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50 Pearls in 50 Minutes: Take Home Points For Dermatologists

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I always enjoy practical conferences that have tips to help my clinical practice. Obviously, this session, “50 Pearls in 50 Minutes,” was a perfect fit for what I look for. 

Great take home points for a medical dermatologist:

1. Nails: If only one nail is abnormal, think tumor first. Work up with a careful look by dermoscopy and get an X-ray. Remember two foot/one hand syndrome — if fingernails on both hands are involved and the patient is immune competent, abnormal nails are likely to be psoriasis rather than fungus. And don’t forget pulse itraconazole 400 mg daily for seven days once a month to treat onychomycosis. This can be helpful when daily terbinafine or weekly fluconazole fail. Apremilast has good data to treat both psoriatic arthritis and psoriatic nails.

2. Surgery: For bleeding — two OTC products help: WoundSeal Powder and Quick clot gauze. To remember: Pre-surgical curette even for non-Mohs cases will help delineate margins; KNOW YOUR ANATOMY before cutting/filling/injecting. Always great advice!; Fill a balloon with cold water as an ice pack; Pulley sutures are very helpful for tight areas.

3. Hair loss: For women, oral Minoxidil 0.25 mg with Spironolactone 25 mg (needs to be compounded) is helpful. It’s also helpful for lichen planopilaris, telogen effluvium, areata, and chemotherapy induced hair loss. Intralesional triamcinolone ~ 5 mg/cc is also helpful — there is often inflammation present along with the hormonal changes. Topical clobetasol may be helpful, as are low level light sources. Also consider fiber sprays to disguise loss. For men, finasteride 1 mg every other day is effective for nervous patients.

4. Low dose Naltrexone recipe: Crush 10 pills of naltrexone 50 mg tablets = 500 mg. Dissolve in orange juice to give desired concentration 100ml, which makes a 1 mg/ml stock solution. Mixture is stable if refrigerated. Cost ~ $15.00 for 3 month supply.

5. Crisaborole may work for seborrhoeic dermatitis that has failed topical steroids and antifungals.

6. Billing in 2021: procedure coding with complex closure will require documentation of how far you undermined; use a sterile ruler under the skin edge and photograph for documentation.

7. Oral acitretin for lichen planus — a forgotten but effective therapy! 30 mg a day. 

8. Hidradenitis: Oral hydroxyzine 50 mg is a good anxiolytic pre- procedure. Topical Resorcinol 15% cream to areas BID is helpful for both acute and chronic lesions. It must be compounded and it is in short supply right now. 

9. Recommend probiotics for patients with acne on oral meds for GI health. Generic doxycycline extended release is now available.

10. PDT is uncomfortable. Things that may help: Pulse the light exposure. Topical steroids before and after treatment help reduce post-procedure pain and inflammation but do not inhibit efficacy. Aggressive photoprotection on the way home. Remember daylight PDT — very non-painful.

11. If you want 30 – 40 mmHg strength compression socks, these are very difficult to get on even with sock aids. You get close to the same effect with two layers of lighter compression – i.e. two socks at 15 mm Hg layered is ~ 30 mm Hg total. Also the sock or stocking underneath helps with donning of the second layer. 

12. For medical mission trips, there is a company called Blessings International that can help with medications at a much lower price than regular pharmacies. 

13. For patient interaction, remember that how you say things matters — for example, a medication with a 1% chance of affecting the liver has a 99% chance that it will not. Remember to also be consistent with how you brand yourself — everyone knows “Dr. Pimple Popper”!

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