The Dirty Dozen: 12 Game-Changing Derm Tips for Non-Derm Clinicians

Outline: 

1. Size matters! 

a. especially when it comes to tubes of topical medication! 

b. it may seem obvious, but inadequate responses are OFTEN due to insufficient quantities 

c. e.g., 15 gm tube of triamcinolone for a rash on BOTH legs or MOST of the trunk (or more) 

d. Goldilocks principle: prescribe the just-right amount! i. not too little 

   ii. but not too much either as patients may use inappropriately (wrong duration/location/diagnosis/patient) 

   iii. be strategic with refills too 

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2. Avoid arbitrary corticosteroid limits or schedules! 

a. many providers (and pharmacists) tell patients to stop after 2 weeks 

b. but this may be too much for an eyelid rash or too little for a stubborn psoriasis plaque 

c. educate patients (treat if itchy, bumpy or scaly; do not treat discoloration/left over "stains") 

d. empower them to determine the appropriate duration & frequency

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3. Stop prescribing corticosteroid/anti-fungal combinations!

a. especially the PCP favorite: Clotrimazole/Betamethasone (aka Lotrisone)

b. but also Nystatin/Triamcinolone (aka Mycolog II) 

c. fungal infections 

  i. Tinea Incognito - results in an atypical appearance, confounding diagnosis 

  ii. Majocchi's granuloma - allows fungus to track down follicle resulting in deep infection requiring up to 3 months of oral anti-fungal therapy 

  iii. increased risk of adverse effects from potent topical steroids (including atrophy to HPA axis suppression) 

d. inflammatory conditions (e.g., contact dermatitis, eczema, etc) 

  i. may exacerbate due to potential irritants & allergens (formulations typically include penetrants such as propylene glycol, emulsifiers, etc.) 

  ii. increased risk of anti-fungal resistance (responsible antimicrobial stewardship improves quality of life for     patients AND providers) 

  iii. increased cost 

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4. Don't be afraid to admit it when you don't know the diagnosis!

a. you know A LOT but you don't have to know EVERYTHING

b. empiric therapeutic trials are valid but first do no harm!

c. e.g., prescribing antibiotics for skin cancers 

d. use common sense, be selective, limit trial period, follow up in timely manner, refer as needed 

e. make friends with your nearest derm colleague to fast track concerning referrals or even text-a-consult privileges 

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5. Learn the difference between cellulitis vs stasis dermatitis! 

a. another non-infectious condition often treated with antibiotics and even hospitalization! 

b. cellulitis is acute, more swollen/painful & almost never bilateral 

c. stasis dermatitis is intermittent to chronic, more scaly & itchy, often bilateral & accompanied by lower extremity edema and/or varicosities 

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6. Back off the Bactrim! 

a. increased resistance 

b. potential serious adverse effects (SJS & TENS)

c. UTIs 

  i. nitrofurantoin effective against most uropathogens even those resistant to TMP-SMX 

  ii. beta-lactams (e.g., amox/clav or cefdinir) 

d. skin infections 

  i. doxycycline covers MRSA & has potent anti-inflammatory effects in the skin

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7. Hold the hydrochlorothiazide! 

a. HCTZ is an effective, inexpensive multi-purpose medication but...

b. it's photosensitizing & increases skin cancer risk! 

c. avoid/discontinue it if the patient has 

  i. history of skin cancers (especially SCC) or many precancers (actinic keratoses). 3-4x higher SCC risk after 5 1/2 years on 25 mg daily 

  ii. lupus erythematosus 

  iii. eruptions on sun-exposed areas after being outside 

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8. Prescribe our secret wart sauce! 

a. WartPeel by Nucara pharmacy in Coralville, IA 

b. $98 (including shipping) but gentler, faster and cost-effective 

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9. Double (or quadruple) down on hives! 

a. if classic edematous appearance and/or individually coming & going within 24 hours 

b. go straight to 4x normal dose of non-sedating H1 antihistamine (e.g., fexofenadine 2 BID) 

c. hold the allergy testing but if lasts > 6 weeks, refer to derm or allergy (we've got the big guns) 

d. Do NOT prescribe: 

  i. topical steroids for urticaria 

  ii. antihistamines for other itchy conditions (most pruritus is NOT mediated by histamine) 

  iii. H2 antihistamines like famotidine (minimally if at all effective) .

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10. Up your acne ante! 

a. so many options, how do you choose? 

b. tretinoin is a good for ALL types of acne 

  i. start low & slow (0.025% HS MWF x 2 weeks with moisturizer BID)

c. if patient has pustules, add an antimicrobial 

  i. OTC BPO wash is easy and cheap  / educate re: bleaching 

  ii. topical clindamycin adds an anti-inflammatory component / never prescribe it without a partner (BPO combo/wash or sulfacetamide wash) d/t potential resistance 

d. isotretinoin is safe, tolerable (in the right hands), and NOT just for your worst cases .

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11. Start recognizing hidradenitis suppurativa (aka HS)! 

a. begins as recurrent acneiform eruptions in skin folds 

b. can progress to become debilitating 

c. maintain low threshold for referral (2 boils in 6 months or 1 lasting 3 months)

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12. Know when to refer! 

a. major advancements in derm therapies over last several years (such as biologics and novel oral medications) can be life changing! 

  i. especially for autoinflammatory conditions such as atopic dermatitis & psoriasis 

  ii. even more so for pediatric patients whose growth, mental health, learning ability, etc can be restored 

b. we also treat hair loss, nail disease, and mucous membrane conditions

  i. yes, we'll happily take your patients with mouth and genital sores

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13. Bonus Baker's Dozen Tip! 

a. Herpes Zoster (aka shingles) does not continue to recur

b. consider Herpes Simplex Virus instead 

c. why it matters: HSV is much more contagious requiring patient education/precautions & proactive treatment plans