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LIVE BLOG: The SKIN-ny on Dermatologic Procedures

In this live blog, Dr. Michael Lewitt covers dermatologic procedures generally and offers a variety of “pearls of wisdom” on those procedures.
Skin complaints
+ Approximately 7 percent of all adult outpatients have a primary skin complaint1 
+ 60 percent of outpatient visits for skin disease are made to non-dermatologists1 
+ Patients with common, chronic medical conditions, such as obesity and diabetes, have increased numbers of skin conditions 
In the Office: A Good Review
Some Principals of Diagnosis
• History of eruption/lesion
– Duration, location, associated symptoms, aggravating/alleviating factors, prior treatment
• “When did it start?”
• “Has it gotten better or worse?”
• “Does it bother you?” “
• “Does it itch?”
• “How do you feel otherwise?” (can give you a clue about associated systemic symptoms)
• “How have you treated it?” (remember to ask about over the counter preparations)
• Medical history (Many dermatologic conditions are associated with systemic diseases)
• Family medical history
• Medications/allergies (Drugs can cause all types of skin rashes)
• Social History (Job/hobbies may cause different exposures that can cause various rashes – allergic contact dermatitis)
• Review of systems
 Physical exam
– Essential requirements
• Completely undressed patient
– Have a chaperone if opposite sex patient • Adequate illumination
– Don’t overlook the scalp, mouth and nails
– Palpation may help
• Texture and consistency • Evaluate for tenderness
– Terminology of skin lesions
Best Tools:
1. Morphology
2. Dermoscopy – Hand-held magnifying tool
3. Microscope 
+ in office tests include:
KOH, Scabies prep, Trichogram, Tzanck
Tips for Dermatology Diagnoses
+ If you have a pigmented lesion, never do a punch biopsy–pathologists don’t like it–a scoop is better.
+ When to do a punch biopsy?
Eruptions, Inflammatory Conditions
+ When to do an incisional biopsy?
When there is concern for massive melanoma
Fear of messing up lymphatics
+ When to do excisional biopsy?
Atypical lesions, carcinoma, melanoma
Outpatient Evaluation for Diagnosis
• Serology studies:
– Lupus/photosensitivity: ANA and panel
– Dermatomyositis: Muscle enzymes, antibodies
– Pruritus: Liver, renal, thyroid, CA w/u, DH Abs
– Lichen planus: Hepatitis C
– Drug eruption: CBC with diff for eosinophils
– Immunobullous: indirect immunofluorescence
• Use patient’s serum on foreign tissue to highlight if circulating autoantibodies exist
Dermatology Diagnosis • Patch testing
– Tool for identifying allergens in patients with allergic contact dermatitis
– Test detects a delayed type IV hypersensitivity reaction
– Takes several days to develop (vs scratch test)
– Screening patch test series (T.R.U.E. test) – composed of medications, fragrances, preservatives metals, rubber compounds and miscellaneous chemicals
Pearls of Wisdom
1. Within reason, try everything you perform on your patients –> Empathy goes much further than sympathy
2. Practice what you preach –> Don’t come in super-tan and then tell your patients to wear sunscreen daily.
3. Dermatology is a team; no player is more
important than another
4. Give back to your community
[image by Tom Hart]

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