The Telederm Experiment

Transcription

1 The Telederm Experiment Teledermatolgy and Primary Care Integrating common dermatology diseases into a system where teledermatology triaging is used Toby Maurer, MD University of California, San Francisco California Health Care Foundation can we make it happen in the Bay Area? La Clinica first group in the Bay Area Primary care provider has any derm question or wants to refer to derm ALL referrals go through telederm even if it is a pt followed by derm in past Obtains verbal consent from pt Provider or assistant takes picture and uploads picture Question can be typed in on web based template at the time of pt visit or later that day, etc Derm group answers question and primary will get notification that derm report is ready Provider will get first pass advice what is it, how to treat, when he/she should see pt back or when to refer OR Provider will be alerted that pt needs derm appointment and pt will be triaged within an appropriate time to be seen in LIVE CLINIC. Derm report is part of the electronic medical record 1

2 Results to date Dermatologists from UCSF read the triage consults and they also staff the live clinics at the primary care providers site We have completed around 2000 consults 85% of consults have been successfully treated by primary provider with derm guidance the GPS system 15% seen in live derm clinic Wait time at San Mateo was 9 months to see DERM. Now we get consults back in 2 days and live clinics booked within 1 month Acne Primary providers have learned from one on one consults Primary providers have had to DO some dermatology Live dermatology clinic difficult cases but time has been properly apportioned to see them 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. 2

3 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? 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 fo another month and then stop the medication 3

4 Spiranolactone Diuretic used in cirrhosis of liver Also an anti androgen Useful in females who have cysts around menstruation mg qday Increased urination, don t use during pregnancy,?electrolyte imbalance Pt told he has psoriasis used some crème in Mexico can t remember name. Worried that his grandchildren could catch this. Pt did not get better 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 bettersend another telederm consult and we will readvise or book pt in derm clinic 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 2 weeks and start him on acitretin 25 qd 4

5 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? Psoriasis What is it? Fast growing skin takes 3 days to come to surface and desquamate Normal rate is 28 days Psoriatic skin has a fast mitotic rate Triggers an inflammatory response in and around affected skin Psoriasis Tx: New onset often preceded by strep infection (strep pharyngitis) especially in the younger age group. In older age group, drugs often unmask psoriasis Drugs: beta blockers, lithium, NSAIDS, antimalarials, terbinafine, gemfibrozil pts on these meds for 3 6 months before onset of psoriasis Decrease the MITOTIC RATE of skin Tar (LCD 5% in TAC 0.1% oint) ( Tar emulsions) topical retinoids (Tazarac) Decrease the INFLAMMATORY Reaction of the skin Steroid Ointment (midpotency 1 st line) Calcipotriene (Dovonex Creme) not on face or groin Clobetasol/Dovonex combination Ultraviolet light 5

6 NO PREDNISONE 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 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 Atopic Dermatitis Deeper exploration re: therapy particularly in pediatrics group Not sure whether it can be generalized to adults Dilute bleach baths decreased severity of atopic derm in kids on body not face Rx: ½ cup of bleach in full bathtub followed by liberal use of emmolients once daily Anderson Curr Opin Ped 2009 Feb 6

7 Do Bleach baths do anything to reduce staph aureus carriage Up to 90% of kids with atopic dermatitis carry staph aureus (usually not MRSA) When the staph burden is great, thought is that there is a flare of eczema Standard treatment is 14 days of p.o. cephalosporin 3 treatment groups: 1) Bleach baths with mupiricin in nose 2) Plain bath water 3) Plain ointment Group 1 reduced staph aureus carriage rate to 4% compared to controls at a rate of 75% Group 1 severity index of atopic derm reduced Lofgren et al Curr Opin Ped 2001 Aug Let s go back in time The old moist wraps: Used about 25 years ago Corticosteroid and ointment goes directly onto skin Moisten first layer kerlex, gauze, socks that are cut open ring out for excess water Dry layer on top sleep in this overnight Can be done nightly for up to 2 weeks until gone OR Every 5 days watch for maceration of skin Nursing Education Two nice studies: Great Britain and Netherlands Atopic families who had the benefit of intense nursing education did much better re: quality of life and severity indices compared to families who just saw the doctor. des Bes et al Acta DermatolVenereol 2011 Jan 7

8 Food Not enough evidence to suggest that any foods or categories of food contribute to atopic dermatitis Not enough evidence to suggest that breast feeding reduces risk for developing atopic dermatitis Not enough evidence to suggest that holding back on solids or milk after 4 6 months of age reduces risk for developing atopic dermatitis Calcineurin inhibitors Tacrolimus (protopic ointment) and pimecrolimus ( elidel cream) Being studied again against corticosteroids Recommendation in children: do not use for extended periods of time, especially in sunexposed areas and in persons who are immunosuppressed My experience works best on face and stops working after around 2 yrs of use Schmitt et al BJD 2011 Feb Cutaneous Tinea KOH is helpful in distinguishing tinea from eczema Topical antifungals x 4 6 weeks your formulary has econazole apply bid Just say NO to Lotrisone PLEASE! Primary Care Provider: weird fungal infection? Not responding to topical or oral antifungals. Should I add topical steroids if so, which one? Won t I exacerbate the tinea? 8

9 How to diagnose This is corynebacterium a bacterial infection that causes pitted keratolysis of the foot and has a very bad odor Use topical erythromycin bid or oral erythromycin for 10 days You are right that antifungals won t work neither will steroids for this condition Not all dystrophic nails= onychomycosis KOH difficult to do and operator dependent CULTURE is gold standard but takes 3 weeks to grow out. Now PCR used in Scotland with high sensitivity and specificity Cost effective and results in 72 hours Alexander et al Br. J Derm 2011 May Onychomycosis Topical treatment use for the right type of lesions Naftin gel for small superficial lesions Penlac (Ciclopirox 8%) reported to work 35 52% of the time cost: expensive Right type of lesions for topicals Lunula not affected Less than 5 nails affected No thickening of nails No separation of nail plate on sides 9

10 Terbinafine (Lamisil) Griseofulvin least hepatotoxic but lower efficacy 250 mg bid x months Fluconazole 150 mg qweek for more than 6 months July 2012 Dermat Tx Gupta AK et al Still the leader of the pack most effective in terms of INITIAL and LONG TERM cure rate. DOSE: 250 mg qd Continuously x 3 months for fingernails and x4 months for toenails (July 2012) i.e. no pulsing Itraconazole can pulse it 400 mg qd x 7 days q month x 4 months BASELINE 1 YR 5 YR Terbinafine 77% 75% 50% Itraconazole 70% 50% 13% Grispeg 41% Fluconazole??? Onychomycosis A New Approach Toenails take months to grow Pulse terbinafine 250 mg per day for 1 week every 2 3 months for one year Booster dose at 9 months (250 mg qd x 1 month) 10

11 Liver toxicity Transaminase elevation 0.4% to 1% with terbinafine and intraconazole Transaminase elevation does not predict liver failure Liver failure 1/100,000 Terbinafine has gone generic What about laser? Photo inactivation laser and destructive laser Destructive laser reduced fungal elements by 75 85% but long term?? Photoinactivation mycologic cure at 9 months=38% (1 study) No randomized controlled studies at this point Pt notes changing mole also itchy. Worried she has melanoma Seborrheic keratosis reassure treatment not covered by county services You can apply cryotherapy 2 x 15 sec thaw cycles or Private derms in your county will do this for a fee 11

12 24 year old with new black bump No others noted 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 Pt notes these get caught on shirt sometimes get inflamed Skin tags benign Primary can snip them off services not covered by county 12

13 On pts back ( I can see it from homunculous) Sometimes wife squeezes out smelly cheese like material 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 out please send to surgery for excision Inflamed Epidermoid Cysts Primary Care Provider: pt came in with 2 day history of enlarging lesion and increasing pain. Started doxycyline Antibiotics USELESS this is abscessed 6 papers and metanalysis shows that antibiotics will not help where an I and D should be 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 13

14 Caution We may not see this for a couple of days (store and forward) so please don t send anything acute or if you must call or write an to personal account and we will pay special attention 30 yr old HIV infected pt started septra 36 hrs ago looks like drug reaction. I have stopped the septra. Should I give him prednisone? Drug Reactions This is toxic epidermal necrolysis. Get him into the ICU with supportive nursing care re: burn victim I will be by later today to do the biopsy/frozen section No evidence to support that prednisone is helpful Start IVIg NOW at high dose 2 mg/kg over 3 days qd infusion not a lot of evidence to support that this works Thiazides known to give photodrug reaction Calcium Channel blockers associated with nonspecific eczematous reactions/itch in the elderlystarts on arms and legs if you can switch pt s to other drugs Summers et al JAMA Dermatol May 2013 Allopurinol rare drug reactions but 25% mortality rate don t use for hyperuricemia risk is too high Kim et al Arthritis Care Res April

15 Total Body Redness: Drug Drug Hypersensitivity Syndrome Allopurinol Dapsone Antiseizure medications Septra Nevirapine/Sustiva/Abacavir (+) fever (+) lymphadenopathy Check kidneys, check liver +/ Prednisone 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 Agree and will book within 1 2 months THE PROCEDURES!!! 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 15

16 Reply from practitioner I like to inject keloids review with me 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? Alopecia Areata Alopecia Areata Autoimmune Occas assoc with atopic dermatitis Stress? Acute onset of well circumscribed, oval patches of non scarring alopecia No cure Prognosis Good: Short duration, limited affected area Bad: long duration, extensive involvement & concomitant AD Treatment No Rx alters prognosis Local areas can be injected with triamcinolone 10mg/ml (Kenalog ) 16

17 Pt has actinic keratosis Can I freeze it with liquid nitrogen? 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 Please explain side effects 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 Likely squamous cell cancer please book with derm within next month for shave biopsy Next steps: I will biopsy send pathology to dermatopath at UCSF If positive will send to plastics or dermsurgery for excision 17

18 Pt notes hair loss and this bald spot x 3 months. No other health problems. Not on any meds Hair loss will need live derm clinic evaluation and possible biopsy for scarring alopecia. I suspect discoid lupus Please order CBC and iron, Vit D, TSH, VDRL, ANA Book within 1 month Discoid Lupus Erythematosis Patchy Scarring Alopecia Biopsy helpful ANA ve Annual ANA if pt has DLE under age 20 5% chance of SLE Check ears, face & trunk Rx: intralesional triamcinolone & antimalarials Pt with new lesions around nose thinks it started when bacon fat hit face No pain or itching 18

19 Cutanous Sarcoidosis This is sarcoid I want to make sure that she does not have systemic involvement Please order Cxray and PFT s Order a G6PD in case I need to start sytemic plaquenil Start clobetasol oint qd to lesions Would like to see within 2 3 weeks Plum colored lesions around orifices Has multiple morphologies and reaction patterns less common Includes annular scaly patches on legs and erythema nodosum Can be only cutaneous but obligated to look for systemic disease Apply potent topical steroids, inject or use plaquinil, MTX, azathioprine, thalidomide, accutane plaquinil will not help with systemic disease Prednisone used for systemic disease As we manage patients in the upcoming years, triage teledermatology allows primary care providers and dermatologists to effectively work together Increased efficiency and access Total cost of specialty service is less Pt outcomes and satisfaction appear to be better Many Thanks! 19