Fall 2006 Vol. 2, No. 4Editor’s Letter & Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3More Components for Your Dermatology Toolbox . . . . . . . . . . . . . . 4

Thoughts on Oral Acne Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 6Building Rapport with Pediatric Patients . . . . . . . . . . . . . . . . . . . . 7

While diagnosis of common dermatoses isoften relatively straightforward, tailor-ing a treatment regimen to the individ-

ual patient is always a challenge. Numerous factors,from natural disease progression to patient behav-ior, can impact the efficacy of therapy. If patientsdon’t use a therapy or don’t use it properly, skinclearance will develop slowly if at all. Thankfully,the dermatology specialty has a number of treat-ment options available—from over-the-counterinterventions to prescription agents in a range ofvehicle formulations—that we can mix and matchin order to optimize therapy. Below, I’ll discuss anumber of relatively new formulations that are fastbecoming standard therapies in my practice alongwith therapeutic pearls that enhance patient con-venience, boost compliance, and promote bettertreatment outcomes.

Simplify Psoriasis TherapyThe new two-in-one formulation of betametha-

Topical Treatment Pearls You Can Use Now

Numerous compensation schemes exist for medical

care providers. Some physicians and mid-levelproviders are salaried employees, others independent

contractors, still others hold stock in the practice or profession-al corporation for which they work. For many Physician

Assistants, ownership in the practice would represent an attrac-tive opportunity. State law may influence whether or not a PA

may be a shareholder in a professional medical corporation.

According to the American Academy of Physician Assistants’website (aapa.org), only Illinois and Tennessee restrict non-physicians from owning shares in a professional corporation,while the laws in Texas are written so that a PA may not be a

shareholder along with a physician in a group. In California,AAPA reports, a PA may own only up to 49 percent of shares

in a professional medical corporation. In Michigan, since PAs

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By Coyle S. Connolly, DO

From overlooked therapies to innovative applications, here are tips to improve treatment outcomesand patient compliance.

Vol. 2 No. 4 • Fall 2006

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Supported by an unrestricted educational grant from Coria Laboratories.

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From Caregiver to Shareholder: Can You Buy In?

DermPerspectives Copyright 2006 by Avondale Medical Publications, LLC630 West Germantown Pike, Suite 123, Plymouth Meeting, PA 19462

Postmaster, please send address changes c/o Avondale Medical Publications, LLC.

Safety that’s reassuring for everyone

www.corialabs.com

• Uniquely formulated to be selectively absorbed where it’s needed1

• Designed to minimize the likelihood of local and systemic side effects

• Proven efficacy as early as Day 41

• The most common adverse events with Cloderm include dryness, irritation, folliculitis, acneiform eruptions, and burning. Cloderm is contraindicated in patients who are hypersensitive to any of the ingredients of this product. As with all topical corticosteroids, systemic absorption can produce reversible HPA-axis suppression.

Please see full prescribing information on reverse side of page.

Reference: 1. Data on file, Healthpoint, Ltd.Cloderm is a registered trademark of Healthpoint, Ltd.©2005 CORIA Laboratories, Ltd. A DFB Company. 137259-1105

For children and adults, Cloderm® is the mid-potency topicalsteroid with proven safety in extensive clinical trials.

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Dear Reader:

Sharing treatment pearls is a time-honored tradition in medical practice, especiallyin dermatology. Although drug development has ramped up in the last few years, thespecialty long suffered from a paucity of new drugs in development. Specialists becameadept at utilizing available therapies in innovative ways and improvising applicationtactics to enhance efficacy and improve compliance. The relatively recent emergence ofmany new and effective therapies only increases the opportunities for medical professionals in dermatology to identify creative approaches to disease management.

In this spirit, I share some topical treatment pearls in this issue of DermPerspectives. Some of the ideas may not strike you as entirely new, but successfulpatient management rarely requires clinicians to “recreate the wheel”; rather, we oftenneed to simply “think outside the box.” Keys to success are a firm basis in science andbest practice guidelines as well as a sense of adaptability.

Adaptability certainly is a hallmark of dermatology and, in fact, the specialty continues to adapt to ongoing changes in managed care, demand for cosmetic services,and other socio-economic issues. Physician Assistants play a critical role in helpingthe specialty adapt and advance. I commend PAs on their dedication to dermatology, andI commend Coria Laboratories for recognizing the important contributions of PAs andfor encouraging their success through support of this publication.

As always, I wish you continued success and welcome your comments about DermPerspectives.

Best wishes,Coyle S. Connolly, DOMedical Editor

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Lette

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Opin

ions

Let us know how to make DermPerspectives more useful for you. Send

your thoughts and story ideas to us.

Send comments via e-mail to:pwinnington@avondalemedical.com

Or via traditional mail c/o:Avondale Medical Publications, LLC

630 West Germantown PikeSuite 123

Plymouth Meeting, PA 19462

Coyle S. Connolly, DO, EditorAssistant Clinical Professor ofDermatology, Philadelphia Collegeof Osteopathic Medicine. President,Coyle S. Connolly, DODermatology and DermatologicSurgery, Linwood, NJ.

Terry Arnold, MA, PA-C is a graduate of the US Air ForceAcademy and completed PA schoolat St. Louis University. He isemployed by Dr. Jeff Alexander inTulsa, OK.

Tell Us What You Think

For Topical Use Only

DESCRIPTION:Cloderm Cream 0.1% contains the medium potencytopical corticosteroid, clocortolone pivalate, in aspecially formulated water-washable emollientcream base consisting of purified water, whitepetrolatum, mineral oil, stearyl alcohol, polyoxyl40 stearate, carbomer 934P, edetate disodium,sodium hydroxide, with methylparaben andpropylparaben as preservatives.

Chemically, clocortolone pivalate is 9-chloro-6α-fluoro-11β,21-dihydroxy-16α methylpregna-1,4-diene-3, 20-dione 21-pivalate.Its structure is as follows:

CLINICAL PHARMACOLOGY:Topical corticosteroids share anti-inflammatory,antipruritic and vasoconstrictive actions.

The mechanism of anti-inflammatory activity of the topical corticosteroids is unclear. Variouslaboratory methods, including vasoconstrictorassays, are used to compare and predict potenciesand/or clinical efficacies of the topical corticos-teroids. There is some evidence to suggest that arecognizable correlation exists between vasocon-strictor potency and therapeutic efficacy in man.

Pharmacokinetics: The extent of percutaneousabsorption of topical corticosteroids is determinedby many factors including the vehicle, the integrity of the epidermal barrier, and the use of occlusive dressings.

Topical corticosteroids can be absorbed from normal intact skin. Inflammation and/or other disease processes in the skin increase percuta-neous absorption. Occlusive dressings substan-tially increase the percutaneous absorption oftopical corticosteroids. Thus, occlusive dressingsmay be a valuable therapeutic adjunct for treatment of resistant dermatoses. (See DOSAGE AND ADMINISTRATION).

Once absorbed through the skin, topical corticosteroids are handled through pharmacokineticpathways similar to systemically administeredcorticosteroids. Corticosteroids are bound to plasma proteins in varying degrees.Corticosteroids are metabolized primarily in the liver and are then excreted by the kidneys.Some of the topical corticosteroids and theirmetabolites are also excreted into the bile.

INDICATIONS AND USAGE:Topical corticosteroids are indicated for the reliefof the inflammatory and pruritic manifestationsof corticosteroid-responsive dermatoses.

CONTRAINDICATIONS:Topical corticosteroids are contraindicated inthose patients with a history of hypersensitivityto any of the components of the preparation.

PRECAUTIONS:General: Systemic absorption of topical corticosteroids has produced reversible hypothal-amic-pituitary-adrenal (HPA) axis suppression,manifestations of Cushing’s syndrome, hyper-glycemia, and glucosuria in some patients.

Conditions which augment systemic absorptioninclude the application of the more potentsteroids, use over large surface areas,prolonged use, and the addition of occlusivedressings.Therefore, patients receiving a largedose of a potent topical steroid applied to a largesurface area or under an occlusive dressingshould be evaluated periodically for evidence of

HPA axis suppression by using the urinary freecortisol and ACTH stimulation tests. If HPA axissuppression is noted, an attempt should be madeto withdraw the drug, to reduce the frequency ofapplication, or to substitute a less potent steroid.

Recovery of HPA axis function is generallyprompt and complete upon discontinuation of the drug. Infrequently, signs and symptoms of steroid withdrawal may occur, requiring supplemental systemic corticosteroids.

Children may absorb proportionally largeramounts of topical corticosteroids and thus be more susceptible to systemic toxicity. (SeePRECAUTIONS-Pediatric Use).

If irritation develops, topical corticosteroidsshould be discontinued and appropriate therapy instituted.

In the presence of dermatological infections, theuse of an appropriate antifungal or antibacterialagent should be instituted. If a favorableresponse does not occur promptly, the corticosteroid should be discontinued until theinfection has been adequately controlled.

Information for the Patient: Patients using topicalcorticosteroids should receive the following information and instructions:

1. This medication is to be used as directed by the physician. It is for external use only.Avoid contact with the eyes.

2. Patients should be advised not to use thismedication for any disorder other than forwhich it was prescribed.

3. The treated skin area should not be bandagedor otherwise covered or wrapped as to beocclusive unless directed by the physician.

4. Patients should report any signs of localadverse reactions especially under occlusivedressing.

5. Parents of pediatric patients should be advisednot to use tight-fitting diapers or plastic pantson a child being treated in the diaper area, asthese garments may constitute occlusivedressings.

Laboratory Tests: The following tests may behelpful in evaluating the HPA axis suppression:

Urinary free cortisol testACTH stimulation test

Carcinogenesis, Mutagenesis, and Impairment ofFertility: Long-term animal studies have not beenperformed to evaluate the carcinogenic potentialor the effect on fertility of topical corticosteroids.

Studies to determine mutagenicity with prednisolone and hydrocortisone have revealed negative results.

Pregnancy Category C: Corticosteroids are generally teratogenic in laboratory animals when administered systemically at relatively lowdosage levels. The more potent corticosteroidshave been shown to be teratogenic after dermalapplication in laboratory animals. There are noadequate and well-controlled studies in pregnantwomen on teratogenic effects from topicallyapplied corticosteroids. Therefore, topical corti-costeroids should be used during pregnancy onlyif the potential benefit justifies the potential riskto the fetus. Drugs of this class should not beused extensively on pregnant patients, in largeamounts, or for prolonged periods of time.

Nursing Mothers: It is not known whether topicaladministration of corticosteroids could result in sufficient systemic absorption to producedetectable quantities in breast milk. Systemicallyadministered corticosteroids are secreted intobreast milk in quantities not likely to have delete-rious effect on the infant. Nevertheless, cautionshould be exercised when topical corticosteroidsare administered to a nursing woman.

Pediatric Use: Pediatric patients may demonstrategreater susceptibility to topical corticosteroid-induced HPA axis suppression and Cushing’ssyndrome than mature patients because of alarger skin surface area body weight ratio.

Hypothalamic-pituitary-adrenal (HPA) axis sup-pression, Cushing’s syndrome, and intracranialhypertension have been reported in childrenreceiving topical corticosteroids. Manifestationsof adrenal suppression in children include lineargrowth retardation, delayed weight gain, lowplasma cortisol levels, and absence of responseto ACTH stimulation. Manifestations of intracranialhypertension include bulging fontanelles,headaches, and bilateral papilledema.

Administration of topical corticosteroids to children should be limited to the least amountcompatible with an effective therapeutic regimen.Chronic corticosteroid therapy may interfere withthe growth and development of children.

ADVERSE REACTIONS:The following local adverse reactions are reportedinfrequently with topical corticosteroids, but mayoccur more frequently with the use of occlusivedressings. These reactions are listed in an approximate decreasing order of occurrence:

BurningItchingIrritationDrynessFolliculitisHypertrichosisAcneform eruptionsHypopigmentationPerioral dermatitisAllergic contact dermatitisMaceration of the skinSecondary infectionSkin atrophyStriaeMiliaria

OVERDOSAGE:Topically applied corticosteroids can be absorbedin sufficient amounts to produce systemic effects(see PRECAUTIONS).

DOSAGE AND ADMINISTRATION:Apply Cloderm (clocortolone pivalate) Cream0.1% sparingly to the affected areas three timesa day and rub in gently.

Occlusive dressings may be used for the man-agement of psoriasis or recalcitrant conditions.

If an infection develops, the use of occlusivedressings should be discontinued and appropriate anti-microbial therapy instituted.

HOW SUPPLIED:Cloderm (clocortolone pivalate) Cream 0.1% is supplied in 15 gram, 45 gram and 90 gramtubes.

Store Cloderm Cream between 15° and 30° C(59° and 86° F). Avoid freezing.

Distributed by:

Healthpoint, Ltd.San Antonio, Texas 782151-800-441-8227

Reorder No. 0064-3100-15 (15g)Reorder No. 0064-3100-45 (45g)Reorder No. 0064-3100-90 (90g)

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Cloderm PI Derm Times 12/13/05 3:23 PM Page 1

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In the 10 years I’ve practiced medicine,I’ve had the great opportunity to workwith a lot of different medical profes-sionals. Some were outstanding clini-cians who could instantly integrate the

most complicated sign/symptom complexinto a diagnosis and treatment plan. I’veworked with others that didn’t have the sameclinical acumen but were incredible commu-nicators and leaders. I’ve been around somethat let their practice become their entire life,resulting in the neglect of their health, family,friends, and hobbies. And I’ve seen a few thatwere clearly using medicine as a “means to anend” for the pursuit of wealth, status, or egoenhancement.

It has caused me to ponder on many occa-sions: What exactly makes a great clinician?Is it all based on clinical education and train-ing? Is it a specific personality trait? Is excel-lence limited to those who were “called” topractice medicine? Are you genetically pre-disposed for greatness, or is it something tobe sought after and acquired? While it maybe a combination of these, I believe thatexcellence in medicine is something that canbe achieved by anyone that truly desires it.In the following paragraphs let’s look atsome attributes that can take you to a higherplane of practice.

Intellectual CuriosityMedicine attracts individuals with a naturalthirst for knowledge. Some are able toquench their thirst in PA school, while oth-ers continue to drink from the well at

annual CME conferences, and still othersdesire and pursue knowledge their entireprofessional lives. Dermatology is anincredibly broad and deep medical special-ty, with a complexity that is seldom appre-ciated by those outside of it. Elements ofour specialtytouch several oth-ers, to includingrheumatol-ogy, psychi-atry,endocrinology,infectious dis-ease, oncology,and more.Dermatologyis also atremendoussource ofambiguity;there is anawful lot thatwe simplydon't under-stand yet.When youconsider everything there is to know andeverthing that is still unknown, it can beoverwhelming and daunting. Where do Istart? How do I acquire enough knowl-edge to see patients confidently? Whatshould I focus on first, and then next? I’msure we all had these questions when westarted in derm, and as the old sayinggoes, “if you don’t know where you’re

headed, almost any road will get youthere.” But, we all know that knowledge isnot a destination or an end point. It’s anendless and timeless pursuit. You have tostay hungry and you must stay curious. It’simportant to take advantage of educational

opportunities that come your way, andthere are a growing number to choosefrom. Start a regular program of dermreading and self-study. Research and writean article on a difficult disease process.Prepare and deliver a lecture to a group ofpeers. Or, for the ultimate learning experi-ence, take on a student that has a naturalintellectual curiosity!

Stocking Your Dermatology Toolbox: Six Essential Attributes for Success

and physicians are both involved in the practice of medicine,

they may both share ownership of a corporation, according toAAPA. Most other states either explicitly permit a PA to be ashareholder in a professional corporation or legislative languageneither explicitly permits nor excludes such ownership.

The specifics of ownership vary from state to state. Formore general information, particularly early on in consideringa buy-in, state regulators and/or local officials may be able to

provide guidance to PAs and physicians. Any PA interested inbecoming a shareholder in a medical corporation ought tohire an attorney who can not only help them make sense of

the law but can represent their interests throughout negotia-tions and buy-in.

Finally, AAPA reminds, regardless of any financial or com-

mercial agreement in place, the physician must meet all super-visory requirements as set forth by law. n

By Terry Arnold, MA, PA-C

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Buying Into a Practice, Continued from p. 1

Intangible attributes separate the great from the good pracitioners. Following up a discussion of tangible tools for a dermatology physician assistant, we'll explore intangible attributes and how touse them to your maximum benefit.

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Open MindednessWith enough practice and experience, almostany task or endeavor can be accomplishedwith confidence. Remember when you gotyour driver’s license? At first you were cau-tious, looking both ways several times beforeentering an intersection, coming to a com-plete stop at stop signs, and cautionsly paral-lel parking in tight spaces. After a couple ofyears, driving becomes second nature and youget more confident but also more careless.You start eating lunch, talking on yourphone, and driving—all at the same time!This is the point where you become danger-ous, not just to yourself but to everyonearound you.

The same is true in medicine. After a fewyears you’ve seen your share of acne, warts,eczema, skin cancers, and other commonmaladies. You have a good feel for the treat-ment options, second line therapies, andadjunctive measures for most things that youroutinely see. In short, you get set in yourways and come to think of your way as theabsolute best. This is especially true if youdon’t keep current with your medical educa-tion and “practice in a vacuum.” It pays tohave an open mind in medicine and to stayhumble. Be open to new ideas, new treat-ments, new protocols, and new ways of look-ing at old problems. This is what keeps lifeinteresting, exciting, and more fulfilling inmedicine.

Focus on DetailWhen I was in the military we were constant-ly told to “pay attention to the details.”Whether you’re flying an F-16, driving anM1 Abrams tank, or launching a missle froma nuclear sub, there are myriad details. That’swhy the military loves checklists, manuals,regulations, operation orders and other listsof instructions. When lives are at stake,details simply can’t be overlooked. The sameis obviously true in medicine and dermatol-ogy. You have to stay focused on the smallstuff so you don’t miss something big!

When you’re doing a biopsy, take time tomeasure and meticulously document thelocation, making the site much easier to findwhen it comes time for treatment. Whenyou’re examining a patient with a rash, it justmakes sense to examine the entire integu-ment, including the hair, nails, and oral cavi-ty. Your pathology log book is another greatplace to show attention to detail. Rigorouslydocument and conduct audits with an eye formissed treatments or ourstanding reports. It’severy clinician’s nightmare to have a cancergo untreated because the path log wasn’taudited. These are but a few examples ofwhere attention to detail can make a big dif-ference.

Listening/Communication SkillsWe tend to think of dermatology as a visualscience, where diagnoses are established pri-marily on physical exam. It becomes almostsecond nature to “look first, listen second.”But, every once in a while, a patient gives

you a tiny pearl of history that clinches adiagnosis. Moreover, patients will frequentlygive you insight into the provocative or pal-liative factors for their condition, leading youto a more effective treatment plan. If youdon’t take time to hear the story and askproblem-focused questions, you’re unlikely toprovide the best care. How many of us havequickly evaluated a new patient and swiftlywritten a script for a seemingly simple prob-lem, only to have the patient tell us that theyalready tried that medication and it didn’twork for them? It’s frustrating, but takingtime to get the full story might avoid some ofthese frustrating moments.

Dermatology is typically a high volumespecialty where it’s not uncommon to see 40

patients in a day. It can be stressful andfatiguing to see this many people, especiallywhen you get behind with a diffiuclt case orprocedure. However, when you feel the mostrushed is when you should really try and takesome additional time. You just never knowwhen someone is going to “give” you thediagnosis that could change their life.

LeadershipJohn Maxwell, the famous author, describesleadership simply in one word: influence.Whether you’re a physician, medical assistant,office manager, or PA, you are also a leaderwithin your office, because we are consciouslyand unconsciously influencing each other allthe time. Some cast a negative influence, andothers consistently and effectively provide apositive influence. You don’t have to own thepractice or pay the bills to be a leader withinyour office. We’ve all seen situations where amore junior level member is the true leaderwithin the organization. He or she knows theothers’ strengths and weaknesses, commuica-tion habits, leadership styles, ambitions, andfears. He or she knows how to blend theorganization’s personnel into a group thatmaximizes strengths and compensates forweaknesses.

Opportunities for positive influence in anoffice environment are everywhere, but I’vefound the most powerful leadership force to

be ‘setting the example.’ Not only is it hypo-critical to ask one thing of your co-workerswithout doing it yourself, it’s just never goingto result in a lasting change. Whether yourealize it or not, the people around you arewatching all the time. They notice if you areperpetually late, don’t stay on top of charting,leave messages unanswered, or wear the samelab coat for weeks on end. Not only do theynotice your behaviors, they will also mimicthem and make them part of their own per-sona. If you really want to effect a positivechange in your organization you have to setthe tone for this change and then lead withyour own example. It sounds simple, but itrequires a lot of reflection, honest feedbackfrom colleagues, commitment, and, morethan anything else, consistency.

BalanceI absolutely love dermatology. I like to thinkabout derm. I like to see derm patients. I liketo read about derm, and I like to write aboutderm subjects. I’m really lucky to have founddermatology, because there isn’t another spe-cialty that gives me as much pleasure andgratification. I also really love church, family,friends, and sports. I like to attend highschool football games, and I like to watch mydaughter play soccer. When you enjoy somany diverse things, it’s easy to let one areastart to dominate the others. Especially whenthings are going poorly in one area of life,you start to compensate by spending moretime and energy in areas where you feel agreater sense of control. If things aren’t goingwell at home, people will frequently turn towork as a form of therapy. This is especiallytrue in medicine, because there is always somuch more that can be done. For many,work becomes the crutch, the mistress, andthe friend.

This is an area that I struggle with everyday. Am I spending enough quality time withmy children? Am I really listening to mywife, or am I asking her the same questionsover and over? Do I spend enough timebuilding and nurturing my friendships withpeople outside of my profession? When wasthe last time I went to the gym, or for a walk,or just sat down and relaxed for more than afew minutes? It pays huge dividendes tomake the effort to inventory your life, priori-tize your activities, and set limits on how youspend your time. The penalties for leading anunbalanced life are numerous and devastatingto your physical and emotional health.

Achieving GreatnessI think we all have the capacity to achievegreatness in the practice of dermatology, andwe certainly have a lot of “tools” at our dis-posal to help us succeed. The ones discussedabove are but a few of the many intangibleattributes that separate great from good prac-titioners. It really pays to take the time toinventory your toolbox, pursue the tools youdon’t possess, sharpen the ones you haven’tused in a while, and discard the ones that arebroken or unnecessary. n

“I’ve found the most powerful

leadership forceto be ‘setting

the example.’”

sone and calcipotriene, Taclonex (Warner-Chilcott) is a once-daily therapy with obvi-ous potential benefit in terms of enhancedpatient convenience and possibly compli-ance. I typically advise patients to apply theointment each evening. (Note that “evening”is not necessarily “bedtime,” though so manyclinicians think in terms of morning andbedtime application. Patients can prolongapplication times by several hours if they arewilling to apply medications as soon as theyget home from work or school rather thanjust before retiring each night.) Although it isvery effective, some patients still need a ther-apeutic “boost,” at which point I adviseocclusion. Instruct patients to occlude thetreatment area with Saran-Wrap every othernight for about two weeks.

The addition of Salex (salicylic acid 6%,Coria Laboratories) to the regimen eachmorning can also enhance outcomes by help-ing to reduce scale and diminish plaques.

Rethink Onychomycosis TherapyPatients who present with onychomycosis—some of whom report a history of yellowing ofthe nails for several years—sometimes simplywant the clinician to make a definitive diag-nosis but do not necessarily desire treatment.Always take time to discuss the diagnosis andthe various treatment options—risks and ben-efits—in order to properly educate the patientand to assess his or her desires. Some patientshave already done research and subsequentlyhave concerns about systemic therapy. On theother hand, I have not found topical ony-chomycosis therapies terribly effective overall.If a patient simply has some yellow discol-oration, is otherwise healthy, and not terriblybothered by onychomycosis (many womenpaint their nails for camouflage), then I gen-erally assure them that treatment is not neces-sary. I instruct them to monitor their nailsand prophylactically apply topical antifungalgel, such as Loprox (Ciclopirox, Medicis), tothe toewebs and feet on a regular basis to pre-vent progression of the infection to tineapedis or to other body sites.

For patients who elect systemic therapy,my drug of choice is terbinafine (Lamisil,

Novartis). The PI recommends liver functionand blood screenings at baseline and sixweeks, however, I generally order them atbaseline and two weeks. Though lab anom-alies are rare, any elevations in liver enzymesor changes in white blood cell count will beevident by two weeks, thus allowing the clini-cian to limit the patient’s exposure to thedrug. I do not repeat labs unless the patientreports symptoms of liver function abnor-malities, such as jaundice or lethargy.

Cut Costs in AD TherapyOne of the most cost-effective interventionsfor atopic dermatitis is triamcinolone 0.1%compounded in a one-to-one ratio withCera-Ve (Coria Laboratories) cream. I oftenprescribe this pharmacy compound when thepatient’s insurance will not cover alternativecorticosteroid formulations or if the co-pay isfinancially burdensome for the patient. I havefound Cera-Ve to be an excellent moisturizerthat is very suitable for compounding. Thisintervention is useful for management ofpsoriasis and other corticosteroid-responsivedermatoses, as well.

Regardless of the initial intervention used,Mymix (Stiefel) is a good choice for mainte-nance of clearance of AD. In many cases, Iadvise patients to begin applying Mymixwith the initiation of topical drug therapy,usually applying the moisturizer each eveningand medications each morning. BecauseMymix is a prescription agent, insuranceissues and financial concerns occasionallyimpact the feasibility of using the agent.Non-prescription Cera-Ve cream is a worth-while alternative.

Hit Hyperpigmentation HarderTri-Luma (Galderma) conveniently providespatients the triple benefit of hydroquinone,tretinoin, and fluocinolone in a single formu-lation. The synergistic effect of these agentsallows speedier clearance than any agentalone, while the retinoid helps improve skintexture and provide skin thickening thatcounters potential thinning from the corti-costeroid. However, some cases of dyspig-mentation require a stronger intervention, inwhich case, I order a pharmacy compound ofhydroquinone 8% with various strengths oftretinoin, depending on the patient’s skintype and anticipated tolerance. Due to the

high potency of hydroquinone 8% patientsrequire clear direction on when and how touse the agent and for what duration.Regularly scheduled follow-ups at two-to-four week intervals permit the clinician tomonitor progress and taper the agent asappropriate.

Offer Spot-on Acne TherapyStill relatively new to the market, clin-damycin 1% foam (Evoclin, Connetics) con-tinues to become a first-line option in mypractice to treat acne on the back and chest.The foam offers spreadability and ease of use;this convenience presumably increases com-pliance. Foams also tend to be a better optionthan creams or lotions for hair-bearing areas.I advise patients to apply the foam twice aday to affected areas.

A new micro-sponge formulation of ben-zoyl peroxide is another versatile addition toour armamentarium. NeoBenz Micro (ben-zoyl peroxide, SkinMedica), available in3.5%, 5.5%, and 8.5% concentrations, is for-mulated with microspheres intended to allowslow delivery of the active agent with less asso-ciated irritation. The availability of severalconcentrations permits flexibility in establish-ing regimens. Most of my patients use the5.5% formulation, though I may choose3.5% for those with very sensitive skin.

One presenation for which NeoBenzMicro has been especially useful is for spot-treatment of acne flares, such as in a womanwith perimenstrual flares. I instruct patientsto apply the agent as needed to affected areasto diminish inflammation and hasten clear-ance. A benefit of benzoyl peroxide is thatthere is no risk of bacterial resistance associ-ated with therapy.

Teach Patients “How” to WashMany clinicians now make a point to advisepatients against using soap on the face orother “sensitive skin” areas and recommendsoap-free moisturizing cleansers, of whichthere are now many options. However, prod-uct selection is just the first step. The unfor-tunate truth is patients don’t know “how” towash appropriately. They may use abrasivewashcloths or loofahs on the face, may vigor-ously dry the skin after washing, or swipe attheir faces with rough paper towels or otherwipes to “cut the oil.”

Page 6

Update on Systemic Acne TherapyDespite this article’s focus on topical interventions, systemicacne therapy warrants mention. Recently approved extended-release Solodyn (Medicis) uses low-dose minocycline to pro-vide direct antimicrobial effects against P acnes as well as anti-inflammatory effects. It is specifically indicated for managementof “inflammatory lesions of non-nodular moderate to severeacne vulgaris in patients 12 years of age and older.”

The recommended once-daily dose of Solodyn is1mg/kg/day, with tablets available in 45mg, 90mg, and 135mgdoses. By permitting use of low doses, Solodyn potentially lim-

its the risks of vestibular side-effects associated with minocy-cline. The company reports no significant CNS side effectsamong patients in clinical trials.

Alternatively, I commonly prescribe delayed-release doxycy-cline (Doryx, Warner-Chilcott) for acne patients. The enteric-coated pellets obviate concerns of stomach upset. Thedelayed-release pellets are not associated with significantCNS side-effects. Standard therapy is 75mg BID. In patientswith minimal or no response, the dose is increased to 100mgBID.

Topical Treatment PearlsContinued from p. 1

Take just a few minutes to advise patientsnot to use any implements to wash their face.They should instead use their fingertips andwarm—not hot—water to gently messagethe face. After rinsing, they should gentlyblot dry prior to applying medication, sun-screen, and/or makeup. Of course, theyrequire advice on selection of these latterskin care products, as well.

Involve an AestheticianBeyond topical medications, certain otherinterventions can prove useful for patientswith acne, including chemical peels and/ormicrodermbrasion. Furthermore, all acnepatients, as noted above, require clear guid-ance on skin care product selection and use.If your practice has an aesthetician on staff,why not let her or him handle this elementof patient education? Even if the patient optsagainst an adjunctive procedure, he or shewill receive important skin care recommen-dations and guidance on selecting productsin the local drug store as well as through thepractice. Such consultations may be wise forpatients with rosacea, melasma, and similarconditions.

Relieve Rosacea RednessStandard topical medical therapy forrosacea in my practice generally includes anantimicrobial agent—either sodium sulfac-etamide/sulfur or metronidazole. But tohasten redness relief, I have found Rosaliacfrom LaRoche-Posay very effective.Formulated for patients with sensitive skin,it contains the caffeine derivative Xanthine,

which helps to reduce redness, and a verylight green tint that helps diminish theappearance of redness but is not evident likea make-up concealer. It is available for dis-pensing and can also be found over-the-counter in a growing number of pharma-cies.

Rosaliac has proven especially helpful forpatients with significant background erythe-ma and broken vessels. For interestedpatients, I also recommend LaRoche-Posay’sToleraine cleanser and moisturizer, which areformulated for sensitive skin.

Wrap Up Wart TherapyLiquid nitrogen freezing remains treatmentof choice for warts. I administer two to threefreeze/thaw cycles per visit and advisepatients that they will need several visits (attwo to five week intervals) to clear the warts.However, application of salicylic acid underocclusion between visits helps to debride tis-sue and may enhance efficacy of therapy.Beginning 10 days after the visit, patientsmay begin applying Trans-Ver-Sal (salicylicacid 15%, Doak Dermatologics) patches tothe wart. Patches are available in 6mm,12mm, and 20mm sizes. They are conven-ient and can even be offered through thepractice dispensary.

Although the 12mm and 20mm patchescan be useful, when patients have largerwarts or larger areas of involvement, such asa mosaic pattern distribution, I generallyrecommend application of Occlusal (sali-cylic acid 17%) followed by duct tape. Thetape may be easier to apply to larger treat-

ment areas and seems to allow greater flexi-bility to cover the treatment area.

Relieve “Chapped” HandsDry, cracked hands are a common complaint,particularly with the change of seasons. Theclinician should always try to identify anyunderlying etiology or allergy/irritant andtreat accordingly. However, for many patients“chapped” hands are the result of non-specif-ic irritation from wet work or other exposurethat simply cannot be avoided. I have foundCera-Ve ointment very effective for relievingthe symptoms of dry, cracked hands. Patientsapply the ointment in the evening or beforebed, when they are more likely to tolerate thesomewhat greasy feel.

For daytime application or for dryness ofother body areas, Cera-Ve lotion is a goodoption. Somewhat more expensive but alsoeffective is Lipikar Baume (LaRoche-Posay),which is a cosmetically elegant fragrance-freeformulation.

Recommend Rubber SpatulasOne of the least expensive, potentially mosthelpful tools a patient can purchase for topi-cal drug application is a simple rubberkitchen spatula. The utensils are perfect forapplying topical creams, lotions, or gels to theback or other hard-to-reach areas. The rubberpaddles are soft and flexible, and patients canquickly and easily wash them between usesand dispose of them when therapy is com-plete. Alternatively, some personal care cata-logs sell long-handled tools for applying med-icines in hard-to-reach areas. n

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Questioning parents about a child’s medical history canbe tricky. Parents may fear you will be critical of thecare they’ve provided and may feel that questions place

blame rather than simply solicit needed information. How youintroduce and formulate questions makes a difference.

“Be supportive and empathetic rather than judgmental orcritical,” says pediatric dermatologist Alanna F. Bree, MD.For example, instead of questioning whether the parent of achild with diaper dermatitis changes the child’s diaper “oftenenough,” simply ask them to estimate how often they changethe child’s diaper. In the same scenario, Dr. Bree says, asking“What have you been putting on this?” may appear disap-proving. Instead, she suggests acknowledging that the con-cerned parent has likely been trying several topicals, or out ofconcern not tried anything aside from what the doctor hasrecommended. Use this approach to solicit the informationyou want. Ask what they used specifically, so that you can nar-row down the best options to try now.

To help direct the encounter and ensure that parents’ con-cerns are met without over-extending the visit, include a directquestion on the intake form, Dr. Bree advises. Sample verbiagemay be: What issues for your child would you like to addresswith the doctor today?

As children age, question them directly, as appropriate.Teens respond favorably to questions about them as individu-als and not just the problem at hand. Informally chatting at

the start of the interview opens them up, Dr. Bree says.Finally, if you wish to address a sensitive issue with a youn

patient, take advantage of one-on-one time as you escort thechild to the scale in a private area of the clinic, Dr. Bree sug-gests. When dealing with sensitive issues related to adoles-cents, simply inform parents that it is your policy to speak pri-vately with the patient, Dr. Bree says. Invite the parent to waitin the reception area, and assure them that you will come getthem once you and the patient have spoken. n

Pediatric History: Easy Ways to Establish Rapport

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