Experienced dermatologists share favorite pearls

Everyone likes a good tip about how to be more efficient or make a task easier. Several experienced dermatologists offered a variety of tips July 27 during “Pearls From Members” (F005). Each speaker focused on an area of interest, from office procedures, to surgical tips, to sharing little-known treatments for dermatologic conditions.

Mark D. Kaufmann, MD

Office Pearls: Living With MACRA” by Mark D. Kaufmann, MD, associate professor at Icahn School of Medicine at Mount Sinai, explained a detail about avoiding a penalty related to MACRA — the Medicare Access and CHIP Reauthorization Act.

“No one should be subject to a 4 percent MIPS (Merit-Based Incentive Payment System) penalty in 2019 because 2017 has been designated a transition year,” Dr. Kaufmann said. “One only needs to submit ‘something’ to CMS to be exempt from the 4 percent penalty in 2019.”

Dr. Kaufmann explained how to submit required data to the Centers for Medicare and Medicaid Services using claims. Even if you do not use an electronic health record or participate in a registry, data can be submitted to be exempt from the 2019 penalty, he said. Learn more at the AAD MACRA tools and resources webpage.

Andrew F. Alexis, MD

Pearls of Color,” by Andrew F. Alexis, MD, associate professor of dermatology at the Icahn School of Medicine at Mount Sinai, focused on hyperpigmentation.

“When treating chronic disorders of hyperpigmentation, such as melasma, the question of how long treatment with hydroquinone can be safely used frequently arises,” Dr. Alexis said. “Based on published studies and clinical experience, six consecutive months of treatment followed by a six-month hiatus of using a non-hydroquinone agent is generally not associated with exogenous ochronosis. Non-hydroquinone agents that can be used after the six-month period include topical azelaic acid, topical retinoids, and a variety of hydroquinone-free cosmeceuticals.”

José Dario Martinez Villarreal, MD

“Pearls from Mexico” by José Dario Martinez Villarreal, MD, a dermatologist from Nuevo León, Mexico, examined the treatment of head lice caused by the ectoparasitic louse Pediculus humanus capitis.

“The actual therapies with topical pediculicide agents and physical removal are far from good. My Rx pearl includes two new agents, the phase 3 agent abametapir in a lotion, and the extract and oil from fruits of Melia azedarach L,” Dr. Martinez said. He added that both treatments are off-label and are not approved by the U.S. FDA.

Theodore Rosen, MD

“Radical Pearls,” by Theodore Rosen, MD, professor of dermatology at Baylor College of Medicine, explained the effect of applying heat to treat molluscum contagiosum in adults and children.

“Hyperthermia has a long history of medical use, notably as both primary and adjunct therapy for infectious diseases, likely due to upregulation of immune responses,” Dr. Rosen said. “A small Chinese prospective study demonstrated about a 50 percent response rate of molluscum after exposure to infrared-generated heat (44 degrees Celsius) for 30 minutes once weekly, for a maximum of 12 weeks. I use a flexible, inexpensive heating pad capable of generating heat in a similar range.”

Kelly M. Cordoro, MD

“Pediatric Pearls: A Potpourri,” by Kelly M. Cordoro, MD, an associate professor of dermatology at the University of California, San Francisco School of Medicine, warned of a danger for infants with eczema and petechiae, who should always undergo investigation.

“Petechiae may be the result of multiple causes, but in infants with eczema, the major concern is thrombocytopenia due to congenital platelet disorders such as Wiscott-Aldrich Syndrome (WAS), among others,” Dr. Cordoro said. “WAS is an immune deficiency syndrome due to mutations in the WASP gene. Typical presentation consists of a triad of immunodeficiency (recurrent infections), thrombocytopenia (petechiae; bloody stool), and eczema. Death usually occurs before age 10 in children who do not receive a bone marrow transplant. Early diagnosis before the onset of severe infections is critical and can be life-saving.”

Scott M. Dinehart, MD

“Surgical Pearls” by Scott M. Dinehart, MD, a dermatologist from Little Rock, Arkansas, addressed one of his pet peeves — the opening of a new package of sutures when only one or two sutures are left to place.

“I replace the needle driver with a pair of forceps without teeth,” he said. “The reason it works is because the diameter is smaller with the forceps and you don’t have to have a lot of suture to form a loop for the instrument tie. While others throw away the suture, you can still get one or two more stitches easily.”

Gary Goldenberg, MD

“DermPath Pearls” by Gary Goldenberg, MD, assistant clinical professor at Icahn School of Medicine at Mount Sinai Hospital, presented “Oy vey! I shaved a melanoma. Is that OK?” It was aimed at dermatologists who shave biopsies for pigmented lesions and sometimes shave a melanoma.

“Is the patient going to do worse because we may not be able to get the whole lesion with a partial biopsy of a shave? The answer is a definite ‘no.’ The patient does not do worse if you do a shave biopsy,” he said. “All of the evidence shows that shave biopsies are OK. We are not missing melanomas. But there is a caveat: You must get some dermis.”

The DermPath Pearls section reminded physicians that it was most important to fully excise the lesion with margins determined by all the prognostic factors available to you.

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