the primary needs to know
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7/23/2015
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What the primary needs to know in the world of increased access
Toby Maurer, MD
University of California, San Francisco
Acne
Primary care provider: Pt has recent onset of bumps on face.What is this and how do I treat. Has used Proactive with minimal change.
7/23/2015
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Topicals
• BP 5% gel (10% ‐more drying)
• Retin A 0.025% ‐ 0.1% ( vehicle determines strength ‐ start with crème)
• Cleocin T or erythromycin topically
– Use 1 qam and 1qhs
– If NO success after 8 weeks, go to p.o.’s
Primary Care Provider: Pt with acne –used retin A but very irritating. What is the next step?
7/23/2015
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• Pt has cystic/scarring acne‐topicals won’t work and in Asians‐Retin A is very irritating.
• Start p.o. antibiotics
P.O. Antibiotics
• TCN ‐ 500 bid x 8 weeks
• Doxycycline ‐ 100 bid x 8 weeks
• Minocycline ‐ 100 bid x 8 weeks
• Taper ‐ Do NOT STOP ABRUPTLY. Once pt’sskin is clear, taper the dose in ½ for another month and then stop the medication
7/23/2015
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• Pt told he has psoriasis‐used some crème in Mexico‐can’t remember name. Worried that his grandchildren could catch this.
• Psoriasis is fast growing skin‐can’t get it from anyone and can’t give it to anyone
• What meds is he on? Certain meds might unmask this like atenelol, lithium, NSAIDS
• Start Clobetasol oint and dovonex crème together. Apply M‐F bid‐weekends off
• Primary see pt again in 6 weeks. If not better‐send another telederm consult and we will readvise or book pt in derm clinic
7/23/2015
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Pt did not get better……
• New pictures show increased total body surface area involvement
• Dermatology triage: I see that pt has liver disease (seen on EMR). First choice systemic drug is acitretin. Please order up baseline LFT’s , fasting TG and cholesterol.
• We will book pt for derm clinic in 3 weeks‐please order baseline labs and start him on acitretin 25 qd
Psoriasis‐when topicals don’t work
• Acitretin‐safer to use in liver disease‐monitor TG, Chol
• Methrotrexate‐titrate dose, follow LFT’s and CBC, needs liver biopsy after 1.5 gm‐great drug if there is psoriatic arthritis
• TNF blockers‐good drugs, expensive, subcuinjections, presecreen for TB and Hep B and cancer risk
• Ultraviolet light‐is pt able to spend the time; is it accessible to pt?
7/23/2015
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NO PREDNISONE
Atopic Dermatitis Body Treatment
• Topical steroids and antihistamines still mainstay of treatment
• Avoid prednisone (oral and injectable)
• Clobetasol ointment qd for 5 days when severe then
• Fluocininide (lidex) oint bid for 2 weeks then
• Triamcinolone 0.1 % oint bid maintenance
• FACE: HC or aclomethasone oint bid
7/23/2015
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Gentle Skin Care discussion
• Steroids are okay to use‐not going to thin out the skin
• Use steroids with grease‐bid
• Bathing or showering 1‐2x’/wk and don’t even dry off after bathing
• Grease up immediately
• Antihistamine (benadryl, atarax, doxepin) at night so pt can sleep and break the itch/scratch cycle
Scabies: Classic treatment
• Permethrin 5% crème‐2 applications 1 week apart
• Must treat all intimates
• Clothing instructions essential
• But patients complain that this is a hassle
7/23/2015
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Crusted scabies
• Scabies mite burden very high
• Have treated with malathion ( a pesticide) and ivermectin (an oral medication)
• Easier to use and higher success rate‐how about using these agents in regular scabies
Scabies
• Oral ivermectin superior to malathion in adults BUT this is second line drug
• While it is easier to give‐it is expensive and overuse might lead to resistance
• We have seen resistance with Kwell (Lindaine)
• First line is still permethrin (elimite)
Martin Annals of DermatolVenerology 2010 Dec
7/23/2015
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• Pt notes changing mole‐also itchy. Worried she has melanoma
• Seborrheic keratosis‐reassure‐treatment not covered by county services
• You can apply cryotherapy 2 x 15 sec thaw cycles or
• Private derms in your county will do this for a fee
7/23/2015
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• 24 year old with new black bump
• No others noted
• Looks like seb keratosis but that is unusual in pt under the age of 29. I want to biopsy this
• We will contact pt for next live derm clinic
• Cc scheduler‐book for live derm in 1 week
7/23/2015
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• Pt notes these get caught on shirt‐sometimes get inflamed
• Skin tags‐benign
• Primary can snip them off‐services not covered by county
7/23/2015
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Ask these questions:
1) Personal or family history of melanoma?
2) History of atypical nevus that has been removed?
3) Presence of new or changing mole‐ i.e. change in size or color?
Melanoma
• Melanoma may be INHERITED or occur SPORADICALLY
• 10% of melanomas are of the INHERITED type Familial Atypical Multiple Mole‐Melanoma Syndrome (FAMMM)
7/23/2015
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Risk Factors for Sporadic (Nonhereditary) Melanoma
• Numerous normal nevi, some atypical nevi
• Sun sensitivity, excessive sun exposure
Clinical Features of FAMMM• Often numerous nevi (30‐100+)• Nevi > 6mm in diameter• New nevi appear throughout life (after age 30)
• Nevi in sun‐protected areas (buttocks, breasts of females)
• Family history of atypical nevi and melanoma
7/23/2015
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Risk Categories (Lifetime Risk)
• Very low risk: pigmented races (Latino,African American ,Asian,etc.)
• Low risk: Caucasian = 1%
• Intermediate risk: Caucasian w/additional risk factors = 2% ‐ 10%
• High risk: FAMMM Syndrome up to 100%
Prevention
• Self examination/spousal exam for low‐risk individuals
• Self examination/spousal exam and regular physician examination (yearly to every several years) for intermediate risk individuals
• Self examination and examination by a dermatologist every 3‐12 months for FAMMM kindred
7/23/2015
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If not sure:
• Measure and see pt back in 3‐6 months for reevaluation!!
• On pts back‐( I can see it from homunculous)
• Sometimes wife squeezes out smelly cheese –like material
7/23/2015
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• Epidermoid cyst‐not inflamed. Does not need to be excised unless repeatedly inflamed.
• Wife should stop squeezing this‐could cause cyst contents to be released into surrounding tissue‐causing inflammation
• If pt wants this excised‐please send to surgery for excision‐may not be covered by insurance
• Primary Care Provider: pt came in with 2 day history of enlarging lesion and increasing pain.
• Started doxycyline
7/23/2015
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Inflamed Epidermoid Cysts
• Antibiotics‐USELESS‐this is abscessed‐6 papers and metanalysis shows that antibiotics will not help where an I and D should be done
• If just starting to become inflamed and cyst is small( < 1 cm), can try intralesional Kenalog injection but see them back in few days‐you can exacerbate the inflammation
• This cyst is bigger than 1 cm
• INCISE and DRAIN and PACK‐send to surgery or ER today
• 6 weeks later, inspect for residual cyst and send pt for excision to surgery
Keloids
• These are keloids
• Did they come from acne‐if so‐look for other acneiform lesions and let me know‐I can discuss systemic acne treatment so that ptdoes not get new keloids after every acne breakout.
• Will need intralesional kenalog‐will book with derm clinic for monthly injections‐book within next two months
7/23/2015
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• 30 yr old with multiple previous biopsies to rule out melanoma. Here for skin check.
• No recent changes in moles
• No family history of melanoma
• Please see in live derm clinic
• Agree and will book within 1‐2 months
Vitiligo
• Immune system hyperactive
• Rare association with thyroid disease and other autoimmmune diseases
• Trial of clobetasol oint qd x 3 months; if not working tacrolimus bid x 3 months then leave it alone
• Makeup, counselling
7/23/2015
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• UV light?
• Punch grafts?
• Sunscreen is imperative
Alopecia areata
• Non‐scarring alopecia‐we have no idea why it starts and we don’t have preventive treatment in terms of halting future episodes
• Inject with intralesional kenalog 10mg/cc q month for at least 6 months to see if there is hair regrowth
• Do you want to do this or do you want us to do this in live derm clinic?
7/23/2015
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• Pt notes hair loss and this bald spot x 3 months. No other health problems. Not on any meds
• Hair loss‐will need live derm clinic evaluation and possible biopsy for scarring alopecia.
• I suspect discoid lupus
• Please order CBC and iron, Vit D, TSH, VDRL, ANA
• Book within 1 month
7/23/2015
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• Pt has actinic keratosis
• Can I freeze it with liquid nitrogen?
• Yes‐2 x 15 sec thaws –appropriate treatment. Please make sure that you have looked at all sun‐exposed areas to rule out non‐melanoma skin cancers
• Please explain side effects
• Please see pt back in 1 month‐if lesion not resolved , please biopsy or send pt for biopsy to live derm clinic
• Other option‐we can book pt for live dermclinic in 4‐6 weeks‐please let me know
7/23/2015
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Actinic Keratosis (AK)
• Who is at risk?
– Over age 35‐40
– Fair‐skinned persons
– Sun‐exposed sites
• Face, forearms, hands, upper trunk
– History of chronic sun exposure
Treatment of AK
• Cryotherapy
• Topical chemotherapy/chemical peel
– Efudex (5FU crème) or Imiquimod
• When to refer?
– Too extensive for local treatment
– Consider biopsy or referral with any lesion that doesn’t resolve with cryotherapy
7/23/2015
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Photodynamic therapy
• Place photosensitizer on skin and then use light therapy‐increases absorbency of light
• Evidence that it changes histologic features of photodamage and changes expression of oncogenes
Uses in:• Actinic keratoses• Basal cell cancers• Superiority studies being evaluated• Bagazgoitia et al BJD 2011 July
• Likely hyperkeratotic AK but book in dermclinic within 1 month‐I need to palpate to r/o Squamous cell cancer
7/23/2015
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• Likely squamous cell cancer‐please book with derm within next month for shave biopsy
Next steps:
I will biopsy‐send pathology to dermatopathat UCSF
If positive‐will send to plastics or dermsurgeryfor excision
• Pt with new lesions around nose‐thinks it started when bacon fat hit face
• No pain or itching
7/23/2015
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• This is sarcoid
• I want to make sure that she does not have systemic involvement
• Please order Cxray and PFT’s
• Order a G6PD in case I need to start sytemicplaquenil
• Start clobetasol oint qd to lesions
• Would like to see within 2‐3 weeks
• As we manage patients in the upcoming years, triage teledermatology allows primary care providers and dermatologists to effectively work together
• Increased efficiency and access
• Total cost of specialty service is less
• Pt outcomes and satisfaction appear to be better
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