Real World Dermatology: Clinical Pearls Galore – Part 2



Here are some more clinical pearls from the 2018 residents conference.  If you haven’t read part one, you can find it here.

From Dr. Dee Anna Glaser’s “What You Really Need to Know about Treating the Aging Face: Fillers and Toxins”:

  • Evaluation during consultation is key. Ask the patient what they would like done, and what their budget is.  While choosing treatments, educate the patient about what you are trying to achieve, and what you can’t achieve with fillers and toxins.
  • Have filler patients come back in 2-4 weeks as a standard rather than just telling them to come back if they feel something is wrong. The patient may have suboptimal results that they won’t notice, and it may be something that you can fix.
  • Always be prepared for an adverse event and have hyaluronidase on hand in case of emergencies. Glaser keeps an emergency box in her clinic with everything she needs in the event of a complication.

From Dr. Mark Lebwohl’s “Topical Therapy Pearls”:

  • Co-administration of salicylic acid with and other keratolytics has been shown to augment the efficacy of topical steroids.  This can be achieved through separate topicals or through compounding.
  • When compounding with salicylic acid, make sure that the pharmacy is not using aspirin (acetyl salicylic acid).
  • Check for interactions between the drugs you are ordering when compounding – some medications inactivate each other when compounded together.
  • Your choice of vehicle matters, not just from a strength standpoint either. Vehicles that are easier to use will increase patient compliance.
  • Calcitriol is less irritating than calcipotriene.
  • Co-administration of tazarotene or ammonium lactate with topical steroids will help prevent atrophy.

From Dr. Amy McMichael’s “What You Need to Know about Skin of Color”:

  • When treating acne in patients of color, keep in mind that post-inflammatory hyperpigmentation will often be a greater concern to them than acne itself.  However, bleaching agents should be held until after acne has cleared.
  • McMichael recommends the term “acne cosmetica” over “pomade acne” as it applies to a greater variety of products. Remind your patients that even if they wear their hair off their face, hair products will be spread to the face while they sleep.
  • Be careful when treating your patients of color with chemical peels, laser and light therapies and microneedling – they will be more likely to develop PIH and keloidal scarring from these treatments.
  • Many other conditions like sarcoid, pseudofolliculitis barbae and discoid lupus may be mistaken for acne in patients of color – keep this in mind when making diagnoses.
  • For more expert tips on skin of color, attend the Skin of Color Update conference.

From Dr. Joslyn Kirby’s “Acne Update: Key Management Issues”

  • Dairy is not a cause of acne – research has shown that children with acne did eat more dairy, but the difference was equivalent to half a serving of milk. However, it was found that the rate of skim milk in the diet was higher in patients with acne, so patients can try cutting out skim milk. Full fat milk products are associated with lower BMI, lower risk of diabetes and no change in cardiovascular risk.
  • A low glycemic index diet produces an average decrease of only 6 pimples.
  • 3 studies show that lower doses of doxycycline such as 20 or 40 mg BID is comparable to 100 mg BID dosing with fewer side effects.
  • Give patients a finite time frame for doxycycline to work before starting, as “giving it one more month” is a common pitfall.
  • Lab changes seen in patients on isotretinoin are dose dependent, so they are likely to show up in the first few months while escalating the dose. Once the patient has reached their maintenance dose, lab changes are rare.  Checking a CBC for patients on the medication is unnecessary, and some lipid changes are to be expected.  Of pancreatitis occurring in patients on isotretinoin, hyperlipidemia is the cause in only about 25% — the rest may be directly related to the drug.
  • Research has shown that adapalene may be an effective treatment for acne scarring.

From Dr. Dawn Sammons’s “The Urban Legends of Dermatology”

  • In the internet age, patients will come to the clinic with strongly held beliefs about topics they have no background in.  The best way to deal with this is correctly educating them with real data.
  • Rifampin is the only antibiotic with a known impact on the efficacy of oral contraceptives.
  • Most retinoids are photostable in sunlight. Patients will be more sensitive to the sun regardless of whether they apply their topical retinoid in the morning or at night, and there is no significant difference in the degree of photosensitization between AM or PM application.  If it is easier for a patient to fit their topical retinoid into their morning routine, they should as this can have a big impact on compliance.