Case Studies From econsults Lessons Learned Karolyn (Kari) Wanat, MD Department of Dermatology and Pathology University of Iowa karolyn-wanat@uiowa.edu
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
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
Cryotherapy Liquid Nitrogen = coldest cryogenic agent (- 196 C) Mechanism of Action Fast freeze intracellular and extracellular ice crystal formation, cell membrane disruption, thermal shock
Cryotherapy Techniques
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
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
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 10-15 seconds
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
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
Nummular Dermatitis Coin-shaped Often secondary to xerosis Itchy to painful Treat underlying skin barrier and treat inflammation (topical corticosteroids and THICK emollients)
Hypersensitivity/Urticarial Dermatitis Dermatographism: wheal develops after stroking skin Pruritus etiologies: Medication Exposure Treatment With dermatographism, treat with antihistamines
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
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
Pyogenic Granuloma (Lobular capillary hemangioma) Trauma Pregnancy Medications BLEED!!!!!!!!!!!!!!!!!!!
Treatment Shave biopsy Cauterize the base If small can use silver nitrate sticks
Orogenital Ulcerations Think herpes virus 1 st, 2 nd, 3 rd Differential diagnosis: Aphthous stomatitis Lipschutz ulcers Behcets Crohns disease
Teledermatology Limitations Images and information is key Need to know patient s context and medications available Know limitations and way to refer
Teledermatology: Best Practices Relationship with providers Able to communicate freely and easily Understanding of therapeutic options available Ability to see patients if not improving
QUESTIONS? karolyn-wanat@uiowa.edu
Resources Bolognia, J., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology. Philadelphia: Elsevier Saunders. Chicago (Author-Date, 15th ed.) Curr Med Res Opin. 2010 Mar;26(3):633-40. doi: 10.1185/03007990903512156 Graber and Wilbur s Family Medicine Examination and Board Review, 4 th edition Cutis. 2016 Jun;97(6):408-12