Teledermatology. Acne. What the primary care physician needs to know in the world of increased access

Transcription

1 Teledermatology What the primary care physician needs to know in the world of increased access Toby Maurer, MD University of California, San Francisco 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? Acne 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? Primary care provider: Pt has recent onset of bumps on face. What is this and how do I treat? Has used proactive with minimal change. 1

2 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? 2

3 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 bid x 8 weeks Doxycycline bid x 8 weeks Minocycline 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 3

4 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 intralesional kenalog Primary Care Provider: Pt told he has psoriasis-used some crème in Mexico-can t remember name. Worried that his grandchildren could catch this. 4

5 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 weeksplease 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, subcu injections, presecreen for TB and Hep B and cancer risk Ultraviolet light-is pt able to spend the time; is it accessible to pt? 5

6 NO PREDNISONE 6

7 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 7

8 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 8

9 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 9

10 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 10

11 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 11

12 Clinical Features of FAMMM Often numerous nevi ( ) 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 12

13 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 13

14 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 14

15 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 pt does 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 15

16 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? 16

17 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 derm clinic in 4-6 weeks-please let me know Likely hyperkeratotic AK but book in derm clinic 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 17

18 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! 18