This continuing medical education activity is jointly provided by the North Carolina Dermatology Association and the Southern Regional Area Health Education Center

North Carolina Dermatology Association

2019 ANNUAL MEETINGFRIDAY HANDOUTS

January 11-13, 2019The Pinehurst Resort, Village of Pinehurst, NC

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Burned Out to On Fire with Passion and Purpose

Clark Gaither, MD, FAAFP, MROMedical Director, NCPHP

January 11, 2019

Presented byPresented by

Unraveling Physician Burnout - The Hallmarks, Scope, Costs, Prevention and Viable Remedies.

PHYSICIAN BURNOUT

ScopeCostsHallmarksCausesViable Remedies

Presented by

SCOPE

• Burnout is an innate hazard of our profession.

• Burnout is progressive in nature.

• Burnout is impossible to alleviate unless the    underlying causes are correctly identified and addressed.

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Presented byPresented by

COSTS

The cost of replacing one physician ranges from                                 

$250,000 to 1.2 million dollars.

The Hallmarks of 

Burnout 

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Emotional Exhaustion

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Depersonalization

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A lack of a sense 

of personal accomplishment.

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Presented by

The Three Hallmarks of Burnout

1. Emotional Exhaustion ‐ Keyword: Exhaustion

2. Depersonalization – Keyword: Cynicism

3. A Lack of Personal Accomplishment –

Keyword: Inefficacy

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Presented by

Stress Is Different from Burnout

Stress is characterized by over‐engagement. Burnout is characterized by disengagement.

In stress emotions are overactive. In burnout emotions are blunted.

Stress produces urgency and hyperactivity. Burnout produces helplessness and hopelessness.

Stress leads to loss of energy. Burnout leads to loss of motivation, ideals and hope.

Stress leads to anxiety disorders. Burnout leads to detachment and depression.

With stress the damage is primarily physical. With burnout the damage is primarily emotional.

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Presented by

Stress Is Different from Burnout

Stress may kill you prematurely. Burnout will make life seem not worth living and increases your risk of suicide.

Stress is more easily identified and treated. Full blown burnout can be much more difficult to manage as it includes stress and many 

other factors.

Stress is almost always recognized by the individual. Burnout may not be recognized as such by the individual as symptoms may be 

incorrectly attributed to some other cause.

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Presented by

Causes of Burnout

• Burnout will occur any time, anywhere there is a major mismatch between the nature of the job and the nature of the person who does the job.

• There are six major job/employee mismatches which cause job related burnout.

• It is not only the number of mismatches present, but their intensity which determines the presence and the rate of job related burnout.

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Work Overload

Mismatch #1

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Lack of 

Control

Mismatch #2

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InsufficientReward

Mismatch #3

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Breakdown of 

Community

Mismatch #4

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Absence of

Fairness

Mismatch #5

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Conflicting Values

Mismatch #6

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Presented by

Work Overload

Lack of Control

Insufficient Reward

Breakdown of Community

Absence of Fairness

Conflicting Values

Work Overload

Lack of Control

Insufficient Reward

Breakdown of Community

Absence of Fairness

Conflicting Values

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Viable Remedies

10% of the time, individuals burn themselves out90% of the time, the work environment burns out individuals

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Individual & Organizational 

Burnout Intervention Strategies – 2 Types

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Individual Burnout Prevention Strategies

MentalEmotional

PhysicalSpiritual

The Four Realms22

Presented by

Nourishing the Four Realms

• Mental —Reading, Learning, Listening, New 

Experiences, Play…

• Emotional —Connections, Self‐Discovery,  Intimacy, Boundaries, Play…

• Physical —Regular Cardiovascular Exercise, 

Check‐ups, Risk Reduction Strategies,

Healthy Behaviors, Play…

• Spiritual — Meditation, Prayer, Nature, Core

Values, Authenticity, Play…

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Unplugged ‐ Jeep Island, Truck Lagoon, FSM

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Presented by

Organizational Strategies

• Survey the workplace for the presence of the six major job/employee (J/E) mismatches which lead to job related burnout (JRB).

• Institute programs and take steps necessary to eliminate or mitigate any J/E mismatches.

• Change the work environment to one which prevents JRB while fostering ENGAGEMENT.

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Presented by

Burnout Consultation Workflow• Initial meeting

• Fact gathering

• Maslach Burnout Inventory (MBI)

• MBI debriefing

• Areas of Work Life Survey (AWAS)

• AWAS debriefing

• DISC Personality Profiles

• DISC debriefing

• Workplace redesign

• Monitor for progress

• Resurvey and Adjust26

Viable remedies for Burnout

Opening the doors to…

ENGAGEMENT!

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ENGAGEMENT is characterized by ...

• Vigor(energy)

• Dedication (involvement)

• Absorption (efficacy)

How? Eliminate Job Mismatches

Resilience TrainingWorkplace RedesignIndividual Coaching

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www.ncphp.org

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919‐870‐4480

www.ncphp.org

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Diet in Dermatology: Translating Evidence Into Practice

Rajani Katta MD

Clinical Professor of DermatologyMcGovern Medical School, UT Houston

Clinical Assistant Professor of MedicineBaylor College of Medicine

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DISCLOSURES

-No relevant conflicts of interest with industry

-Author of a book for the general public on diet and dermatology

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The Epsom Salt Problem

• So many common misconceptions (gluten anyone?) and extreme recommendations

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The Epsom Salt Problem

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Objective

• Be able to address common myths and misconceptions about skin and diet

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The Jenny McCarthy Effect

• The proliferation of “skin care experts”, “wellness bloggers”, “celebrity experts” and more

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“If you ask a parent of an autistic child if they wantthe measles or the autism, we will stand in line forthe f___ing measles.”

-Jenny McCarthy, TIME Magazine 2009

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In Dermatology:Welcome to Sugar Bear Hair Gummies

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Objective

• Speak with authority, providing recommendations that are grounded in scientific research

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The Translation Challenge

• Can be challenging to take complex scientific evidence, sift through it, and then translate that to clear recommendations

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Translator

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Objective

• Be able to translate nuanced scientific evidence into straightforward, actionable recommendations

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FACT

Many (or most) of your patients believe that diet may impact the skin.

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FACT

Some of your patients are consuming diets or nutritional supplements recommended by:

– Their herbalist

– Their naturopath

– Their homeopath

– A “wellness activist” who recommends it on her blog

– Their friend who read about it on a blog

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Skin and Diet

• Diet has always been a part of medicine

• We’ve known for centuries that diet impacts the skin.– Poor wound healing in diabetics

– Acanthosis nigricans

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FRAMEWORK

CO-MORBIDITIES: Review risk of potential co-morbidities for each skin disease/ condition

TRIGGERS: Discuss potential triggers: eating patterns/ foods/ nutrients that may worsen skin disease

HELPERS: Discuss potential “helpers”: eating patterns/ foods/ nutrients that may help in the treatment of skin disease

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The Goal

Translate evidence-based research into recommendations that are:

–Specific

– Individualized

–Actionable

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Diet and Psoriasis

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Can we play a role in protecting our psoriasis patients?

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Psoriasis pts at risk

• Higher prevalence of comorbidities, including obesity, diabetes, hypertension, and dyslipidemia

• Meta-analysis of 27 observational studies: psoriasis is associated with both increased prevalence and incidence of diabetes.

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Psoriasis pts with increased risk of MI

Study comparing MI risk in over 130,000 psoriasis patients (with over 500,000 controls)

Patients with psoriasis had increased adjusted relative risk for MI, even after adjusting for HTN, DM, hyperlipidemia

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Psoriasis

Dietary changes are a must to prevent systemic disease

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Risk of MI Mild Psoriasis:1.29

Severe Psoriasis:1.70

Risk of Stroke Mild Psoriasis:1.12

Severe Psoriasis:1.56

Risk of CV Mortality

Mild Psoriasis:1.03

Severe Psoriasis:1.39

Psoriasis and Comorbid DiseasesArmstrong et al. 2013

Armstrong EJ, Harskamp CT, Armstrong AW. Psoriasis and major adverse cardiovascular events: a systematic review and meta-analysis of observational studies. J Am Heart Assoc 2013; 2:e000062.

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Evidence-based risk reduction

• Mediterranean diet for CV disease prevention

• DASH diet for prevention of HTN

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Dietary interventions in psoriasis

• 55 studies meeting the inclusion criteria

• Represent 77,557 unique participants – 4,534 with psoriasis

-Ford AR, Siegel M, Bagel J, et al. Dietary Recommendations for Adults With Psoriasis or Psoriatic Arthritis From the Medical Board of the National Psoriasis Foundation:A Systematic Review . JAMA Dermatol.Published online June 20, 2018.

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• “Based on the literature, we strongly recommend dietary weight reduction with a hypocaloric diet in overweight and obese patients with psoriasis.

• We weakly recommend a gluten-free diet only in patients who test positive for serologic markers of gluten sensitivity.”

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Psoriasis and Weight Loss

• Meta-analysis of 5 RCTs of weight loss interventions– Lifestyle intervention via diet or exercise in overweight/obese pts

– Greater improvement in PASI scores in wt loss intervention groups

• Weight loss has also improved response to systemic tx– RCT of pts on CyA

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Psoriasis and celiac disease

• Increased risk of celiac disease– In one study 2.2 fold higher risk

• Case reports describe resolution of psoriasis with gluten-free diet in patients with celiac disease

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More Research Needed

• Small studies indicate that even patients without celiac disease may benefit from GFD, if they test positive for gluten antibodies

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Psoriasis and Gluten Antibodies

• 16% of pso pts with IgA and/or IgG to gliadin (AGA)

• Of 33 AGA, 30 completed a GF diet for 3 mos

– Resulted in significant decrease in mean PASI

– This included 16 pts with normal histology on duodenal bx

• When resumed ordinary diet, 18/30 worsened

• 6 patients neg for AGA did NOT improve

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Summary

Reduce risk of co-morbidities (CV disease, DM, HTN, other)-Diets supported by evidence to reduce risk: Mediterranean diet, DASH diet

Helpers-Weight loss to improve response to therapy-Weight loss to improve PASI scores

Triggers-Increased risk of celiac disease-Gluten-free diet may help those with gluten antibodies

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ACTION ITEMS

1. Screen during history and physical-BMI-History of GI symptoms (gluten allergy/hypersensitivity)

2. Educate on increased risk of co-morbidities3. Eval by primary MD4. All pts >45 should be screened for DM

-Consider HgA1C to indicate 3mo of BS-Screen at younger age if overweight/obese/ family history/ certain ethnic groups/ other risk factors

5. If overweight/obese-and with pre-diabetes, refer to diabetes prevention program for both diabetes prevention and weight loss -Consider referral to nutritionist

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Diet and Atopic Dermatitis

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Is there a relationship between an impaired skin barrier and an

impaired gut barrier?

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Synbiotics=Probiotics with Prebiotics

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Why would prebiotics with probiotics work to improve the skin?

What lessons are here for our patients?

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Atopic Dermatitis: Helpers

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• In a meta-analysis, the use of synbiotics showed promise in the treatment of atopic dermatitis in adults and children over the age of 1 year

• Many differences in study design– Different bacterial strains, dosages, duration

– Different types of prebiotics

• Significant variability in individual response

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Prebiotic foods include many vegetables

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PUFAs may improve skin barrier function

• Supplementation with flaxseed oil [source of PUFAs] for 12 weeks

• Resulted in less sensitivity to known irritant

• Less TEWL [trans-epidermal water loss]

• Smoother skin

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AD and Food Allergies

• Strongly correlated

• Overall estimated prevalence of food allergy in children with AD has ranged widely, from 20% to 80%

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Food Allergens as an Exacerbating Factor in AD

• Clearly play a role in some patients

• However, prevalence unknown

• Studies indicate that those most likely to be impacted are infants and children with moderate to severe AD

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Recent Updates• Medical records of 387,439 adults (mean age 43) with AD

• Compared to 1,528,477 matched controls

• Patients with severe AD

– 20% increased risk of stroke

– 40-50% increased risk of unstable angina, MI, Afib, and CV death

– 70% increased risk of heart failure

-Silverwood R, Forbes HJ, Abuabara K, et al. Severe and predominantly active atopic eczema in adulthood and long-term risk of CV disease: population-based cohort study. BMJ May 23, 2018

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Reduce risk of co-morbidities-More research needed, but severe AD may be associated with higher risk of heart disease

Helpers-Synbiotics in adults and children over the age of 1 year

Triggers-3 main types of foods allergies that may result in flare of AD-These include IgE-mediated, immediate-type hypersensitivity/ delayed eczematous reactions which may flare AD up to 48 hours later/ and systemic contact dermatitis, which may also lead to a delayed flare

SUMMARY

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Action Items

1. Food diary and possible testinga. Issue of food allergies in eczema is very complexb. Patient handout: https://www.skinanddiet.com/diet-and-eczema-food-

triggers2. Increased fiber in diet via fruits, vegetables, whole grains (if not allergic)3. Consider synbiotics or increased consumption of fermented foods containing

live, active cultures

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Diet and Acne

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RCT of Acne Treatment

• 43 male patients

• 12-week intervention study

• Investigator-blinded

• Intervention resulted in– Greater decrease in total lesion counts

– Reduction of free androgen index

– Increase in insulin-like growth factor binding protein

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RCT of Acne Treatment

• Later studies of same intervention:– Decrease in skin sebum

– By histology, decreased skin inflammation

– By histology, decreased sebaceous gland size

– Decreased androgen bioavailability

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SIDE EFFECTS

• Minimal side effects

• No lab monitoring needed

• Low cost

• Generic (no prior auth needed!)

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Low Glycemic Index Diet

• Focus on carbs that do not raise blood glucose levels as quickly

• In RCT– 25% protein/ 30% fat/ 45% low GI carbs [NOT a low-carb diet]

– Volunteers were asked to replace high GI carbs with protein such as fish and poultry

– Used whole grain bread instead of white bread

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What do our patients believe?

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From: Diet and acne: an exploratory survey study of patient beliefs. Nguyen Q, Markus R, Katta R. Derm Pract Concept April 2016:6.

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But it’s not the chocolate--it’s the sugar

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Role of Dairy Unclear

• Epidemiologic studies suggest that it may play a role in some individuals

• Case series of whey protein supplements serving as a trigger

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Counseling Patients

• Provide information

• For teenagers, consider feasibility– Reduce sugar-loaded sodas/sports drinks/ teas

• Emphasize that this is only one aspect of treatment

• However, it is completely under your control

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Helpers- Low glycemic-index diet has been shown to result in clinical improvement,

favorable serum hormone levels, change in sebum levels, and reduction in skin inflammation and sebaceous gland size (demonstrated by skin biopsy)

Triggers- Role of dairy unknown; may be a trigger in some individuals- Case series of whey protein supplements triggering severe acne resistant to

treatment

More research needed- Role of zinc, omega-3 fatty acids, fiber, probiotics, antioxidants

SUMMARY

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ACTION ITEMS

1. Educate on role played by sugar and processed carbs2. For motivated individuals, consider further education on

low glycemic index dietary recommendations3. Emphasize that diet is only ONE aspect of therapy4. Consider individual patient and feasibility of dietary

change5. Consider d/c of whey protein supplements6. Explain that role of dairy remains unknown, but may

possibly serve as a trigger in some individuals

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Diet and Rosacea

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Dermatologists discuss spicy foods and alcohol as rosacea triggers.

What do our patients say?

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Dietary Triggers in Rosacea

• Survey by National Rosacea Society

• Over 400 pts

• 78% had tried altering their diet

• 95% indicated this had helped reduce flares

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Food Triggers in Rosacea

• Hot sauce 54%

• Wine 52%

• Cayenne pepper 47%

• Hard liquor 42%

• Red pepper 37%

• Hot coffee 33%

• Tomatoes 30%

• Hot tea 30%

• Beer 30%

• Chocolate 23%

• Citrus 22%

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What do these foods have in common?

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All are vasodilators

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Food Triggers in Rosacea: Cinnamaldehyde

• Hot sauce 54%

• Wine 52%

• Cayenne pepper 47%

• Hard liquor 42%

• Red pepper 37%

• Hot coffee 33%

• Tomatoes 30%

• Hot tea 30%

• Beer 30%

• Chocolate 23%

• Citrus 22%

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Vasodilators

• Alcohol

• Hot beverages

• Activation of transient receptor potential channels that control neurogenic vasodilation– Capsaicin

– Cinnamaldehyde

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Gut-skin connection in rosacea?

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Rosacea and GI Disease

• Population-based cohort study of close to 50K patients with rosacea

• Increased risk of multiple GI conditions and diseases

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CeD CD UC IBS HPI SIBO

GI co-morbidities in Rosacea

Rosacea and gastrointestinal disorders: a population-based cohort study.

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Rosacea and SIBO

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Rosacea and SIBO

• In one center, found increased risk of SIBO [small intestinal bacterial overgrowth] in pts with rosacea

• Treatment of SIBO in 40 patients led to remission of rosacea in all

• This persisted in the majority at 3-year follow-up

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More research needed

• Rosacea patients may have increased risk of CV disease

• Inflammatory pathways

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SUMMARY

Reduce risk of co-morbidities- Population studies of close to 50K individuals indicate increased risk of GI conditions

Helpers- Case series of SIBO (small intestinal bacterial overgrowth) treatment resulting in long-term resolution of rosacea- Consider measures to support gut flora, including prebiotics and probiotics

Triggers- Consider foods and beverages that result in vasodilation, either directly or via neurogenic vasodilation via role of TRP channels [transient receptor potential channels]- Hot beverages- Alcohol- Capsaicin-related: spicy foods, red pepper, cayenne pepper- Cinnamaldehyde-related: cinnamon, tomatoes, citrus, chocolate

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ACTION ITEMS

1. Screen with history for GI co-morbidities2. Refer to GI if necessary3. Education on food and beverage triggers,

including handout4. Food diary vs 8-week elimination of

potential rosacea triggers

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Diet and Aging Skin

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Diabetes impairs wound healing.

Does this impact collagen in other ways?

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How can you increase a person’s MED?

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Wrinkling

Loss of elasticity

Brown spots (solar lentigos)

Rough, dry texture

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The 3 Main Forces That Age The Skin

• Oxidation

• Major and minor inflammation

• Glycation

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Aging Skin

• Multiple points to impact this process

• UV radiation– Oxidation and increased free radicals

– Damage to DNA, proteins

• Damage triggers inflammation– Increase of MMPs such as collagenase and elastase, leading to

further damage

• Glycation results in weakened collagen framework

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Some dietary antioxidants limit cellular damage induced by UV

radiation

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Dietary antioxidants

• UV exposure is associated with oxidative stress

• UV-induced reactive oxygen species (ROS) can degrade dermal collagen and elastic fibers.

• Dietary antioxidants may counteract ROS

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Antioxidants that combat photoaging in laboratory studies

• Lycopene-tomatoes

• Ellagic acid-raspberries

• Genistein-soy

• Curcumin-turmeric

• Quercetin-onions

• Resveratrol-grapes

• Polyphenols-green tea110

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• Avoid production of AGEs to limit wrinkling/ loss of elasticity

• That means avoid sugar spikes

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Everybody’s different

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Summary

Role of oxidation-Foods naturally rich in antioxidants-Fruits, vegetables, whole grains, spices, herbs

Role of inflammation-Anti-inflammatory foods-Similar to foods naturally rich in antioxidants-Omega-3 fatty acids

Role of glycation-“Sugar sag”-Strategies to reduce blood glucose levels

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Action Items

• Mediterranean diet, DASH diet, MIND diet

• Emphasis on unprocessed foods

• More fruits, vegetables, nuts, seeds

• More spices and herbs

• Fermented foods

• Less processed foods/ less sugar/ less refined carbohydrates

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KattaMD.com

SkinAndDiet.com

SkinAndDiet.com/infographics

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