Derm Topics

Real World Dermatology: Clinical Pearls Galore – Part 1



This June, I had the pleasure of attending the Real World Dermatology for Residents conference in Las Vegas.  This conference brought together distinguished dermatologists from across the country to educate residents on practical topics that ranged from treatment guidelines, to clinical pears, to advice about achieving success on the boards.  Here are some of the pearls I took away from this informative conference (in my own words).

From Dr. Theodore Rosen’s talk “What You Really Need to Know about STDs”:

  • Syphilis, gonorrhea and chlamydia are on the rise across the world – this includes elderly patients (patients using medication for erectile dysfunction are three times more likely to contract STIs, including HIV).
  • Don’t forget about classic signs and symptoms such as “Bullhead clap” in gonorrhea.
  • 3-7% of secondary syphilis presents with hair loss.
  • Most genital herpes is spread while the patient is asymptomatic – suppressive antivirals will decrease this shedding. Furthermore, stress will produce longer and more frequent outbreaks.

From Dr. Boni Elewski’s “Treating the Challenging Onychomycosis Patient”:

  • Keep in mind that only half of abnormal nails have fungus – the other half don’t.
  • If a PAS or KOH show septate hyphae, there is 90% certainty that the fungus in question is a dermatophyte.
  • There are several treatment options for onychomycosis in addition to oral terbinafine – these include weekly fluconazole (fungal Fridays!), pulse dose itraconazole (covers non-dermatophytes and terbinafine-resistant strains) and topicals such as tavaborole and efinaconazole.
  • Topical efinaconazole is particularly effective in treating white superficial onychomycosis.

From Dr. James Sligh’s talk “What You Really Need to Know about AK Therapy”:

  • Patients may claim that they are “allergic” to 5-fluoruracil or imiquimod after previous courses. It is important to counsel these patients extensively on what to expect when using these medications and coach them through the process.  Sligh recommends having a staff member call the patient during the middle of their course to check in and reassure them about the course of treatment.
  • In patients with severe reactions to 5-fluorouracil, suspect dihydropyrimidine dehydrogenase deficiency.
  • Lower concentration imiquimod preparations are on the market and may help mitigate side effects.
  • Nicotinamide supplementation has been shown effective in reducing actinic keratoses and nonmelanoma skin cancers over placebo. This intervention is very easy to implement with minimal cost in at-risk patients.

From Dr. Darell Rigel’s “Critical Issues in Skin Cancer Prevention, Diagnosis and Management That You Need to Know”:

  • American’s have a 1/24 chance of getting melanoma of any kind.
  • A useful soundbite for patients is that “1 American dies every hour from melanoma.”
  • However, melanoma deaths have been decreasing over the last two years.
  • Novel approaches to melanoma diagnosis such as tape stripping assays may be helpful when deciding whether or not to biopsy a lesion.

From Dr. April Armstrong’s “Clinical Research Concepts for the Boards and Tools for the Road”:

  • Have a good understanding of clinical research concepts for the boards. These include definitions of p-value, confidence interval, sensitivity, specificity, positive and negative predictive value and type I and II error.
  • You also will be asked to interpret the meaning of values such as the confidence interval and calculate other values such as sensitivity and specificity.

Stay tuned for part 2, with more clinical pearls from Drs. Dee Anna Glaser, Mark Lebwohl, Amy McMichael, Joslyn Kirby, and Dawn Sammons.