30 Tips in 30 Minutes
Joseph B. Chastain Chair of Dermatology
Tulane University Health Sciences Center
New Orleans, LA
Skinphysicians and surgeons
Dr. Pimple Popper
Professor of Dermatology and Pediatrics
Vice-Chair, Department of Dermatology
Chief, Pediatric and Adolescent Dermatology
University of California, San Diego and Rady Children’s Hospital
San Diego, CA
Director of Dermatology & Dermatologic Surgery
Memorial Sloan Kettering Cancer Center
Basking Ridge, NJ
Illinois Dermatology Institute
Professor of Dermatology
Eastern Virginia Medical School
This multispeaker session is always an audience favorite; this year, the panel included medical, surgical, as well as practice management tips. Erin Boh, MD, PhD, kicked off the session with a tip on identifying cutaneous T cell lymphoma (CTCL) in clinical practice. This can be difficult because CTCL can mimic psoriasis, atopic dermatitis, and drug eruptions, but Dr Boh emphasized the importance of early recognition to increase disease-specific survival. Dr Boh also discussed the use and monitoring of methotrexate in clinical practice as well as labs for a thorough work-up of prurigo nodularis. Dr Boh concluded with tips on the work-up of pretibial myxedema, which includes thyroid function studies and biopsy, as well as the early use of biopsies in dupilumab nonresponders after 3 to 4 months of therapy to rule out CTCL.
Sandra Lee, MD, discussed in-office procedural pearls, such as using a 15-blade in its wrapper for an inexpensive shave biopsy and covering cysts with a transparent film dressing prior to local anesthesia to prevent splashing. Dr Lee recommended using tumescent anesthesia for large lipoma excisions and attempting to aspirate large pilar cysts before excision as many can become liquified. Dr Lee concluded with a tip on a clinical maneuver to determine whether large lipomas are superficial or are lying underneath a muscle.
The next panelist, Lawrence F. Eichenfield, MD, began with a tip on using an otoscope or flashlight to evaluate for transillumination of cysts and look for calcification in pilomatricomas. Dr Eichenfield advised documenting body surface area involvement for all moderate-to-severe inflammatory skin diseases and told the audience that one thumb size is approximately 1% of the scalp when evaluating alopecia areata. For reducing pain during procedures or injections in children, Dr Eichenfield recommended lidocaine 4% cream, listening to music, utilizing the Zimmer cooler, and a wrapping technique for immobilizing smaller children.
Steven Wang, MD, continued the discussion with surgical tips for the office. Dr Wang recommended doing multiple scouting shave biopsies in a clock pattern on the periphery of large pigmented facial lesions suspected to be lentigo maligna. For nonsurgical treatment of lentigo maligna, Dr Wang gave tips on using imiquimod cream 5 times weekly for 12 weeks. Dr Wang’s next 2 tips were on the use of ferric subsulfate solution as a landmark for scalp biopsies that may need further surgical treatment and the use of heating packs to enhance aminolevulinic acid incubation prior to photodynamic therapy. Dr Wang concluded with a recommendation for weekly intralesional triamcinolone injections for keratoacanthomas on the lower extremities.
G. Michael Lewitt, MD, gave the audience a few medical pearls, the first being to check a Tb spot on patients who have an indeterminate QuantiFERON Gold test. For cases of psoriasiform dermatitis with overlapping eczematous features on the hands and feet, Dr Lewitt recommended treating with a systemic JAK inhibitor for rapid improvement. When using immunosuppressive medications, Dr Lewitt reminded the audience to avoid the concomitant use of live vaccines, including the MMR, rotavirus, and varicella vaccines. To conclude, Dr Lewitt recommended sticking to a strict order when performing total body skin exams, even when patients come in with a list of things to address.
David M. Pariser, MD, concluded the session with a few office efficiency and medical tips for the audience. Starting with office efficiency, Dr Pariser recommended getting a scribe for each provider and making sure they are well-trained in billing to help save time. Moving on to medical dermatology, Dr Pariser reviewed evidence for a novel targeted alkali thermolysis patch as an in-office treatment for axillary hyperhidrosis. In studies, a single 3-minute application led to reduction in excessive sweating for up to 3 months. Dr Pariser concluded with a discussion of efficacy of various field treatments for actinic keratoses and recommended occlusion of aminolevulinic acid for photodynamic therapy.