Dermatology Patient Handouts

Patient Handouts: Overview

Educational handouts are becoming routine in health care, helping to promote health literacy in patients and their caregivers. To be effective, handouts must be tailored to various target audiences. Patient handouts are educational aids that aspire to provide information about your (or a family member's) diagnosis and treatments and to answer most frequently asked questions. We will attempt to augment what is available for skin conditions with unique handouts that are informative and current.  The OJCPCD's handouts are not designed to scare patients or promote expensive treatments when there are more reasonable and safer alternatives.  This is a work in progress and will be added to over the coming months and years.

Actinic Keratoses: The Truth

Actinic Keratoses (AKs) are rough scaly spots which appear on the sun-damaged skin. They are especially common in fair-skinned persons and are caused by repeated sun exposures over many years. Sun-damaged skin is dry and wrinkled and may form persistently scaly spots: actinic (solar) keratosis.  For an overview please see DermNet.NZ  In our opinion, AKs are routinely and systematically overtreated in the U.S.

AKs = Cash Cow

The standard treatment of a AKs calls for removal of the defective skin cells with liquid nitrogen, topical fluorouracil or imiquimod. New skin then forms from deeper cells which have escaped sun damage. However, there is no evidence that treatment of most AKs is of any value. Removal of all AKs is quick and easy and very lucrative for practicing physicians in some countries.

 While textbooks of dermatology state that around 10% of AKs progress to skin cancer (squamous cell carcinoma, SCC) if left untreated, this number was derived from no study and crept into the literature without factual basis. The only decent study on the malignant transformation of AKs was performed in Australia by Professor Robin Marks, a research dermatologist.

This is an abstract of Robin Marks' study:
Br J Dermatol 1986 Dec;115(6):649-655
Spontaneous remission of solar keratoses: the case for conservative management.
Marks R, Foley P, Goodman G, Hage BH, Selwood TS

One thousand and forty people aged 40 years and over, 616 (59.2%) of whom had solar keratoses, were followed for 12 months. Two hundred and twenty-four people (36.4%) had a spontaneous remission of at least one  of their solar keratoses. A total of 485 lesions (25.9%) underwent spontaneous remission out of the 1873 lesions that were present at the  first examination of these 224 people. There was no significant difference between the number of lesions present at the initial examination in those who had a spontaneous remission compared with those  who did not. There was a 21.8% increase in the total number of solar keratoses in the 1040 people studied in the 12-month period, due to new lesions forming at the same time as remissions were occurring. The incidence rate of squamous cell carcinoma occurring in the people with solar keratoses was 0.24% for each solar keratosis present at the original examination. With a substantial proportion of solar keratoses remitting spontaneously, plus the low rate of malignant transformation and the low potential for metastasis to occur from squamous cell carcinoma arising in a solar keratosis, the rationale of treating all solar keratoses appears questionable.

Comment: Robin Marks could not get his study published in the United States or Australia. The reason was that dermatologists derive a significant proportion of their income from these usually banal lesions. The image of the dermatologist running from room to room with a spray bottle of liquid nitrogen is all too familiar to elderly patients in the United States.

There are lesions which look like AKs which need treatment. These are the hypertrophic AKs which can be indistinguishable from early squamous cell carcinomas. An experienced dermatologist will be able to tell the banal from the worrisome in most cases. However, it will be a long time before the average practitioner will give up income for the pursuit of truth - so it is caveat emptor.

A retired physician we know saw a dermatologist for routine care.  The latter froze ~ 15 lesions with liquid nitrogen and the bill to Medicare was > $1000 for the ten minute office visit.  The retired doctor wrote to the dermatologist and said if this wasn't fixed he would be reported for fraud.  Was it?  You be the judge.

The take-home message is that most actinic keratoses are innocuous.  They can simply be observed.  A small subset will progress to squamous cell cancer -- but these behave and look different.  What is important is that AKs are markers for persons at risk to develop skin cancers (squamous cell, basal cell and melanoma) and these individuals need to perform regular self-skin exams and visit a dermatologist periodically.  There will be dermatologists who disagree with this.  However, this handout is our opinion based on years of practice and a study of the pertinent literature.

Printable Version: Download Actinic Keratoses

Tinea Versicolor

Tinea versicolor (TV) is one of the most common skin disorders, especially in warm humid environments.  In Hawaii, where it is very prevalent, it is called “kani” or “haole rot.” In parts of the Caribbean, “Louda.”  It is caused by a Pityrosporum yeast which is normally found on the scalp. If you live in a warm climate, there will likely be a lay term for TV.

Here is a short handout which you may find valuable:  Download Tinea Versicolor

Brachioradial Pruritus

BRP is a commonly encountered itchy conditionof the arms, usually involving the skin just above and below the elbows.

There are two main theories as to the etiology of BRP.

1. That it is caused by sunlight (a photodermatitis).

2. That it is neurogenic and results from nerve impingement in the cervical

   spine.

Here are some thoughts about BRP.

 

Typical Location of BRP

 

Treatment Protocol