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What the primary care physician needs to know in the world of

increased accessToby Maurer, MD

University of California, San Francisco

Teledermatology• In the world of dermatology-teledermatology

is powering many processes of medicine• Direct to consumer-barristas?• Contracted derms reading pictures sent from

PCP’s and providing advice-who owns the advice/are these diagnoses/ who monitors the advice?

• What happens when the advice does not cut it or when it is wrong?

• In what network does the pt enter when they have to be seen by the DERMATOLOGIST?

• How do we strengthen the partnership between the PCP and derm to provide the best care to the pt?

AcnePrimary care provider: Pt has recent onset of bumps on face. What is this and how do I treat? Has used “proactive “with minimal change.

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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?

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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’s

skin is clear, taper the dose in ½ for another month and then stop the medication

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Acne Rosacea• Rosacea-if just red-laser or makeup• If papules-start doxy 100 bid x 8 wks then

topical flagyl daily for maintenance• Seb derm: topical HC 1% oint plus econazole

crème bid and seb derm shampoo (tar, ketaconazole,selenium, zinc)

Acne Keloidalis Nuchae• Never buzz cut hair again• Topical clobetasol qam and topical retin a

0.1% crème/gel qhs x 3 months• If very inflamed, add doxycyline 100 bid x 2

months• See pt back in 3 months• If no change, send back another consult-we

can book him in clinic for intralesionalkenalog

• Primary Care Provider:Pt told he has psoriasis-used some crème in Mexico-can’t remember name. Worried that his grandchildren could catch this.

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• 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

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?

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NO PREDNISONE

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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

Gentle Skin Care discussion• Steroids are okay to use-not going to thin out

the skin BUT give limited amts of potent steroids• 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

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Scabies: Classic treatment• Permethrin 5% crème-2 applications 1 week

apart• Must treat all intimates• Clothing instructions essential

• Primary Care Provider:Pt notes changing mole-also itchy. Worried she has melanoma

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• Seborrheic keratosis-OBSERVE over time-Alert to pt-if bleeds or grows rapidly-return to you ASAP!

• You can apply cryotherapy 2 x 15 sec thaw cycles or

• Private derms in your county will do this for a fee

• Primary Care Provider:24 year old with new black bump• No others noted

• Teledermatology Response: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

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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

• Primary Care Provider: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• Teledermatology response:Agree and will book within 1-2 months

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Melanoma• Melanoma may be INHERITED or occur

SPORADICALLY• 10% of melanomas are of the INHERITED type

Familial Atypical Multiple Mole-Melanoma Syndrome (FAMMM)

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?

Risk Factors for Sporadic (Nonhereditary) Melanoma

• Numerous normal nevi, some atypical nevi• Sun sensitivity, excessive sun exposure

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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

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

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If not sure:• Measure and see pt back in 3-6 months for

reevaluation!!Teledermatology Response:• Have pt come back-take another picture and

let’s compare

• Primary Care Provider:On pts back-Sometimes wife squeezes out smelly cheese –like material. Advice?

• 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

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• Primary Care Provider:Pt came in with 2 day history of enlarging

lesion and increasing pain.• Started doxycyline

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

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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

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

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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?

• Pt has actinic keratosis• Can I freeze it with liquid nitrogen?

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• 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

• ARE ANY SPOTS BLEEDING?

• Please explain side effects of LN2• 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

• Likely hyperkeratotic AK but book in dermclinic within 1 month-I need to palpate to r/o Squamous cell cancer

• Next steps:• I will biopsy-send pathology to

dermatopath at UCSF

• If positive-will send to plastics or dermsurgery for excision

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Teledermatology as part of Dermatology

• Increased efficiency and access• Total cost of specialty service is less• Pt outcomes and satisfaction appear to be

better• Over next few days-hope to develop skills to

make dermatology a better partnership specialty with primary care!