic steatohepatitis (NASH), Chronic obstructive pulmonary disease (COPD), Adverse infectious disease outcomes, Chronic and end stage renal disease, Peptic ulcer disease
  • Perform a skin biopsy if the diagnosis is not certain or if the patient is not responding appropriately to treatment. Connective tissue diseases and cutaneous T cell lymphoma can mimic psoriasis and may be exacerbated by psoriasis treatments
  • Putting a patient on an immune suppressive medication? Be sure to consider age appropriate cancer screening and vaccinations to lower the risk of complications

Social Media: Clinical Pearls

Jeffrey Benabio, MD

How does social media impact the clinician? How can we better utilize social media. Dr Benabio gives us some important insights…

  • Simply put, social media, refers to digital technologies that allow people to connect and to share information.
  • Over 60% of US adults read online reviews when seeking a new doctor, and 44% of those consider Yelp the most trusted review site.
  • 
Facebook, the behemoth of social networks, has 1.35 billion monthly active users.
  • 60% of social media users are likely to trust content posted by physicians online.
  • 18 to 24-year-olds are twice as likely than 45 to 54-year-olds to use social media for healthcare-related discussions.
  • Senior citizens are one of the fastest growing segments who use social media for their health information.
  • 90% percent of adults ages 18-24 say they would trust medical information shared by others in their social networks.
  • 
YouTube, which has over 1 billion unique visitors a month, reaches more US adults ages 18-34 than any cable network.

Pruritis: Clinical Pearls

Matthew J. Zirwas, MD

What are the key issues we should remember when managing an itchy patient? Dr Zirwas provides his clinical pearls…

  • Don’t go crazy with labs – they very rarely give an answer.
  • In itch with an underlying systemic cause, the underlying systemic is usually either obvious or is diagnosed prior to itch onset.
  • If you don’t have a definite diagnosis, address each entity in your differential one at a time.
  • Every adult with new onset severe itch and a non-specific rash should be treated for scabies, regardless of results of scabies prep.
  • Peppermint extract is cheap, available at most grocery stores, and can be mixed into any moisturizer or topical steroid to give immediate, short term itch relief.
  • Gabapentin is pretty reliably effective, but often need 600 mg tid to 900 mg tid.
  • Mirtazapine is very good for night-time itch but can cause significant weight gain.
  • Butorphanol nasal spray is VERY effective, but is a controlled substance because it has opioid effects.

 

Nail Disease: Clinical Pearls

Nat Jellinek, MD

Clinical Pearls from Dr Jellinek discussing an in-depth range of nail topics…

  • Longitudinal melanonychia may represent a heterogeneous group of conditions, from primary melanocytic causes to fungal/bacterial infections, hemorrhage, and exogenous causes, among others.  The dermatologist’s job is to diagnose nail melanoma.
  • Too often early nail melanoma, presenting as longitudinal melanonychia, is observed rather than biopsied.  Clinically differentiating benign from malignant is difficult.  Biopsy and pathologic examination remains the gold standard for diagnosis.  Earlier biopsies diagnose earlier melanoma.
  • Digital myxoid cysts represent ganglions from the DIPJ.  Most treatments, one way or another, involve scarring the stalk that extends from the joint to the tissues around the nail.
  • Nail squamous cell carcinoma is usually associated with HPV-16.  It is difficult to clinically differentiate refractory-to-treatment ungual/periungual warts from carcinoma.  Only biopsy with depth can make this diagnosis reliably.
  • Midline nail dystrophies are often confusing, with habit tic deformity and median canaliform dystrophy occasionally demonstrating overlap features.  Careful examination can usually distinguish the two.