Teledermatology In the world of dermatology-teledermatology What - - PowerPoint PPT Presentation

8/8/2016 1

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

Toby Maurer, MD University of California, San Francisco

Teledermatology

• 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?

• What happens when the advice does not cut it
• r 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?

Acne

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.

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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?

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• 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 for another month and then stop the medication

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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.

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• 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 weeks-

please 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?

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NO PREDNISONE

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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

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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

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• 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

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• 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

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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

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Clinical Features of FAMMM

• Often numerous nevi (30-100+)
• 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

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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

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• 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

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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
• ther autoimmmune diseases
• Trial of clobetasol oint qd x 3 months; if not

working tacrolimus bid x 3 months then leave it alone

• Makeup, counselling

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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?

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• 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

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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!