ALL THINGS DERMATOLOGY - Dr Aravind Chandran Dermatologist

ALL THINGS
DERMATOLOGY
    Dr Aravind Chandran
                 Dermatologist
 Auckland District Health Board and Skin Specialist Centre
              Honorary Lecturer
                  University of Auckland

∧
ALL THINGS
DERMATOLOGY
    PITFALLS & PRACTICAL TIPS
   Dr Aravind Chandran
                Dermatologist
Auckland District Health Board and Skin Specialist Centre
             Honorary Lecturer
                 University of Auckland

Outline
■ Pitfalls and practical tips in managing skin
  conditions
   Use of Steroids
   Liquid Nitrogen/Cryotherapy
   Diagnosing Pigmented lesions
   Clinical Photography

Steroids in dermatology

Steroids in dermatology
– Topical
   ■ Formulations – ointment , cream, lotions, gel, foam
   ■ Combinations : antifungals, antimicrobial, antibacterial
   ■ Compounded

– Oral
  ■ “Standard” course
  ■ Slow taper
  ■ Mini-pulse

– Intra-lesional
– Intramuscular
– Intravenous

Topical Steroids in Dermatology
■ “Pillar” of skin therapeutics
   – Ease of use
   – Less systemic effects
   – Safe in pregnancy ( class I –III)

■ Potency and steroid step ladder

Topical Steroids - Pitfalls

■ Suboptimal medication use
   – Wrong potency –
        ■   scalp vs vs hands and feet vs face vs body vs flexures
    –   Improper formulation
■ Insufficient dosage
    – Steroid phobia – patient and practitioner
    – Under use more common than overuse

■ Lack of patient adherence as a result of inadequate patient education or adverse drug
  events

■ The use of combination steroid/antifungal formulations

Topical Steroids
■ Practical Tips:
   – Familiarize topical steroids potencies
   – Finger tip units FTU
   – Consider formulation
        ■   Location
        ■   weeping?
        ■   Contact sensitivity
    –   Occlusion
    –   Wet wraps
    –   Tachyphylaxis
    –   “Weekend” therapy - for prevention frequent flares
    –   Patient education, written plans, information leaflets

ORAL Steroids
■ Used for inflammatory skin disease
   – Often over prescribed
■ Long-term use associated with significant side effects
■ PITFALLS
   – No formal diagnosis
   – Repeated course – short and sharp
   – Lack of bone protection and immunization in longer term use

■ TIPS:
   -   Establish a diagnosis before committing to treatment course
   - Slower taper and supplementing with potent topical to prevent rebound
   - Plan for early switch to steroid sparing agents
   - AVOID in psoriasis – may de-stabilise and result in erythroderma or pustular
      psoriasis
   - Medical alert bracelets
   - Bone protection

Intramuscular steroids
■ Under utilised
■ IM vs PO steroids
   – Equally effective
   – Better compliance especially with need for long tapering doses
        ■   Greater efficacy and safety

    –   Lower total dose when used long-term – fewer side effects

    –   Adverse effects (as per oral ) PLUS
        ■   IM can result in lipoatrophy at injection site
        ■   Dysmenorrhea in females

LIQUID NTROGEN
 CRYOTHERAPY

LN - Cryotherapy
■ Effective, simple and inexpensive treatment
■ Suitable for outpatient setting and poor surgical candidates
■ most commonly used
   – actinic keratoses
   – warts, molluscum
   – benign, premalignant lesions
   – malignant (superficial) lesions
■ Destruction of benign lesions requires temperatures of −20°C to −30°C
■ Effective removal of malignant tissue often requires temperatures of
  −40°C to −50°C.

Mechanism of action

Cryotherapy - PITFALLS
■ Treating undiagnosed lesions
   – Avoid in pigmented lesions
   – If unsure biopsy first
■ Do not treat thickened or raised lesion
■ Under treating malignant lesions
■ Poor cosmetic results in exposed sites
■ Single/long cycles
   – Swelling, blistering, ulceration
■ Caution on special sites:
   – Pretibial lesions – prone to ulceration
   – Eyelids- swelling, haemorrhage
   – Hair-bearing skin – may result in scarring and alopecia

CRYOTHERAPY- TIPS
                                          Medscape image
– Cone tip
   ■ Reduces contamination and
     focuses treatment
– Feathering at edged to avoid abrupt
  cut off
– Overlapping treatment areas for large
  areas
– De-bulking hyperkeratotic areas
– Use nozzles and attachments
– In malignant lesion
   ■ Draw a margin
   ■ Repeated ‘freeze – thaw’ cycles

PIGMENTED LESIONS -
    DIAGNOSIS

Biopsy of pigmented skin lesions
■ 2010 NZMA Audit by Rademaker et al
■ 37% of cases referred had no useful clinical information
     ■   OUTPUT results = INPUT of information provided
     ■   40% of lesions where a melanoma was considered, and 32.5% of lesions identified as pigmented
         lesions, were punch biopsied

■ 2470 patients with melanoma, punch and shave biopsy significantly increased the odds of
  misdiagnosis by 16.6- and 2.6-fold respectively, compared to excisional biopsy. Punch biopsy
  increased the risk of a misdiagnosis with adverse outcome by 20-fold (p < 0.001).
■ Smaller the percentage of lesion removed by biopsy, the greater the degree of inaccuracy was
  likely to occur

■    Whole lesion if possible

■ Serial punch or representative incisional bx – not single punch biopsy

CLINICAL PHOTOGRAPHY

Clinical Photography
■ Documentation – rash, lesions, cosmetic procedures
■ Treatment progress
■ Monitoring/Self observation with “selfies”
■ Professional development/learning
■ Medico-legal
■ Referrals
■ Tele-dermatology opinions

Pitfalls and TIPS
■ Consents – informed consent - verbal or written
■ Patient identification or de-identification in with facial photos
■ Lesion observation Macro +/- Dermoscopy (not ONLY dermoscopic images)
   – Location/distribution shot – waist up/down/front back/arms and legs
   – Close-up macro
   – Dermoscopy if available

■ Taking the photograph
   – Get to know your equipment
   – Composition

■ Storage and handling of images – patient privacy

Lighting

           ©AppwoRx

POSITIONING

              ©AppwoRx

BACKGROUND

             ©AppwoRx

Clinical Photography apps
■ Picsafe
■ Epitomyze capture
■ Rx Photo

END
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