Dear Derm Authority with Dr. Dendy Engelman

Derm Authority

What was the most important lessons I learned my first years out in practice?

Keep your eyes open, figuratively of course. In the field of medicine, things are changing so fast (yet so slow) so keep your eyes open and absorb every bit of information. Just because residency is over, it doesn’t mean you’re done with learning. Every 8 years, the amount of medical information doubles, so you have to keep current. I’m always learning and teaching.

When is the right time to add a partner/additional provider?

I always think the more the merrier; there is nothing better than being able to inspire each other. Just make sure personalities mesh.

For Mohs surgery of 2 different sites, does a 59 modifier apply?

On initial visits when patients state coming in for only “skin cancer screening”, and not aware of any issues, or requests “full skin exam” and no significant personal or family history, how do you handle these?  My office staff is great at briefing patients – We tell them to make sure to note any new or changing growths on the skin. Know your family history of melanoma and non-melanoma skin cancers – as they are different and convey different genetic risks. Often patients bucket all skin cancers as “melanoma” and this is not the case.

But there is always a chance that will happen so I will still perform a mole check – evaluating the entire integumentary system (skin, hair, nails) for abnormal growths. Moles are pigmented skin lesions that can have malignant potential, but other skin lesions can also be malignant and not derived from moles- ex: basal cell, squamous cell, Merkel cell carcinoma.

Afterwards, we will probably do a follow up call to the patient to get their history. The standard of care is an annual exam. Some exceptions to this rule are if you have more than 100 pigmented lesions, a personal or family history of skin cancer, or have a history of blistering sunburns or extensive history of indoor tanning. If any of these apply, then your provider may encourage quarterly or biannual skin examinations.

When doing a biopsy (ie a patient wants a mole or something else gone that looks benign) when is it beneficial to code for shave excision/removal vs shave biopsy (we always are told to code shave biopsy for everything)

Biopsies are done when there is evidence clinically (and/or dermatoscopically) that a mole or other skin lesion doesn’t look completely healthy.

Usually shave removal of it’s a pigmented lesion and it has likely broken one or more of the ABCDE rules

Usually shave biopsies if it’s superficial (predominately epidermal) such as warts, and a non-pigmented lesson, then it may be a translucent papules concerning for basal cell carcinoma or a scaly red lesion that may be a squamous cell carcinoma.

Can D23.5 and L81.4 be used for skin exam and benign nevi in general?

For physical exam, is it true that you can get 12 total, separate bullet points from the skin exam alone (in addition to the 1-2 point from constitutional exam)?

If you see a new patient and they have a rash which you biopsy, can you bill for the e&m too or does the procedure (biopsy) negate it?

I have trouble eliciting review of systems that are pertinent to dermatology — sometimes i feel like i am asking unrelated ROS questions just to get points to hit a level of service the attending wants — any tips on appropriate review of systems for new patients

What treatment protocols do you recommend for teenagers with acne, and how do your recommendations differ from adult patients?

Adult acne, teen acne… they’re all acne and caused by a combination of things including hormonal imbalance, stress, dietary, etc. The only difference is where they appear. Teen acne usually appears on the T-zone area, if not all over, whereas adult acne presents on the chin and jawline.

No matter what age you have acne, it can be frustrating and it is understandable. The best thing you can do is to continue doing what you’ve always done; don’t aggravate it and let it go away.

The truth is when you are actually aware of the pimple; you are already towards the end of its life cycle. Pimples start 2-3 weeks before it ever reaches the skin’s surface.

  • Stage 1: Coast is clear – Research has shown that while you can’t see it, there is inflammation around the hair follicle predisposing to acne.
  • Stage 2: Flat Red Bump – First noticeable sign, which is a signal to start acting by removing any makeup or product that potentially irritate the area even more
  • Stage 3: The follicle fills with oil, dirt/debris – use a leave-on salicylic acid to help open the follicle and give the trapped oil a way to come to the skin’s surface.
  • Stage 4: Pop – Red bumps and pus pimples develop when breakouts become very inflamed.
  • Stage 5: The end – An oil gland balloon has formed under the skin and it’s fills with oil, plugged with dirt, and inflamed.

With regular care (gentle washing) a pimple can take 3-7 days to heal. If you decide to pick at your face the pimple can linger on for weeks and potentially lead to scarring.

Larger cystic pimples can last up to a month, or longer with additional irritation due to messing with face.

Overall tips –

  • Invest in a multivitamin – zinc in the vitamin reduces skin inflammation while vitamin E can help heal your skin.
  • Warm compress – help bring the pimple to a head by applying a warm compress for five minutes three times a day.
  • Cold Compress – if pain is really bad, a cold compress can provide temporary relief as it numbs the area and reduces fluid accumulation and edema.
  • Put a Mask on it – When you have one area of your face red and angry, it is hard not to focus all your attention on it. However, it is important to not disrupt the surrounding areas less the stress induces additional breakouts. Toss on a calming/hydrating mask like Derm-Institute’s new super-hydrating mask that you wear overnight on top of serum to lock in hydration.

Specific to the acne —

  • Whiteheads & Blackheads- Since this type of acne is considered mild, OTC products that contain ingredients such as salicylic acid, benzoyl peroxide, and retinol should do the trick. These products work by killing bacteria, drying excess oil, and forcing the skin to shed dead skin cells.
  • Cystic acne- Antibiotic tablets (oral antibiotics) are usually used in combination with a topical treatment (retinoids) to treat more severe acne.

Lay off the drying acne treatments – since this cystic acne happens underneath the skin’s surface, it is likely that you will be drying out the surrounding skin area before it gets to the cyst, thereby irritating the surrounding area and exacerbating the infection. Instead apply a serum that can be absorbed like iS Clinical Pro-heal serum Advance and layer a balm like Elizabeth Arden Eight Hour Cream over it to “force the product in” like a medical occlusion.

Cortisone Shot – inject the pimple with cortisone, a steroid that reduces inflammation under the skin and shrinks swelling around the infection. Within six hours the pimple should be gone.

  • T-zone acne-Whiteheads are typically what is found on the t-zone area so OTC products that contain salicylic acid, benzoyl peroxide, and retinol should clear this type of acne.
  • Hormonal acne-For women, oral contraception should balance your hormone levels and essentially clear your skin. If not, Co-cyprindiol is a hormonal treatment that can be used for more severe acne that doesn’t respond to antibiotics. It helps to reduce the production of sebum.

So at what point do you see a doctor?

  • A dermatologist can help diagnose and treat your condition, typically with an oral medication. Acne scars may need treatment as well, often with a procedure like microdermabrasion to remove the damaged layers of skin.
  • Unlike normal acne, cystic acne lives under the skin, so they don’t have openings making it difficult to “pop”. They also require special care because it is a deep inflammation, it is possible that they can leave scars if left untreated or if treated incorrectly, pitting can result.

Did you enjoy this article?  If so, read more Dear Derm Authority here.

Related posts: