1. PLEASE SIGN-IN ON YOUR OWN MOBILE PHONE:
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20 min, until 8:55p
5 min to introduce develop ppl them and gallup data.
10 minute small group break out sessions.
5 quick shareback summary, next steps communication

2. What the primary needs to know in the world of increased access
Toby Maurer, MD
University of California, San Francisco

3. Mechanics of Telederm Thank you for your patience!!!!!
Things are changing-but slowly
Will be easier to access
Will be easier to take pics, record history and question and send to us

4. But the basics Please send multiple photos
Ask the question-what do you want us to answer for you? Give us a little history PLEASE
Everything should go through telederm-this is your referral route, your guidance, the medical home for our patients

7. Concern for scleroderma-we will book in clinic in 1-2 wks for bx
please check BP’s-is pt on meds?
We will confirm with bx and order high resolution CT scan-pulmonary HTN

9. ACUTE Matters CALL our service for ACUTE concerns:
Pager: the resident
Toby’s Office:
Jung-hee-derm nurse:

10. Acne
Primary care provider: Pt has recent onset of bumps on face. What is this and how do I treat. Has used “proactive “with minimal change.

12. Topicals BP 5% gel (10% - more drying)
Retin A 0.025% - 0.1% ( vehicle determines strength - start with crème)
Cleocin T or erythromycin topically
Use 1 qam and 1qhs
If NO success after 8 weeks, go to p.o.’s

13. Primary Care Provider: Pt with acne –used Retin -A but very irritating
Primary Care Provider: Pt with acne –used Retin -A but very irritating. What is the next step?

15. Pt has cystic/scarring acne-topicals won’t work and in Asians-Retin A is very irritating.
Start p.o. antibiotics

16. Doxycycline - 100 bid x 8 weeks
P.O. Antibiotics
TCN bid x 8 weeks
Doxycycline bid x 8 weeks
Minocycline bid x 8 weeks
Taper - Do NOT STOP ABRUPTLY. Once pt’s skin is clear, taper the dose in ½ for another month and then stop the medication
In women-may add spiranolactone 50 qd-will help to taper and maintain clear complexion

18. Pt told he has psoriasis-used some crème in Mexico-can’t remember name
Pt told he has psoriasis-used some crème in Mexico-can’t remember name. Worried that his grandchildren could catch this.

20. Psoriasis is fast growing skin-can’t get it from anyone and can’t give it to anyone
What meds is he on? Certain meds might unmask this like atenelol, lithium, NSAIDS
Start Clobetasol oint and dovonex crème together. Apply M-F bid-weekends off
Primary see pt again in 6 weeks. If not better- send another telederm consult and we will readvise or book pt in derm clinic

21. Pt did not get better……
New pictures show increased total body surface area involvement
Dermatology triage: I see that pt has liver disease (seen on EMR). First choice systemic drug is acitretin. Please order up baseline LFT’s , fasting TG and cholesterol.
We will book pt for derm clinic in 6 weeks- please order baseline labs and start him on acitretin 25 qd

22. Psoriasis-when topicals don’t work
Acitretin-safer to use in liver disease-monitor TG, Chol
Methrotrexate-titrate dose, follow LFT’s and CBC, needs liver biopsy after 1.5 gm-great drug if there is psoriatic arthritis
TNF blockers-good drugs, expensive, subcu injections, presecreen for TB and Hep B and cancer risk
Ultraviolet light-is pt able to spend the time; is it accessible to pt?

23. NO PREDNISONE

27. Atopic Dermatitis Body Treatment
Topical steroids and antihistamines still mainstay of treatment
Avoid prednisone (oral and injectable)
Clobetasol ointment qd for 5 days when severe then
Fluocininide (lidex) oint bid for 2 weeks then
Triamcinolone 0.1 % oint bid maintenance
FACE: HC or aclomethasone oint bid

29. Gentle Skin Care discussion
Steroids are okay to use-not going to thin out the skin BUT give limited amts of potent steroids
Use steroids with grease-bid
Bathing or showering 1-2x’/wk and don’t even dry off after bathing
Grease up immediately
Antihistamine (benadryl, atarax, doxepin) at night so pt can sleep and break the itch/scratch cycle but beware of warnings re: age and antihistamines

32. Scabies: Classic treatment
Permethrin 5% crème-2 applications 1 week apart
Must treat all intimates
Clothing instructions essential and it is PAINFUL to follow through:

33. Prepare 3 days of clean clothing and linens
Sleep in old linens night that you have permethrin on
Next morning-start using clean clothing and sheets
Everything else goes into black plastic garbage bags for 3 days
Only do this with first application of permethrin ( NOT THE SECOND application)
Pts will itch for 3 wks even with all the right treatment- give them TAC 0.1% crème and atarax 25 qhs

34. Scabies
Oral ivermectin superior to malathion in adults BUT this is second line drug
While it is easier to give-it is expensive and overuse might lead to resistance
We have seen resistance with Kwell (Lindaine)
First line is still permethrin (elimite)
Martin Annals of DermatolVenerology 2010 Dec

36. Pt notes changing mole-also itchy. Worried she has melanoma

37. Seborrheic keratosis-reassure-observe over time
treatment not covered by county services
You can apply cryotherapy 2 x 15 sec thaw cycles or
Private derms in your county will do this for a fee

38. This is a communication to the doctor
This is me talking to you and it is only ADVICE
You are free to take it or leave it and feel free to question us-call or write!!!!!!
Use tact please when conveying info to patients
Always OBSERVE over time-ask patient to be aware and to come back to you ASAP if has concern, notes rapid growth
We are not infallible but as a system we have decided not to remove everything-but we need to be cautious, receptive, respectful

40. 24 year old with new black bump
No others noted

41. Looks like seb keratosis but that is unusual in pt under the age of 29
Looks like seb keratosis but that is unusual in pt under the age of 29. I want to biopsy this
We will contact pt for next live derm clinic
Cc scheduler-book for live derm in 1 week
You will know about this by reading report inn L jellybean

43. Pt notes these get caught on shirt-sometimes get inflamed

44. Skin tags-benign
Primary can snip them off-services not covered by county

45. 30 yr old with multiple previous biopsies to rule out melanoma
30 yr old with multiple previous biopsies to rule out melanoma. Here for skin check.
No recent changes in moles
No family history of melanoma
Please see in live derm clinic
Agree and will book within 1-2 months

47. Ask these questions: 1) Personal or family history of melanoma?
2) History of atypical nevus that has been removed?
3) Presence of new or changing mole- i.e. change in size or color?