Case Studies From econsults Lessons Learned

Transcription

1 Case Studies From econsults Lessons Learned Karolyn (Kari) Wanat, MD Department of Dermatology and Pathology University of Iowa

2 econsults Health care innovation award for controlled costs and improving quality between primary care and specialty services Objectives Improve communication and coordination between PCPs and specialists formalizing the curbside consultation Improve referral efficiency, effectiveness, tracking Align with goals: patient-centered care, improved quality, improved training & education, value

3 Pearls for Actinic Keratosese Treat with destruction Cryotherapy: start low and can always repeat Topical chemotherapy: 5-fluorouracil cream twice daily for 2-3 weeks Observation Biopsy

4 Cryotherapy Liquid Nitrogen = coldest cryogenic agent (- 196 C) Mechanism of Action Fast freeze intracellular and extracellular ice crystal formation, cell membrane disruption, thermal shock

5 Cryotherapy Techniques

6 Cryotherapy Cautions Hyper / Hypopigmentation in all skin types Higher risk in darker skin types Damages melanocytes 1 st Do NOT treat lesions suspected to be melanocytic If an actinic keratosis does not resolve after 2-3 cryotherapy treatments, biopsy it

7 Cryotherapy Patient Counseling Blister might develop Okay to puncture with sterile needle Leave blister roof intact No special care Wash 1-2 times daily Apply Vaseline

8 Freeze Cycles vs Freeze Borders Hold Cry-Ac 1-2 cm from lesion to be treated Borders: one freeze-thaw cycle that lasts about 10 sections with a border of 1-2 mm around visible lesion Cycles: typically 2 freeze-thaw cycles that each last seconds

9 Atopic Dermatitis Changes in temperature or weather conditions such as heat or low humidity often worsen atopic dermatitis Atopic dermatitis, allergies (such as hay fever), asthma or hives. No cure for atopic dermatitis Waxes and wanes

10 Atopic Dermatitis Topical corticosteroids: Hydrocortisone 2.5% ointment for face Triamcinolone 0.1% ointment for body May use twice daily UNTIL RESOLVED, then once daily for week, then 2-3x/week as needed Repeat for flares THICK emollients: squeeze out or scoop out

11 Nummular Dermatitis Coin-shaped Often secondary to xerosis Itchy to painful Treat underlying skin barrier and treat inflammation (topical corticosteroids and THICK emollients)

12 Hypersensitivity/Urticarial Dermatitis Dermatographism: wheal develops after stroking skin Pruritus etiologies: Medication Exposure Treatment With dermatographism, treat with antihistamines

13 Hypersensitivity/Hives Treat with 2 nd generation antihistamines Up to 3-4x dose is ok Combine anti-histamines Avoid aspirin, NSAIDS & codeine Topical medication can be soothing, but not good for solo therapy

14 Tinea Versicolor Malassezia furfur (or Pityrosporum) Treatment -Selenium sulfide shampoo and ketoconazole 2% shampoo, to be alternated as a body wash to the area Apply, lather, rinse after 5 minutes Ketoconazole 2% cream to back (and any other areas involved) twice daily

15 Pyogenic Granuloma (Lobular capillary hemangioma) Trauma Pregnancy Medications BLEED!!!!!!!!!!!!!!!!!!!

16 Treatment Shave biopsy Cauterize the base If small can use silver nitrate sticks

17 Orogenital Ulcerations Think herpes virus 1 st, 2 nd, 3 rd Differential diagnosis: Aphthous stomatitis Lipschutz ulcers Behcets Crohns disease

18 Teledermatology Limitations Images and information is key Need to know patient s context and medications available Know limitations and way to refer

19 Teledermatology: Best Practices Relationship with providers Able to communicate freely and easily Understanding of therapeutic options available Ability to see patients if not improving

20 QUESTIONS?

21 Resources Bolognia, J., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology. Philadelphia: Elsevier Saunders. Chicago (Author-Date, 15th ed.) Curr Med Res Opin Mar;26(3): doi: / Graber and Wilbur s Family Medicine Examination and Board Review, 4 th edition Cutis Jun;97(6):408-12