The Telederm Experiment California Health Care Foundation-can we - - PowerPoint PPT Presentation

8/5/2013 1

Teledermatolgy and Primary Care

Integrating common dermatology diseases into a system where teledermatology triaging is used

Toby Maurer, MD University of California, San Francisco

The Telederm Experiment

• 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
• r wants to refer to derm
• ALL referrals go through telederm-even if it is

a pt followed by derm in past

8/5/2013 2

• 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

• r 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

8/5/2013 3

• Dermatologists from UCSF read the triage

consults and they also staff the live clinics at the primary care providers site

Results to date

• 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

• Primary providers have learned from one on
• ne consults
• Primary providers have had to DO some

dermatology

• Live dermatology clinic –difficult cases but

time has been properly apportioned to see them

8/5/2013 4

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.

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?

8/5/2013 5

• 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

8/5/2013 6

• Pt told he has psoriasis-used some crème in

Mexico-can’t remember name. Worried that his grandchildren could catch this.

• 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?

8/5/2013 7

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

8/5/2013 8

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

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!

Topicals NOT ENOUGH Here!

8/5/2013 9

Topicals vs orals

Orals NEEDED Topicals sufficient

Tinea Pedis

Topicals or orals? Topicals or orals?

• 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?

8/5/2013 10

• 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

• 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

8/5/2013 11

• 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

8/5/2013 12

• Pt notes these get caught on shirt-sometimes

get inflamed

• Skin tags-benign
• Primary can snip them off-services not

covered by county

• On pts back-( I can see it from

homunculous)

• Sometimes wife squeezes out smelly

cheese –like material

8/5/2013 13

• 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

• 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

8/5/2013 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 email 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?

• 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

8/5/2013 15

• 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

8/5/2013 16

• 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

Reply from practitioner

• I like to inject keloids-review with me

8/5/2013 17

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 notes hair loss and this bald spot x 3
• months. No other health problems. Not on

any meds

8/5/2013 18

• 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
• 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

8/5/2013 19

• 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

8/5/2013 20

• Pt with new lesions around nose-thinks it

started when bacon fat hit face

• No pain or itching
• 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

22 yr old Brazilian 2 wk h/o blisters

8/5/2013 21

• Send to derm live clinic next week
• We do workup for pempigus with biopsy and

direct immunofleurescence

• Started prednisone
• Came back to derm for f/u -staph impetigo-

stopped prednisone and started antibiotics

• 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!