I WON’T MISS THAT ONE NEXT TIME…..€¦ · Scabies DF DX 2 1. Tinea corporis 2. Granuloma...
Transcript of I WON’T MISS THAT ONE NEXT TIME…..€¦ · Scabies DF DX 2 1. Tinea corporis 2. Granuloma...
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 1
I WON’T MISS THAT ONE NEXT TIME…..
JANUARY 29, 2018
RICHARD E JOHNSON, DO, FAAD, FAOCD
OBJECTIVES
• A couple of days away from the office, cell phones off please
• A little time with friends, family, and colleagues
• Obtain required CME in a relaxed, no-stress venue
• Recognize some commonly seen dermatologic entities
• Getting through winter with minimal use of the snowblower
• Reinforcing your visual-diagnostic skills with the requisite
dermatology pics
• Win the powerball…..but only if it’s more than $800 million
RISK MANAGEMENT—PATIENT SAFETY
From POMA website….“12 CME credit hours in the areas of patient safety or risk management (either Category 1 or Category 2).”
For Florida licensees: “medical errors” requirement
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 2
Activities in patient safety and risk management may include the following topics:
Patient safety Risk management Improving medical records and record keeping Reducing medical errors Professional conduct and ethics Improving communications Preventative medicine Health-care quality improvements
DISCLOSURES………….1. I’m old
2. I can be opinionated at times
3. I still use paper charts
4. I don’t think “we” have a health care problem in the United States
……..”we” have a health INSURANCE COMPANY problem in the United States (see #2 above)
5. I attempt, as best as I can, to be a patient advocate: cost effective treatments, prior
authorizations fights on the patients’ behalf, follow-up care
(……hey, that’s an osteopathic approach.)
6. I attempt to provide useful, relevant, and fun lectures with information that can be used to fulfill
#5 above
7. Oh, and I have no drug company affiliations, but I do tend to slip in brand names occasionally
(see #1 above)
IF IN DOUBT
• Biopsy
• Refer
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 3
Patient-initiatedi.e. pt’s reason for
visit
Physician-initiatedi.e. incidental finding
I don’t like it
Changes noted…
Cosmetic•bx cost•tx cost•path fees•scar•results you want?
Refer Reassure
Pt returns
referbxor tx
Change•size•shape•color•symptoms
Obvious diagnosis
Not sure of
diagnosis, but…
bx-txright then referbx
tx refer
No this is not an insurance company lecture
A BASS-ACKWARDS LECTURE
• My first attempt
• May be my last attempt
• Get your clickers ready…..participant input from the get-go
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 4
• Get the brain cells started before going into the room
• Each case presented as if medical assistant gave you a brief raison d’etre for the next patient
• Pick from group of possible diagnoses
• Add more into
• What’s a derm lecture without pictures
• Whittle down the list of usual suspects and “possibles”
• Make the final, and of course, the correct diagnosis
• Maybe some treatment pearls
• Repeat with the next patient’s saga
7 YEAR OLD MALE WITH MOM AND DAD
??
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 5
7 YEAR OLD MALE
DF DX 11. Acne
2. Warts
3. Tinea corporis
4. Psoriasis
5. Granuloma annulare
6. Molluscum
7. Flea bites
8. Scabies
DF DX 21. Tinea corporis
2. Granuloma annulare
3. Seborrheic dermatitis
4. Psoriasis
5. Flea bites
6. Scabies
7. Impetigo
8. Bed bugs
DF DX 31. Molluscum
2. Tinea corporis
3. Impetigo
4. Granuloma annulare
5. Warts
6. Pyogenic granuloma
7. Bed bugs
8. Psoriasis
USE CLICKERS HERE
1. Acne2. Warts3. Tinea corporis4. Psoriasis5. Granuloma annulare6. Molluscum7. Flea bites8. Scabies
DF DX #1
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 6
1. Tinea corporis2. Granuloma annulare3. Seborrheic dermatitis4. Psoriasis5. Flea bites6. Scabies7. Impetigo8. Bed bugs
Df Dx #2
1. Molluscum2. Tinea corporis3. Impetigo4. Granuloma annulare5. Warts 6. Pyogenic granuloma7. Bed bugs8. Psoriasis
Df Dx #3
All three groups are correct at this point………
Let’s get some info from the patient…….
(I try to converse directly with the patients; if possible and when applicable)
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 7
HISTORY
• Present for 6 months
• No symptoms, just there
• Prior treatments = no help
• Topical antifungal
• Triple antibiotic
• OTC hydrocortisone
• No other family members with it
• No family history of same
7 YEAR OLD MALE
DF DX 1
1. Acne
2. Warts
3. Tinea corporis
4. Psoriasis
5. Granuloma annulare
6. Molluscum
7. Flea bites
8. Scabies
DF DX 2
1. Tinea corporis
2. Granuloma annulare
3. Seborrheic dermatitis
4. Psoriasis
5. Flea bites
6. Scabies
7. Impetigo
8. Bed bugs
DF DX 3
1. Molluscum
2. Tinea corporis
3. Impetigo
4. Granuloma annulare
5. Warts
6. Pyogenic granuloma
7. Bed bugs
8. Psoriasis
7 YEAR OLD MALE
DF DX 11. Tinea corporis
2. Psoriasis
3. Granuloma annulare
4. Molluscum
DF DX 21. Tinea corporis
2. Granuloma annulare
3. Seborrheic dermatitis
4. Psoriasis
5. Impetigo
DF DX 31. Molluscum
2. Tinea corporis
3. Impetigo
4. Granuloma annulare
5. Pyogenic granuloma
6. Psoriasis
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 8
USE CLICKERS HERE
PHYSICAL EXAM
• Several round/ovoid lesions
• Raised rubbery/firm rim with essentially clear center
• No scale
• Flesh colored
• No inflammation
7 YEAR OLD MALE
DF DX 11. Tinea corporis
2. Psoriasis
3. Granuloma annulare
4. Molluscum
DF DX 21. Tinea corporis
2. Granuloma annulare
3. Seborrheic dermatitis
4. Psoriasis
5. Impetigo
DF DX 31. Molluscum
2. Tinea corporis
3. Impetigo
4. Granuloma annulare
5. Pyogenic granuloma
6. Psoriasis
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 9
7 YEAR OLD MALE
DF DX 11. Granuloma annulare
2. Molluscum
DF DX 21. Granuloma annulare
DF DX 31. Molluscum
2. Granuloma annulare
3. Pyogenic granuloma
WHAT’S A DERM LECTURE WITHOUT PICTURES
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 10
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 11
GRANULOMA ANNULARE
• Generally children and young adults—but, diseases don’t read the textbooks
• Generally self-limiting—but, diseases don’t read the textbooks
• Etiology: trauma, insect bites, viral induced,
? medications (allopurinal), sun exposure…….
TYPES OF GRANULOMA ANNULARE
• Localized lesions
• Generalized
• Subcutaneous
• Perforating
• Patch
• Actinic
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 12
LOCALIZED
• Most commonly seen type
• Raised rubbery edge
• Centrally, surface normal color/texture, may be slightly depress/hyperpigmented
• More than half of the patients have single lesion
……but diseases don’t read the textbooks
GENERALIZED GRANULOMA ANNULARE
• About 10-15% of patients have more than 10 lesions
• More in <10yo and >50yo
• Generally truncal in distribution
• Generally rings are <5cm
• ???may be a marker for diabetes
SUBCUTANEOUS GRANULOMA ANNULARE
• BB sized to “large” painless papules/nodules
• Elbows, knees, and ankles most
common sites
• ??may be a marker for diabetes or abnormal glucose tolerance
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 13
PERFORATING GRANULOMA ANNULARE
• Superficial small papules
• Hands and fingers
• May develop umbilication (?? MC’s)
• Ulceration rarely occurs, but is possible
• 1/3 +/- patients have diabetes
PATCH GRANULOMA ANNULARE
• Subtle pink patches without induration or scale
• Women > men
• Proximal extremities most common sites
• Localized and generalized variants have been
described
ACTINIC GRANULOMA
• Large annular plaques develop on face or
other actinically damaged skin
• May be quite large and elevated
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 14
TREATMENT
• Rarely needs biopsy• Perhaps with less common variants, but with classic GA, no biopsy needed
• Benign neglect
• Topical steroids—with or without occlusion• Atrophy potential
• Intralesional steroids
• Cryotherapy
• Oral retinoids—isotretinoin with iPledge “hassles” vs acitretin• Seems to be effective, but relapses expected when d/c med
CAVEATS
• Not all round rashes are ringworm
• Firm-edged asymptomatic annulare lesion dorsum of foot/hand
think GA
• Biopsy rarely needed for classic GA, but if done for confirmation,
sometimes lesions resolves with biopsy—”therapeutic biopsy”
• Generalized, “sudden onset” GA, consider any new meds started
…..?allopurinol
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 15
75 YEAR OLD MALE
75 YEAR OLD MALE
DF DX 11. BCC/SCC
2. Seborrheic keratosis
3. Tinea
4. Psoriasis
5. Eczema
6. Stasis dermatitis
7. Bateman’s purpura
DF DX 21. Tinea
2. Seborrhea
3. Seborrheic dermatitis
4. Rosacea
5. Stasis dermatitis
6. Actinic keratosis
7. Eczema
DF DX 31. BCC/SCC
2. Tinea
3. Eczema
4. Onychomycosis
5. Psoriasis
6. Bateman’s purpura
7. Seborrheic keratosis
CLICKER RESPONSE PAGE
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 16
ONCE AGAIN, ALL CORRECT
HISTORY AND PHYSICAL WILL HELP
HISTORY
• Present for “awhile”• “Patient-speak”: anywhere from this morning to “I was born with it.
• After conversing with the patient: about 8 months
• Itchy at first, now, not at all
• Prior treatments
• OTC: Benadryl cream and hydrocortisone 1%
• Rx: betamethasone for 3 months and since then, about 4 months fluocinolone
• Was size of quarter, now whole back of hand
1. BCC/SCC
2. Seborrheic keratosis
3. Tinea
4. Psoriasis
5. Eczema
6. Stasis dermatitis
7. Bateman’s purpura
DF DX 1
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 17
1. SCC
2. Seborrheic keratosis
3. Tinea
4. Psoriasis
5. Eczema
6. Stasis dermatitis
7. Bateman’s purpura
DF DX 1
1. SCC
2. Tinea
3. Psoriasis
4. Eczema
DF DX 1
1. Tinea
2. Seborrhea
3. Seborrheic dermatitis
4. Rosacea
5. Stasis dermatitis
6. Actinic keratosis
7. Eczema
DF DX 2
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 18
1. Tinea
2. Eczema
DF DX 2
1. BCC/SCC
2. Tinea
3. Eczema
4. Onychomycosis
5. Psoriasis
6. Bateman’s purpura
7. Seborrheic keratosis
DF DX 3
1. SCC
2. Tinea
3. Eczema
4. Onychomycosis
5. Psoriasis
6. Bateman’s purpura
7. Seborrheic keratosis
DF DX 3
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 19
1. SCC
2. Tinea
3. Eczema
4. Psoriasis
DF DX 3
75 YEAR OLD MALE
DF DX 1
1. SCC
2. Tinea
3. Psoriasis
4. Eczema
DF DX 2
1. Tinea
2. Eczema
DF DX 3
1. SCC
2. Tinea
3. Eczema
4. Psoriasis
ALL THREE PRETTY MUCH THE SAME
LET’S SEE WHAT THE PATIENT HAS
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 20
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 21
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 22
75 YEAR OLD MALE
DF DX 1
1. SCC
2. Tinea
3. Psoriasis
4. Eczema
DF DX 2
1. Tinea
2. Eczema
DF DX 3
1. SCC
2. Tinea
3. Eczema
4. Psoriasis
TINEA INCOGNITO
• Remember, diseases don’t read the textbook…..
• Generally:
scaly edged, clear center…..tinea
scaly throughout…..eczema
• One hand only…..probably not eczema
• Any onychomycotic nails?
• Check the feet………….
two foot, one hand syndrome
• Biopsy, if in doubt.
TREATMENT
• Topical may do it, but not
wrong adding short-term oral
• Majocchi’s granuloma-type
needs oral and topical
• Wrestlers………shampoo?
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 23
PATIENT IN ROOM #3
• Was here an hour before his appointment time
…… “to beat the crowd”
• Has another appointment across town scheduled for 30
minutes after his scheduled appointment was to start here.
68 YEAR OLD MALE
?
68 YEAR OLD MALE
DF DX 11. BCC/SCC
2. Seborrheic keratosis
3. Tinea
4. Psoriasis
5. Warts
6. Lichen simplex
chronicus
7. Tags
DF DX 21. Changing mole
2. Seborrhea
3. Seborrheic dermatitis
4. Rosacea
5. Lichen simplex
chronicus
6. Scabies
7. Lyme disease
DF DX 31. BCC/SCC
2. Tinea
3. Scabies
4. Hair loss
5. Psoriasis
6. Lichen simplex
chronicus
7. Seborrheic keratosis
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 24
CLICKERS
No fooling you…… all acceptable.
Let’s get some history
68 YEAR OLD MALE
• Itchy rash in groin for last 6 months
• Scrubbing with antibacterial soap
• No Rx treatments
• OTC hydrocortisone 1% and clotrimazole creams,
…..on and off use
• “I think it started this summer with “crotch-rot”
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 25
68 YEAR OLD MALE
DF DX 11. BCC/SCC
2. Seborrheic keratosis
3. Tinea
4. Psoriasis
5. Warts
6. Lichen simplex
chronicus
7. Tags
DF DX 21. Changing mole
2. Seborrhea
3. Seborrheic dermatitis
4. Rosacea
5. Lichen simplex
chronicus
6. Scabies
7. Lyme disease
DF DX 31. BCC/SCC
2. Tinea
3. Scabies
4. Hair loss
5. Psoriasis
6. Lichen simplex
chronicus
7. Seborrheic keratosis
68 YEAR OLD MALE
DF DX 11. Tinea
2. Psoriasis
3. Lichen simplex
chronicus
DF DX 21. Changing mole
2. Seborrhea
3. Seborrheic dermatitis
4. Rosacea
5. Lichen simplex
chronicus
6. Scabies
7. Lyme disease
DF DX 31. BCC/SCC
2. Tinea
3. Scabies
4. Hair loss
5. Psoriasis
6. Lichen simplex
chronicus
7. Seborrheic keratosis
68 YEAR OLD MALE
DF DX 11. Tinea
2. Psoriasis
3. Lichen simplex
chronicus
DF DX 21. Seborrheic dermatitis
2. Lichen simplex
chronicus
3. Scabies
DF DX 31. BCC/SCC
2. Tinea
3. Scabies
4. Hair loss
5. Psoriasis
6. Lichen simplex
chronicus
7. Seborrheic keratosis
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 26
68 YEAR OLD MALE
DF DX 11. Tinea
2. Psoriasis
3. Lichen simplex
chronicus
DF DX 21. Seborrheic dermatitis
2. Lichen simplex
chronicus
3. Scabies
DF DX 31. Tinea
2. Scabies
3. Psoriasis
4. Lichen simplex
chronicus
EXAM TIME
• Red inflamed lichenified scrotum with minimal crease or
thigh involvement
• Some excoriations noted
• No nodules noted
• No other body areas
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 27
68 YEAR OLD MALE
DF DX 11. Tinea
2. Psoriasis
3. Lichen simplex
chronicus
DF DX 21. Seborrheic dermatitis
2. Lichen simplex
chronicus
3. Scabies
DF DX 31. Tinea
2. Scabies
3. Psoriasis
4. Lichen simplex
chronicus
CLICKERS
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 28
68 YEAR OLD MALE
DF DX 11. Tinea
2. Psoriasis
3. Lichen simplex
chronicus
DF DX 21. Seborrheic dermatitis
2. Lichen simplex
chronicus
3. Scabies
DF DX 31. Tinea
2. Scabies
3. Psoriasis
4. Lichen simplex
chronicus
68 YEAR OLD MALE
DF DX 11. Lichen simplex
chronicus
DF DX 21. Lichen simplex
chronicus
DF DX 31. Lichen simplex
chronicus
RASS
• Red Angry Scrotum Syndrome
• Much more common in males…………
females get it too, but LSC only name they get
• Lichen Simplex Chronicus
• Also seen ankles, elbows; anywhere chronic friction/scratching
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 29
TREATMENT
• Long term care
• Often recurrent
• Castle moat analogy—rebuilding barrier function
• Sprained thumb analogy—wash to wash, not wash to wash rash
• Patient education key to treatment success
• 2/2/2 dosing of topical steroids
32 YEAR OLD FEMALE
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 30
32 YEAR OLD FEMALE
DF DX 11. Acne
2. Annoying mole
3. Eczema
4. Psoriasis
5. Warts
6. Rosacea
7. Shingles
DF DX 21. Tags
2. Onychomycosis
3. Hair loss
4. Warts
5. BCC
6. Scabies
7. Tinea
DF DX 31. Rosacea
2. Tinea
3. Shingles
4. Hair loss
5. Annoying mole
6. Eczema
7. Tags
CLICKER PAGE
HISTORY
• Present for about 3 years
• Regularly/occasionally shaves to bleed
• No symptoms
• Was flatter, now more raised
• Other similar lesions on legs and arms, but not in the way
• Tried wart medicine for a couple of days, but “never
bothered me, so I stopped using it.”
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 31
32 YEAR OLD FEMALE
DF DX 11. Acne
2. Annoying mole
3. Eczema
4. Psoriasis
5. Warts
6. Rosacea
7. Shingles
DF DX 21. Tags
2. Onychomycosis
3. Hair loss
4. Warts
5. BCC
6. Scabies
7. Tinea
DF DX 31. Rosacea
2. Tinea
3. Shingles
4. Hair loss
5. Annoying mole
6. Eczema
7. Tags
32 YEAR OLD FEMALE
DF DX 11. Annoying mole
2. Warts
DF DX 21. Tags
2. Onychomycosis
3. Hair loss
4. Warts
5. BCC
6. Scabies
7. Tinea
DF DX 31. Rosacea
2. Tinea
3. Shingles
4. Hair loss
5. Annoying mole
6. Eczema
7. Tags
32 YEAR OLD FEMALE
DF DX 11. Annoying mole
2. Warts
DF DX 21. Warts
2. BCC
DF DX 31. Rosacea
2. Tinea
3. Shingles
4. Hair loss
5. Annoying mole
6. Eczema
7. Tags
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 32
32 YEAR OLD FEMALE
DF DX 11. Annoying mole
2. Warts
DF DX 21. Warts
2. BCC
DF DX 31. Annoying mole
PHYSICAL EXAM
• Firm pink/red nodule
• Small surface scab
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 33
32 YEAR OLD FEMALE
DF DX 11. Annoying mole
2. Warts
DF DX 21. Warts
2. BCC
DF DX 31. Annoying mole
32 YEAR OLD FEMALE
DF DX 11. Annoying mole
DF DX 21. BCC
DF DX 31. Annoying mole
If in doubt, biopsy
ANNOYING MOLE
• Dermatofibroma• Trauma induced ??
• Firm
• Flat or domed
• Dimples
• Not easily traumatized, as opposed to BCC
.…..remember, diseases don’t read the textbook.
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 34
TREATMENT
• Benign neglect
• Surgery
• Cryosurgery
• IL injections
Lightening Round
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 35
3 SECOND VISUAL
• Pick your diagnosis
• Review picture
• Discuss
PICK YOUR POISON
1. Vasculitis
2. Zoster
3. Contact dermatitis
4. Erythema ab igne
5. Urticaria
6. Leprosy
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 36
CLICKERS
Erythema ab igne
…..also known as hot water bottle rash, fire stains, laptop thigh, granny's tartan and toasted skin syndrome
…..caused by long-term exposure to heat (infrared radiation)
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 37
READY?
HERE’S THE PITCH…..STRIKE 2
HHHMMMMMMMMM?
1. Melanoma
2. Eclipse mole
3. Tinea capitis
4. Bug bite site
5. I don’t know, but I’m going to biopsy it
6. I don’t know, but I’m going to refer
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 38
CLICKERS
ECLIPSE MOLE
• Nevus en cocarde
• Benign
• biopsy/refer certainly an option
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 39
HERE’S THE WINDUP
…..STRIKE 3
AND………….
1. Onychomycosis
2. Psoriasis
3. Onychomadesis
4. Oops, be more careful with closing the car door
5. Paronychia
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 40
CLICKERS
ONYCHOMADESIS
• Proximal, complete separation of the nail plate from nail bed
• Results from full, but temporary, arrest of nail growth
• Stressful events, commonly seen after Hand-Foot-Mouth Disease
• Beau’s lines—transverse grooves cause be partial arrest of nail
growth
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 41
BOTTOM OF THE NINTH
TWO OUTS,3-2 COUNT
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 42
WELL……………..?
1. Melanoma
2. Halo nevus
3. Lyme disease
4. Bateman’s purpura
CLICKERS
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 43
HALO NEVUS
Central lesion characteristics and symmetry of halo may determine decision tree
1. If benign appearing and centrally placed nevus with symmetrical depigmentation is noted, need not be removed….patient’s age??
Periodic evaluation of lesion and patient recommended
2. Biopsy/refer:
Atypical appearing central nevus
asymmetrical halo
eccentric placement of nevus in halo
personal or family hx of atypical nevi and/or melanoma
OOPS, LOOKS LIKE EXTRA INNINGS
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 44
WHAT’S IT GONNA BE?
1. Psoriasis
2. Tinea versicolor
3. Pityriasis alba
4. Vitiligo
5. Tinea faciale and corporis
CLICKERS
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 45
PITYRIASIS ALBA
-- more common in children than adults
-- often seen in atopic patients
-- most common sites are face and upper lateral arms
-- usually begins with non-specific erythema and gradually
becomes scaly and hypopigmented
-- caused by transient and mild dermal inflammation
TREATMENT
emollient moisturizers
-- mild inflammation treated with anti-inflammatory
Protopic® and Elidil® probably work better than topical steroids
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 46
POST-LECTURE QUESTIONS
1. This “reverse” lecture format was a bust
2. This “reverse” lecture format was okay
3. Some of the lecturer’s objectives were met
(sorry, no powerball winning today)
4. Enough with winter already!
5. Yea!! The end.
CLICKERS
“I Won’t Miss That One Next Time…”Richard E. Johnson, DO
POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 47
DISCLOSURES………….1. I’m old
2. I can be opinionated at times
3. I still use paper charts
4. I don’t think “we” have a health care problem in the United States
……..”we” have a health INSURANCE COMPANY problem in the United States (see #2 above)
5. I attempt, as best as I can, to be a patient advocate: cost effective treatments, prior authorizations fights on the patients’ behalf, follow-up care
(……hey, that’s an osteopathic approach.)
6. I attempt to provide useful, relevant, and fun lectures with information that can
be used to fulfill #5 above5. Oh, and I have no drug company affiliations, but I do tend to slip in brand names occasionally
(see #1 above)
…….JUST SAYIN’
PAPER CHART
• Diagnosis made in about 5 seconds
• Chart note: same
• Patient education: 2 minutes
• Chit-chat time: 2 minutes
• Visit complete: 4+ minutes
EMR
• Meaningful use entries: 5 minutes
• Entry of history: 3 minutes
• Look at patient/diagnosis: 5 seconds
• Entry of PE: 3 minutes
• Patient education: 2 minutes
• Entry documenting same: 3 minutes
• Chit-chat time: not allowed, no time
• Visit complete: 16+++ minutes
How many visits per day/week/month/year are like this for EVERY specialty…….Where are our national organizations?
See # 2 under “DISCLAIMERS”