DermHelpCentral

Topical Steroids

Hywell Williams, professor of dermato-epidemiology, at the Centre of Evidence Based Dermatology, Queen's Medical Centre, University of Nottingham has written an important article on the use of steroid creams.  He believes that most steroid creams can be effectively used in once daily applications as opposed to twice or more times a day. This will cut down on side-effects and expense.

The article was published in the British Medical Journal in June of 2007.  Here's a Download corticosteroid_creams.pdf -- the Key Points follow:

Established topical corticosteroids such as betamethasone valerate have typically been used twice
daily or more frequently for treating inflammatory episodes of eczema
Reducing the frequency of application to once daily does not seem to result in loss of efficacy and
could lead to fewer local side effects
Using topical corticosteroids just once a day may be more convenient for patients and may save costs
if established preparations are used

Maine-Dartmouth Lecture

The Art and Science of Dermatology

Presented:  July 19 and 20th
Waterville and Augusta, Maine

David J. Elpern, M.D.
12 Meadow Street, Williamstown MA 01267
email: djelpern@gmail.com
URL: http://www.davidelpern.com

Grand Rounds is a time-honored institution.  In 1978, Franz Ingelfinger, then the editor of the New England Journal of Medicine wrote a brilliant Sounding Board piece entitled the "Graying of Grand Rounds."  I post it here for any who are interested to read it.  Download ingelfinger_graying.pdf

The following is intended as a guide for primary care residents to validate and facilitate their handling of most cutaneous disorders.

Continuing Medical Education (as typified by didactic lectures) may entertain physicians and trainees, but has no impact on performance. 
See Zeiger: Continuous Medical Education  Download zeiger_cme.pdf

Unacceptably Long Waits for Dermatology Appointment

See: Download Resneck.pdf  

Research has shown that PCPs perform poorly on diagnosis of skin disease:

I think the training need not be didactic, since didactic lectures have been shown not to be effective.  But can be case-specific.  Over three years, one can get a working knowledge of cutaneous disease one patient at a time.

The best part of the top 20 Skin Disorders seen in primary care can be handled by F.P.s

Resources to Aid in Dx and Rx
of Skin Disorders

• Dermnet:  The Mother of All Derm Sites
• eMedicine: Free Updated Online Derm Text
• Clinical Knowledge Summaries from the NIH

Image Banks:

I think Dermnet is the best (see above)
Others:

• DermIS has thousands of images
  
• Global Skin Atlas
• Dermatology Image Database:  University of Iowa
• DermAtlas.org

Web Sites and Blogs

• Virtual Grand Rounds in Dermatology
• VGRD Blog
• Skin Cancer Clinic
• DermCentral

We all work together



Illustrative Cases:

Procedures F.P.s should be comfortable with:

• Punch Biopsy
• Shave Biopsy
• KOH Prep
• Tzanck Prep
• Simple excisions

Punch Biopsy

3 and 4 mm punches
Needle holder
Scissors
Forceps (optional)
4-0 and 5-0 nylon sutures
Gauze
Non-sterile gloves





Shave Biopsy

Xylocalne 1% with epi
1 cc syringe + 30 guage needle for infiltration
1/2 of a "Blue Blade" razor
Guaze
Aluminum Chloride for hemostasis   

   

Hyfrecator (Electrosurgery - Coagulator)

This is one of many models you can choose from.

 

   

Because of the long waits for consultation, if you take the time you can make most diagnoses.  This is not quantum mechanics.  You can be the doctor who is there:

On Skin Cancer and Screening
New York Times, July 10, 2007
Doctors Balk at Cancer Ad, Citing Lack of Evidence
By CHRISTIE ASCHWANDEN
Some doctors are questioning a cancer society ad campaign on sunscreen because most skin cancer is not life-threatening.

The Thesis
Cancers follow three basic patterns: turtles, birds and bears.
1. Turtles move so slowly that you can still capture them while they’re moving slowly along;
2. The birds fly away so quickly that you can’t catch them in time;
3. The bears can escape if you ignore them, but if you catch them in time, you can capture them.

For the full article go to Permalink. 

If, at any time, you want to submit a case for suggestions to VGRD or VGRD 2.0, please follow this format:

• History
• Physical Exam
• Clinical Photo (please save and send as a small jpeg file)
  
• Lab Tests and Biopsies if done
• Specific Questions

What else would you like to know?

Contact me at any time:  David J Elpern

 

 

The Skin Type Solution

The Skin Type Solution
By Leslie Baumann, M.D.

The Skin Type Solution
ISBN-10: 0553383302

Book Review

Reviewed by Caitlin O’Brien

    How many of you have asked your dermatologist a question about pores, oily skin, fine wrinkles or a related concern only to get a curt unhelpful answer?  This is a complex issue that your skin doctor may not be expert in or may be too busy to spend much time on.  Those few cosmetic dermatologists out there (usually in a major metro center) are booked months in advance and often charge $500 for a consultation.

    Dr. Leslie Baumann, a Professor of Dermatology at the University of Miami School of Medicine and an internationally respected researcher, has written a book that many people will find invaluable.  The thesis of this NY Times Bestseller is that there are 16 different skin types and each one has unique maintenance and therapeutic requirements. Once you take the questionnaire in Chapter 3 of the book and find out your skin type, you will learn all about your skin’s unique needs and what ingredients to look for in products.  In fact, Baumann lists over 2000 skin care products of about 300 different brands that are right for your skin type. In addition, you can visit the corresponding web site SkinTypesSlutions.com which allows you to discuss your skin issues with other people of the same skin type! 

    The problem with the marketing of skin care products is that very few of us know their skin type. Each lotion, face wash, cream, gel is geared towards a different skin type, but people are usually unaware of which product is best suited for them. So when you go into a store to buy a skin care product, you could potentially be harming, not helping, your skin if you purchase an inappropriate product.

    People waste thousands of dollars on skin care products that either don’t work, or may even damage their skin.  Leslie Baumann’s book The Skin Type Solution helps you determine your own skin type, formulate a skin care plan and find the right products to buy.  You only have to read chapter 3 to find out your type and then read the chapter that corresponds with your “Baumann Skin Type”- there is no need to read the entire book- just these 2 important chapters.

    The book begins by briefly explaining what constitutes different types of skin. The first major category that defines your skin type is skin hydration, oily or dry skin. Once this is determined your skin is broken down into three other major categories. The first is your skin sensitivity, sensitive vs. resistant; the second is your pigmentation, non vs. pigmented, and the last is wrinkled skin vs. tight. Each factor is combined to make one definite skin type, for example someone with oily, resistant, pigmented, and tight skin would be an ORPT.  There are sixteen possible skin types, so you don’t have to worry about your skin type not being included. She covers every type of skin, and gives the tools to take care of your skin. It does not take a trip to the dermatologist to figure out what skin type you have.  Baumann includes a 63-point questionnaire that helps you to classify your own skin type. Once you determine what type of skin you have, your turn to the chapter that pertains to your skin type.

    Each chapter begins with a brief explanation of your skin type. Baumann explains many common symptoms or problems that are unique to each skin type, and some risks you may run into if you do not take proper care of your skin. She looks at all the factors that could affect your skin’s health and then offers solutions based on her extensive experience as a world-recognized cosmetic dermatologist.

    Each ‘About your Skin’ section is followed by the ‘Everyday Care’ suggestions tailored to particular skin types.   Here Baumann offers daily morning and night skin care regimens. For example, for someone with oily, sensitive, pigmented, and wrinkled (OSWP) skin recommends this morning regimen:    
        1) Wash with a cleanser
        2) Apply a skin lightener
        3) Apply eye cream (optional)
        4) Apply SPF facial lotion or sunscreen regimen
        5) Apply a foundation with SPF
        6) Apply oil-absorbing powder
The pm regimen has a similar skin care plan. After telling you what you need to do, Baumann provides list of products that she recommends.

    These products are broken down into categories, and she includes affordable ones and well as expensive options. The point of her book is not to induce you to spend thousands of dollars on skin care products, but to offer reasonable options. She also underscores her professional preferences, which more often than not are affordable.  The best thing about The Skin Type Solution is that she gives you many choices. You aren’t limited to one brand, or just pricey products. The book also includes charts of ingredients that are compatible with each skin type and those, which you should not use. Dr. Baumann explains those choices which are appropriate and those that are not recommended, She wants you to be able take care of your skin without having to go through all the trouble of searching in shops for the right product.

    This book is not intended solely for people who are having problems with their skin.  It gives everyone the tools to take better care of her or his skin. It will help prevent many consumers from naively buying inappropriate and expensive products that may be a waste of money for them; Baumann provides the tools to find the right products.  The Skin Type Solution is about offering answers to your skin care questions.  Dr. Baumann makes it easy for anyone to classify their skin type, follow a simple skin care plan, and essentially take the best possible care of one’s skin.

    So the next time you visit your dermatologist, take The Skin Type Solution along with you.  Instead of receiving a blank stare from your doctor when you mention the “T-zone”, you may help her or him to learn how to guide you better and to be of assistance to other patients.

Dr. Baumann maintains the the SkinTypeSolution website and TheSkinGuru blog.  Please visit them for more information or specific questions. Her book can be ordered directly through Amazon or through one of Dr. Baumann's web sites.

Tattoo Removal

It is estimated that "as many as 45 million Americans have tattoos. This number is based on the finding by a Harris Interactive Poll in 2003 that 16 percent of all adults and 36 percent of people 25 to 29 had at least one tattoo. The poll also found that 17 percent of tattooed Americans regretted it."

Natasha Singer's article Erasing Tattoos, Out of Regret or for a New Canvas in the June 17 New York Times
addresses the "growing industry catering to people who may not have thought about the implications [that tattoos are] “forever” the first time around.

Continuous Professional Education

We came across an article recently which suggests that the standard educational method of attending lectures is a poor way of learning.  It suggests that studying real patients in depth is a much better way of learning.  Some medical schools have adopted the "PBL" -- "problem based learning" syllabus.  For practicing physicians a more interactive format may be a better way of providing continuing professional education than the lectures which we traditionally attend at conferences and hospital rounds.

An excellent article appeared in The Journal of General Internal Medicine on this topic in 2004.  Here are the particulars:

Toward Continuous Medical Education  click on Download zeiger_cme.pdf for full article
Roni F Zeiger, MD
Gen Intern Med. 2005 January; 20(1): 91–94.

While traditional continuing medical education (CME) courses increase participants' knowledge, they have minimal impact on the more relevant end points of physician behavior and patient outcomes. The interactive potential of online CME and its flexibility in time and place offer potential improvements over traditional CME. However, more emphasis should be placed on continuing education that occurs when clinicians search for answers to questions that arise in clinical practice, instead of that which occurs at an arbitrary time designated for CME. The use of learning portfolios and informationists can be integrated with self-directed CME to help foster a culture of lifelong learning.

No-Ad Sunscreen

The July 2007 Consumer Reports magazine lists sunscreen "Best Buys"  Their recommendation is the No-Ad line.  It's available at most drugstore and supermarket chains.