Blemishes, zits, pimples.
These are all common names for the skin disease called acne. Acne is so common during childhood and teenage years that it is considered a normal right of passage. However, when the acne becomes so severe that there is either ridicule from friends or actual disfigurement of the face, then medical treatment becomes necessary. First, let us describe all of the different types of skin lesions that may be found in acne. The pearly lesion of acne is the open comedo or blackhead. An open comedo is a hair follicle opening that is blocked by accumulated skin cells. The dark color is caused by oxidation of the protein on exposure to hair. A closed comedo, also called a whitehead, is the skin lesion which has a thin layer of normal skin overlying it and is not exposed to the air. Both of these lesions may rupture or break open and expose their contents to the surrounding inflammatory cells in the skin. When this happens, the next skin lesion that will be observed is a red raised bump which dermatologists call inflammatory papules and patients call a pimple or a zit. Sometimes the inflammatory papules develop a collection of pus or white blood cells on the surface and would then be called a pustule. A deeper and more serious type of inflammation may develop below the surface of the skin and this would become a cyst which is usually very painful to the patient as well as being disfiguring. All of the inflammatory types of acne lesions including papules, pustules, and cysts may heal with scarring, especially if they are squeezed or otherwise manipulated by the patient. That is why mothers and dermatologists frequently recommend that patients not “squeeze their pimples.”
What are the causes of Acne?
There are several contributory factors to acne, but it is known that it is necessary to have the four following factors in order for acne to develop:
Because acne can be such an emotionally charged issue as well as a devastating skin condition, there are many questions and myths surrounding acne that can be dealt with simply at this time.
Acne Treatment
The earliest and simplest cases of acne probably began in pre-pubescent children around 10-12 years of age. They can be treated with the few over-the-counter agents that are effective for acne. We recommend the cleansers that contain 2% Salicylic acid (Neutrogena oil-free acne cleanser and store brand), astringent or dry agents that contain rubbing alcohol or acetone, and the Benzoyl peroxide products which are available as cleansers and gels in 5 and 10 percent concentration. These medications are effective for mild cases with oily skin, but if inflammatory papules and pustules persist, then a consultation with a dermatologist is recommended for prescription medications which are much more effective. Medications for acne may be prescribed by the topical or local application route or by the systemic or internal dosing route such as by tablets or capsules. First we will cover topicals by medication category.
TOPICALS
Retinoids: Synthetic medicines derived from Vitamin A which causes normalization of skin cell growth within hair follicles allowing for the reduction of the obstruction to the opening to the skin surface, thereby preventing blockage, bacterial overgrowth, and rupture.
Tretinoin: Tretinoin is Vitamin A acid. It was first developed as Retin-A and is available in various concentrations of creams and gels. It is very effective for treatment of all forms of acne except for the deep cystic nodules.
Adapalene: Originally called Differin is also available in cream and gel form and may be slightly less effective than Tretinoin but also is less irritating to the skin.
Tazarotene: Available in different concentration of creams and gels is a synthetic aromatic form of Vitamin A that is slightly more irritating than Tretinoin but probably more effective at normalizing the cell growth within the hair follicles. This drug is also approved for the treatment of psoriasis which is definitely a disease of abnormal skin cell growth recognized by thick red raised scaling plaques on elbows and knees.
ANTIBIOTICS
Benzoyl Peroxide Products: These are available as creams, gels, and cleansers, both by prescription and over-the-counter in varying concentrations from 2.5%- 10%. Drying of the skin and irritation increases with the concentration of the drug. Benzoyl peroxide is a mild antibiotic for the skin. Some of the benefits may result from the exfoliation of the skin caused by the drying effect.
Erythromycin: This is one of the first antibiotics available in topical form for the treatment of acne. Antibiotics are used for both their antibacterial effect and anti-inflammatory effect on acne. Because Erythromycin has been around so long for the treatment of acne, many of the bacteria have become resistant to it, and therefore may not be as effective as Clindamycin.
Clindamycin: Clindamycin is available in liquid solution, and gel form. It is very effective at helping to clear mild to moderate superficial inflammatory acne lesions.
Combination: After years of use of Erythromycin and Clindamycin topically in the treatment of acne, it became apparent that these medicines were losing some of their effectiveness because the bacteria were becoming resistant to the antibiotic effect of these drugs. They were able to maintain their anti-inflammatory effects, however. With the addition of Benzoyl peroxide to the treatment regimen, antibiotic resistance has been delayed. Therefore, pharmaceutical companies have developed active combinations of two anti-acne drugs in one cream or gel. For example, Clindamycin has been combined with Benzoyl peroxide, Erythromycin has been combined with Benzoyl peroxide and Benzoyl peroxide has been combined with Adapalene.
Anti-Inflammatory: A new topical drug for acne has been approved called Aczone which is 5% Dapsone gel. It is a new class of acne treatment which has been available as an oral drug for many years but considered to be too toxic for the treatment of acne. The topical formulation is safe and without significant side effects, however, it is only mildly effective for acne. It may be useful in combination with some of the other medications in this list to substitute for other medications that have either been too irritating or cause allergies.
ORAL AGENTS
ANTIBIOTICS
The Tetracycline class of antibiotics was the first oral and topical antibiotic that came into general use. The topical formulation was dropped because it made the skin glow in ultraviolet light, not a pretty sight in the discotheques of the 1980’s. These medicines are very effective as antibiotic and anti-inflammatory drugs because they are concentrated in the oily or lipid layers of the skin including concentrating in the sebum where the P.acnes bacteria grow. Tetracycline is very safe and inexpensive. Occasionally people may suffer from mild gastrointestinal side effects and women may develop vaginal yeast infections as with any other broad spectrum antibiotic. There are some minor disadvantages: 1) Tetracycline is best taken on an empty stomach which means one hour before or two hours after a meal. This may be difficult for some of our busy teenage patients that find themselves eating snacks throughout the day. 2) Tetracycline may not be taken with dairy products at the same time as swallowing the capsule because the calcium in milk or cheese prevents the antibiotic from being absorbed well into the bloodstream. So it is best to take the capsule on an empty stomach with a full glass of water. 3) Tetracycline is slightly sun sensitizing. That means that you may be more likely to get a sunburn even after a shorter exposure to the sun than usual. This can be more of a problem to patients who live in southern or tropical climates where it is sunny even during the winter.
To overcome some of the shortcomings of Tetracycline, different but related chemical derivatives of Tetracycline were developed. One of these is Doxycycline. It may be taken with food or dairy products. It has slightly more gastrointestinal side effects than Tetracycline and is definitely more sun sensitizing than Tetracycline. The patient must be willing not to get excessive sun exposure while taking the medication and to diligently use sunscreens which are broad spectrum, that is, blocking both UVB and UVA. Minocycline is also very effective for all forms of acne including cystic acne. It concentrates in the lipid fractions of skin very well. It is less likely to cause gastrointestinal side effects than Doxycycline and is much less sun sensitizing than Doxycycline. One disadvantage that occasionally occurs is darkening of the skin either generalized after sun exposure or in healing inflammatory lesions or bruises.
None of the Tetracycline antibiotics should be given during pregnancy because the medication accumulates in the forming teeth and bones of the developing fetus. For the same reason, Tetracycline should not be given to children until after puberty when their bones stop growing at about age 16.
While it is uncommon, some patients develop rashes or hives when taking Tetracycline antibiotics. If that happens, the antibiotic must be stopped and usually cannot be substituted with another antibiotic in the same category.
Erythromycin
Erythromycin is also one of the first medications that was used for acne in both topical and oral form. Most of the bacteria have developed resistance to Erythromycin, and it is considered not to be as effective as the other alternatives listed here. However, because it is cheap and relatively safe, it can be tried as a second line therapy for a patient who cannot tolerate the Tetracycline antibiotics.
Sulfa containing antibiotics such as Bactrim and Septra which are most often used for urinary tract and other infections, are also very effective for certain forms of acne, especially in older females who have tried many of the other treatments. Naturally, if the patient is known to be allergic to Sulfa containing antibiotics, they cannot be used. There is also a fairly high incidence of developing rashes from taking Sulfa antibiotics. Again, if this happens, then the medication must be stopped immediately. There is also a slight amount of sun sensitivity associated with Sulfa-containing antibiotics, and the patient must be aware of their tendency to sunburn more easily and to avoid tanning salons and therapeutic ultraviolet light.
Clindamycin
Clindamycin is very effective for acne and other acne-like diseases. The main side effect is that it can cause diarrhea which may lead to a more serious condition called colitis. This side effect was once considered to be more common than it is today, so the drug may have been under utilized. Clindamycin has been making a comeback of sorts, again especially for patients who are either resistant or intolerant to the other antibiotics on this list.
RETINOIDS
The only retinoid or Vitamin A derivative that is approved for the treatment of acne in the U.S. is Isotretinoin, which is better known by its original brand name Accutane. This medication is remarkably effective at healing the most severe and resistant forms of acne which are usually cystic and scarring and involve the face as well as the back and chest. It has many minor side effects which relate mostly to dryness of the skin and mucous membranes, but it is notorious for its more serious side effects which include teratogenicity (the ability to cause birth defects in women who are pregnant at the time of taking the medication), causing mood changes that may result in depression and suicidal thoughts, and diarrhea which may lead to inflammatory bowel diseases (ulcerative colitis and Crohn’s disease). Because most of our acne patients are young and therefore of childbearing potential, the Federal Drug Administration and the American Academy of Dermatology have implemented very strict control on the prescribing of this medication by a program called “ iPledge.” This program requires that the patients return for a follow up appointment for every refill of a prescription including a pregnancy test for females and blood tests for males and females.
The medication is dosed by the weight of the patient, and the treatment is continued until an effective cumulative dose is reached or the patient’s skin is completely clear. About 80 percent of treated patients will enjoy a nearly complete remission or “cure” of their acne which may only recur as mild superficial lesions that can be treated topically. Of the remaining 20 percent some will require a second or a third treatment course of Accutane in order to obtain a satisfactory response. A minority of patients may still require oral medication after discontinuing the Accutane. A course of Accutane is typically between 3 and 6 months.
HORMONES
Because we know that the male hormone is necessary for the appearance and sustaining of acne, it is reasonable to expect that the female hormone counteracts the effect of the male hormone. Therefore, females may benefit from the addition of estrogen to their hormone balance. Certain oral contraceptive pills have been developed which contain a small amount of estrogen and have been shown to be beneficial for the treatment of acne as well as for providing contraception. Examples of brands are Ortho-tricyclen and Yaz. Some dermatologists are comfortable prescribing birth control pills for their patients for the treatment of acne, but others prefer that these drugs be provided by their current gynecologists so that a more thorough evaluation of their female reproductive health may be undertaken to include pap smears, breast exams, and management of the menstrual cycle.
COMBINATIONS
In order to get the best response in any given patient, it is common to prescribe a combination of a topical medication and an oral medication. A typical example of a patient with moderate acne would be treated with topical Clindamycin solution in the morning, Tretinoin cream at bedtime and oral Tetracycline or Minocycline during the day. There are also some combinations to be avoided. For example, the Tetracycline antibiotic should not be given at the same time to patients who are also taking Accutane. A rare side effect of swelling of the brain has been reported with the latter combination. On the other hand, for the young females who are taking Accutane, it would it be beneficial for them to take one of the oral contraceptive agents that improve acne and also prevent pregnancy while taking Accutane which could result in a birth defect. Most dermatologists would also not prescribe a topical Retinoid such as Tretinoin, Adapalene, or Tazarotene while the patient was also taking Accutane because of the extreme dryness and exfoliation that this combination of two Retinoids might cause.
ROSACEA
Rosacea, also known as Acne Rosacea or “adult acne,” is a skin disease that appears very similar to common teenage acne except is really thought to be a different disease with a different cause. For example, it usually affects adults of middle age, around 40’s and 50’s. There is a genetic tendency for this disease, so that you are more likely to acquire it if one or both of your parents had it. There is also a tendency for certain ethic groups to get Rosacea, notably Celtic- English- Welsh and Northern European populations and Americans with this ancestry .
Rosacea, as one might expect from the name, begins as a flushing or blushing tendency which usually affects the face, neck, and upper chest associated with emotion or stressful situations. This is considered to be the first and mildest stage of Rosacea and suggests that the disease is based on a sensitivity of the blood vessels to either emotional or thermal stimuli.
After the flushing stage which may result in permanent dilation of small blood vessels on the face called capillaries, the next stages of Rosacea include the development of red papules and pustules, usually localized to the central face. This would include the nose and cheeks. Sometimes there is swelling of the face including the eyelids associated with flare ups of Rosacea. There are also forms of Rosacea where the pimples and pustules may be seen either on the skin around the mouth or the skin around the eyes which would be called perioral or periocular dermatitis, respectively. The fourth and most serious stage of Rosacea is usually only seen in men and involves the nose with an enlargement of the oil glands in the skin. This condition is known as Rhinophyma and describes an enlarged, lumpy-bumpy, and misshapened nose. The patient may also have the inflammatory papules and pustules and dilated capillaries called telangiectases on the nose or on the facial skin around the nose. The Rhinophyma has been associated with alcoholism because of the alleged behavior of the famous comedian WC Fields, but certainly not all patients who have Rosacea or Rhinophyma are alcoholics.
We know that there are many triggers for the development or cause of Rosacea. The most commons ones are sun exposure, hot environment, and vigorous exercise which all have the same effect of increasing the dilation of the blood vessels on the skin leading to redness but also the development of inflammatory papules and pustules. Other less common but important aggravating factors for Rosacea include emotional stress, drinking alcohol, especially red wine, and eating spicy foods. Finishing up the list of triggers includes drinking extremely hot or cold liquids. Contrary to popular belief, caffeinated drinks are not the problem but rather the temperature of the drink itself. Therefore, more tepid or lukewarm water would help prevent the Rosacea flare up for people who like to drink caffeinated teas and coffee. Skin affected by Rosacea tends to be very sensitive, and certain skin care products may not react well with it. This might include any of your everyday cosmetics and cleansers. For this reason, the treatment of Rosacea is different from the treatment for common acne in some respects: the exfoliating or drying treatment used in acne patients who generally have oily skin often cannot be tolerated on the already reddened and sensitive skin of Rosacea patients. A small subset of patients with Rosacea of the skin will also develop a form of Rosacea that affects the eyes, especially the membranes inside the eyelid and the outside white membrane of the eye globe. The most severe form of Rosacea may even affect the cornea. The patient who complains of dry eyes or a gritty sensation in their eyes who also has Rosacea of the skin should be referred to an eye doctor along with the dermatologist.
In most cases, the diagnosis of Rosacea can be made by the dermatologist after taking a history of aggravating factors and an examination of the skin. Occasionally, because of the sun sensitivity, other diagnoses may have to be entertained such as Lupus of the skin. Therefore, additional blood testing or skin biopsies may be performed in such cases.
TREATMENT OF ROSACEA
The treatment of Rosacea should always include informing the patient about all of the aggravating factors that may be relevant to their lifestyle and asking them to reduce or eliminate those triggers. In addition, the two most effective medications for Rosacea are oral Tetracycline and topical Metronidazole cream or gel. The former can be used in low doses or for a short period of time followed by the use of the latter for chronic maintenance. The patient should be informed that Rosacea is a chronic disease and if they discontinue the medications which are helping them, then the condition is more likely to recur. An alternative to Metronidazole cream is Azelaic acid gel. A cleanser containing 5 percent precipitated Sulfur and 10 percent Sulfacetamide is also very helpful for Rosacea patients when used 1-2 times daily. Unfortunately, these medications do not really help an established Rhinophyma , and those patients may require some form of cosmetic treatment of their noses to reduce the enlargement and smooth out the irregularities. The dilated capillary spots called telangiectasias can be treated by certain types of lasers that are specific for blood vessels.
What is vitiligo?
Vitiligo is a common autoimmune skin disease that causes gradual loss of the natural brown pigment melanin in the skin. It affects about 1% of persons worldwide irrespective of gender, age, race, or nationality. It occasionally is associated with other autoimmune diseases such as psoriasis, alopecia areata, thyroid illness, diabetes, and pernicious anemia.
How does vitiligo behave?
When vitiligo first appears, the affected skin gets lighter in slowly enlarging dots and circles which may join together. In light-skinned people the difference between vitiligo and their normal skin may be difficult to detect until they get tanned. In dark-skinned individuals, the early changes are very obvious and distressing and eventually become bone-white. If the affected skin is hairy, the hair will turn white also.
Vitiligo can occur on any part of the body skin, but it does have a tendency to involve skin overlying joints or bony prominences. The face, neck, underarms, and private areas are also frequently affected.
Can vitiligo be treated?
In my experience, topical creams have been largely ineffective for vitiligo. Sometimes treating an underlying condition such as hyperthyroidism helps to improve vitiligo, and occasionally one sees spontaneous repigmentation. By far, the treatments that work best include exposure to ultraviolet light.
Sunlight
Natural sunlight alone is usually ineffective because the depigmented skin burns easily before the remaining pigment-producing cells can be stimulated enough to make melanin. Moreover, a burn or any other type of injury to the normal skin may induce more vitiligo.
Psoralen + UVA light = PUVA
Many years ago, a plant extract called Psoralen was discovered which when combined with long wave ultraviolet light called UVA, helped to repigment vitiligo. This treatment is now called PUVA. Recently, it has been determined that after many PUVA treatment exposures which are required for vitiligo, the risk of skin cancer is markedly increased.
Narrowband UVB
Short wave narrowband ultraviolet B (NBUVB) without Psoralen was tried next and found to be just as successful as PUVA at repigmenting skin. The dose of UVB is gradually raised to avoid burning of the normal skin while producing “pinking” of the vitiligo. The risk of skin cancer does not seem to be increased by NBUVB, but this possibility must always be borne in mind.
Polypodium leucotomos (fern plant) extract
Another plant that has attracted our attention is the tropical fern Polypodium leucotomos (PL). Extracts of PL when ingested have been shown to prevent sunburn and protect skin of people who have photosensitive skin. It has several different actions on skin: 1) potent anti-oxidant; 2) reduces cell death caused by sunburn; 3) prevents DNA damage caused by UVB which could lead to skin cancer; 4) reduces number of mast cells in skin which can release inflammatory chemicals such as histamine.
Study of fern extract in treatment of vitiligo
In 2007 Polypodium leucotomos extract was investigated in the treatment of vitiligo in 50 patients at a university in the Netherlands. Half of the patients received narrowband ultraviolet B (NBUVB) twice weekly plus the fern extract daily in capsiules by mouth and half received NBUVB alone for 6 months. Results showed that about twice as many patients receiving the fern extract experienced repigmentation of the head and neck areas.
After reviewing the above investigations, we have been recommending that our patients receive the treatment of first choice, NBUVB, delivered by a full body cabinet or by an excimer laser for targeted therapy of vitiligo skin lesions. We also advise patients to obtain Polypodium leucotomos extract and take one or two capsules daily, especially if vitiligo involves the head and neck areas, to enhance repigmentation.
How to obtain Polypodium leucotomos extract (Heliocare)
Polypodium leucotomos extract is an over the counter product that is usually purchased over the internet. It is classified as a supplement rather than a drug and is therefore not FDA-approved. I found many sources after a search. The brand that I am most familiar with and have clinical experience with is called Heliocare. It was mentioned briefly as a sunscreen pill in recent issues of the popular magazines For Women First and Consumer Reports. Heliocare contains 240 mg of the fern extract plus green tea extract and beta-carotene. It costs less than a dollar per capsule, but prices vary, so please shop around. We sell Heliocare in the office for the lowest price we could find on the internet as a convenience for patients.
Electronic medical records (EMR’s), also called electronic health records (EHR’s), are in the news a lot these days, along with buzzwords like healthcare reform and tort reform. The topic is currently of greater importance to doctors that are contemplating or implementing EMR in their practices. The federal government is offering a financial incentive to offices that make the leap now. Less than half of practices have done so. By 2014, the incentive will switch to a financial penalty for not having done so.
EMR is basically a software program that allows the user to obtain and digitally store a patient’s complete medical history, progress notes, laboratory and X-ray reports, photographs and other images. There are many advantages to doing this compared to the standard manual chart with handwritten or transcribed notes with lab and X-ray reports attached. The biggest advantage in my view is accessibility to the chart at all times in the office and even after hours in an emergency as long as the user has an authorized personal identifier and password to protect confidentiality.
In very large multispecialty group practices, such as the Veteran’s Administration, Mayo Clinic, and Cleveland Clinic, wherein many different doctors, specialties and labs provide services to an individual patient, EMR’s have become a necessity. In the past I worked in VA clinics and the Cleveland Clinic where charts were either “in transit,” in another doctor’s office waiting for a dictation or lab report, or simply “lost.” It was even acceptable at that time to ask patients to hand-carry charts to the appointment desk and then from the dermatology office to their next appointment in the hematology department, for example, a practice that would be unthinkable today. It was not unusual to observe patients reading their charts in the corridors, waiting rooms, and even the cafeteria! Not so any longer.
In large healthcare systems like those mentioned above, nearly all the laboratory and radiology services are performed in house. Thus, the results of ordered tests can appear in the record, and the provider can be notified of this event by email as soon as the test is completed. But in many private practices, patients are given prescriptions for blood and urine tests and X-rays or scans. The patients then in turn take these orders to their local hospital or private commercial lab mandated by their insurance carrier. The hospital or lab then faxes or mails the report which then has to be attached to the paper chart and reviewed by the physician. You can see that there are many points along the way where the result may not connect to the chart or that that the doctor might not receive it in a timely manner.
When the private practice doctors obtain EMR’s, they may be able to integrate their most commonly used hospital and lab systems into the ordering doctor’s notifications or “task list.” Any result that is not digitally integrated has to be scanned into the medical record otherwise a new paper file for that patient begins to accumulate, has to be stored and brought out for each susequent visit. Even the large centers with well established EMR’s have to do this now when a patient arrives for a second opinion consultation carrying over 100 pages of photocopied chart material, a fairly common occurrence.
Thus, while I am a proponent of EMR’s, I am not in favor of moving so fast, especially for the specialty of dermatology about which I possess the most knowledge. First of all, EMR’s are expensive, and while we all must have them eventually, I do not think the best one exists yet. And naturally, just as telephones have gone from land to cell to smart, television from black & white to color to HD to 3D, music from vinyl to tape to CD to MP3 to iTunes, the latest EMR program will be the fastest, cheapest, most robust and specialized.
When a medical practice decides to adopt an EMR, they will usually first adopt a practice management system that allows for digital appointment making and integrating billing and collection systems. When everything is on line and operative, the EMR can even calculate the appropriate level of service and the charges before the patient reaches the checkout desk and without the doctor having to also fill in the “superbill.” That’s if everything is working smoothly. Let me tell you about my experience working with two very different EMR systems, Epic and Nextgen. The views presented here are my personal opinions; I have no conflicts of interest, and I am not currently using an EMR.
I believe that most of the larger EMR programs were at least initially intended for use in general medical practices that provide primary care, such as family medicine, internal medicine, and pediatrics. Then as specialists joined these groups and had to be converted to using the EMR, the vendors added layers of new appropriate programs to piggyback on the already established default program without reinventing the wheel. In some cases, a better more efficient product could have been developed if they had trashed the entire program and wrote a new one which included dermatology, ophthalmology, plastic surgery, ENT, and so on. Or had just created a separate product for each specialty that wants to use an EMR with input from the specialty societies, not just a few consultant doctors.
It is difficult for doctors who have been in practice for 10 or more years using paper charts to convert to EMR. It is somewhat easier for the newer generations of doctors who grew up using computers at home and in school for doing research, homework, and writing papers. Besides the initial outlay in the tens of thousands of dollars for the software, hardware–computers in every exam room and printers and scanners at nurse stations–contracts for classroom, on site and on the job training with all clinical staff are necessary (often included in the price package), as well as maintenance, updates, troubleshooting, and customization which usually cost extra. In order to accomplish all of that with everyone working in the practice, there is naturally down time from clinical practice, that is, you see less patients which increases cost.
When the Cleveland Clinic installed Epic in its Naples facility, the program had been in use for years in Cleveland and Weston, Florida, and there were experts in all of its many robust features available for troubleshooting. However, they were not readily available to help. The training process was brief, only about 3 weeks, and very superficial as I came to understand much later. Moreover, it was not the policy that all physicians were required to use the Epic EMR in Naples which really defeated the purpose of the EMR. I was unable to view the results of some other physician exams on the digital record because they were never entered, even though I was the one who had requested that doctor’s consultation in the first place! Epic was also not integrated into the billing system, thus the doctor also had to manually complete a superbill for the charges. On the other hand, I was able to see for the first time the results of examinations and lab tests on my patients who also had seen my colleagues in Cleveland and Weston, which was an unexpected bonus that improved communication and patient care.
Epic has features for creating diagrams and anatomic figures which are very helpful for the dermatologist for documenting biopsy sites on a face or the distribution of rashes like psoriasis or eczema on the body. These were not taught to me, and it wasn’t until my second year of using Epic that I was comfortable enough to experiment with all the buttons and search through all the figures to be able to the use the program more efficiently. Epic slowed down my progress through a schedule until the beginning of the second year after implementation, and by the end of second year I could see the same number of patients as before with the manual chart and not run late.
Vendors of EMR software advertise that their products allow the doctor to see more patients with less staff. I firmly believe that this is false on both accounts. My experience has been with two different EMR systems that you must reduce the appointment schedule to be able to use and learn the new system for up to 3 months, not including time for classroom and home study for the doctors and staff. The same number of support staff or more are needed to document the reason for visit, medicines, allergies, etc. on the computer and then scribe for the doctor in order for the doctor to be able face, touch and perform procedures on the patient instead of facing a monitor and touching only a keyboard.
Nextgen was a doozy. I haven’t looked at it in over a year, so it may have been improved. If it hasn’t been improved, then HMA “wuz robbed.” HMA is the Naples-based hospital management company that bought the Cleveland Clinic operation in Naples, Florida in good faith in 2006. They renamed the hospital Physicians Regional Medical Center and were granted rights to use or lease Epic for a certain length of time after the sale. When that deadline came, the Cleveland Clinic abruptly turned off Epic by contract and HMA gave us Nextgen. As I stated earlier, this program was not sophisticated and consisted of layer upon layer of primitive systems requiring multiple keystrokes and pages to accomplish one function. Unfortunately, a simple office visit requires dozens of functions, and a complex consultation many more, thereby equalling hundreds of keystrokes. You might as well type the note, except most of us doctors are neither fast nor accurate typists!
To be fair to HMA, they did try to patch some of Nextgen’s weaknesses and deficiencies by purchasing Dragon Naturally, a superior voice recognition program that allowed us to insert templates for review of systems and normal exams related to our specialty which saved some time. Dragon also worked very well for dictating a more complicated specialty consultation which Nextgen itself had no way of accomodating because it seemed to be designed mainly for general medical histories and physical exams and straightforward cases.
I know that the ophthalmology and ENT specialties had a hard time with Nextgen. They had to completely redesign and customize their visits. I understood what was going on a little better with dermatology. It appeared that one group of dermatologists advised a software writer what they mainly did in their practice, the order and flow of procedures, and what diseases they treated. There were short programs for basal cell carcinoma and acne, but no physical exam for a full body skin exam. I guess they expected us to use the internal medical exam including heart and lungs, except dermatologists rarely ever use a stethoscope nowadays. There were some anatomic diagrams in the images section, but they were poor for a skin exam. The trainers from Nextgen were helpful. Although they weren’t there for us long enough, they did help add better skin anatomic diagrams and taught us how to mark the spots where procedures were performed.
Phototherapy using narrowband UVB and PUVA is a large part of my psoriasis practice, and we were accustomed to documenting all of the parameters of treatment, i.e. skin type, energy, time, on Epic for each visit. Apparently, the dermatology practice that advised Nextgen employed only the Xtrac laser for psoriasis. So we gained a program to document Xtrac treatment but not UVB or PUVA and didn’t have the laser at that time, rendering the system impotent for our needs.
Because it took so much extra time free-typing data or using the word recognition software for dictating, I usually worked about 1 1/2 hours after the last patient was seen and had to come in at least one weekend day for a couple of hours to clean up my in-box which contained the results of all the blood tests and biopsies that came in electronically from the in-house labs and answer the prescription refill requests which came electronically 24 hours a day from pharmacies.
Here is my bottom line advice to doctors in general and dermatologists in particular. Remember, I am not a tekkie, just a practicing dermatologist.
1. If you don’t already have an EMR, don’t get one until after the government deadline.
2. The money lost in federal bonuses for going on line early and the money paid in penalties will not exceed the cost for a bad system that needs reconfiguring or replacement.
3. Buy the least expensive and most customizable EMR program which has been developed or recommended by your specialty society.
Treating moderate to severe psoriasis is difficult in the best of cases, but the most serious challenge I have encountered in practice is treating patients who were formerly treated with Raptiva.
In the way of background, Raptiva was a new biologic immunomodulating drug that was introduced by Genentech in 2003 for the treatment of moderate to severe psoriasis. Raptiva was a monoclonal antibody directed against a specific component of leucocyte function antigen-1 expressed on human T-lymphocytes. By blocking the interaction of LFA-1 with other molecules, T-cell activation and migration into psoriasis skin lesions was inhibited.
The early pivotal studies of Raptiva in the treatment of psoriasis indicated that it was very successful in clearing skin in about 40% of patients. Raptiva was a little more difficult to use in practice and somewhat less effective than later arriving competitors such as Enbrel, Humira, and Remicade. The latter drugs work by blocking a pro-inflammatory compound called tumor necrosis factor which is elevated in psoriasis patients. This advance caused most dermatologists to shy away from Raptiva in favor of the others, significantly reducing Raptiva’s market share as they began to dominate the marketplace.
Raptiva became a niche drug. First, only very experienced clinicians with a high volume of psoriasis patients would use it. After a while, it seemed that only patients who had failed to respond well to tumor necrosis factor inhibitors became candidates for Raptiva. The other niches were patients with psoriasis of the palms and soles, especially the pustular type, which can be quite disabling, and overweight patients, because the dose of Raptiva was based on the weight of the patient.
It is understood that all of the biologic drugs improve psoriasis by inhibiting a portion of the immune system involved in the inflammatory process which is also required for fighting off and preventing infection and cancer. For this reason, I tell patients who are about to receive any of these drugs that there is an increased risk of infection, especially reactivation of dormant tuberculosis, and certain types of cancer, especially lymphoma. These warnings are also clearly pointed out in the package insert material mandated by the FDA. The infections and lymphomas have been more prevalent in patients with more serious illnesses such as rheumatoid arthritis and Crohn’s disease which are also often treated with other immunosuppressive drugs.
Thus, in 2008 we were surprised to learn of the first cases of progessive multifocal leukoencephalopathy (PML) occurring in otherwise healthy patients with psoriasis who were not also receiving other immunosuppressive drugs. PML is viral infection of the central nervous system caused by the JC-virus which lays dormant in most people. Early on, some of the neurologic symptoms are like multiple sclerosis (MS), but PML is rapidly progressive, not treatable and may be fatal. By the time four cases of PML had been reported in psoriasis patients on Raptiva, in rapid succession, the European Union removed it from the market, the FDA required stronger package insert warning language about PML and other infections, and the manufacturer Genentech voluntarily withdrew the drug . At least three of the affected patients are known to have died. Curiously, another monoclonal antibody called Tysabri which has a different mechanism of action than Raptiva, used in the treatment of MS, was associated with 2 cases of PML , one fatal. Tysabri was withdrawn in 2005 and reapproved by the FDA in 2006.
In the first few months of 2009, I either called or saw all of my patients on Raptiva and asked them if they wanted to stop Raptiva immediately given the newly discovered risk factor, or did they want to continue it until the last vial of stock would be available in June. What would you do? As a doctor, I want to first do no harm and preferred them all to stop immediately. However, you can only answer the question honestly if you have severe disabling psoriasis and have been clear for years on Raptiva alone. Most of my patients had already been through and either failed or had side effects from narrow band UVB phototherapy, hand and foot PUVA, methotrexate, Soriatane, Enbrel, and/or Humira. Some had painful pustular psoriasis of the palms and soles which made them unable to work with their hands or to walk normally. Their psoriasis had been totally gone for years when nothing else had worked. They didn’t even have to think about something that had been the focus of their lives except to give themselves that one little shot once per week. I believe they all used Raptiva to the very last vial, and some tapered it off by dose or by frequency in attempts to both reduce risk while staying clear. No one brought in any unused Raptiva for me to destroy or return to Genentech. On my next blog, I will discuss what happened next and how I handled the cases, but happily, none of my patients developed PML.
In the strict sense dermatitis simply means inflammation of the skin. The inflammation can be caused by chemical irritants such as solvents or detergents, allergens such as resin from poison ivy plants, superficial yeast or bacterial infections, and genetic tendencies toward dryness of the skin and sensitivity to changes in climate called atopic dermatitis.
Psoriasis is not included with dermatitis. Although it is also marked by redness indicating inflammation, the rapid turnover of skin cells is the predominant abnormality which leads to thickness and scaling of the lesions.
The most common types of dermatitis are seborrheic, allergic, and atopic.
Seborrheic dermatitis consists of light scaling on the scalp also known as dandruff and redness with yellowish greasy flakes on the face, especially in the eyebrows, sides of the nose, behind the ears, and in the moustache and beard areas of men. Mild cases are controlled by over the counter anti-dandruff shampoos and facial moisturizers or 1% hydrocortisone cream. Recently, it was learned that a certain type of yeast is found growing in the scales of seborrhea, and that treatment is vastly improved with the anti-yeast shampoo and cream containing 2% ketoconazole.
The best example of allergic contact dermatitis is the reaction to the resin in poison ivy plants. The rash consists of red raised bumps in lines or blotches with small clear fluid filled blisters on top. The rash is very itchy, and the skin sometimes weeps fluid. The rash develops 2-14 days after contact with the responsible substances. Other commonly encountered skin allergens that cause dermatitis include nickel in costume jewelry (think of unexplained rashes on ear lobes, necks, and fingers), neomycin, the popular topical antibiotic found in triple-antibiotic Neosporin ointment, as well as fragrances and preservatives found in scores of cosmetics, sunscreens, and prescription medicines.
The skin rash may be treated with either topically applied high potency cortisone creams or prednsone pills and shots. Antihistamines such as benadryl and anti-itch creams may be used to reduce the symptoms. The prevention of allergic contact dermatitis requires determining the cause and eliminating it from the environment if possible.
Probably the most difficult to treat dermatitis is the most common dermatitis known as atopic dermatitis or eczema. This condition affects about 4% of the population at some time in their lives, and is more common and more severe in children. The word atopy refers to an increased sensitivity to the environment including temperature, humidity, textures of clothing, and allergens in foods and in the air. An atopic person is also more likely to have asthma, food sensitivities, and be allergic to penicillin. The atopic tendency is a genetic trait, that is, it is inherited. Any of the features may be inherited singly or together. In other words, the allergies do not cause the eczema; they are separate components of the atopic tendency.
The rash begins as dry itchy skin. In very young children the face and diaper areas are affected first with redness. Later the skin folds of the neck, wrist, elbow and knee creases are attacked with scratch marks, accentuated skin lines, and breaks in the skin leading to infection. In adults, the eczema persists as hand dermatitis aggravated by wet work, soaps, cleaning agents, and food preparation.
Treatment has to be tailored to the individual case based on age, but generally consists of the combination of reduced bathing and exposure to water, use of gentle or super-fatted soaps, liberal use of bland moisurizers, antihistamines for itching and to help sleeping through the night. More severe cases require topical or oral antibiotics, medium to high potency corticosteroid ointments, or internal steroids such as short-acting prednisone or intramuscular injections of long-acting Kenalog. Newer non-steroidal creams for eczema suppress the local inflammation. These calcineurin inhibitors are named Elidel and Protopic and are only available by prescription. Chronic cases of eczema may also be helped by graded sun exposure. If so, then our narrow band ultraviolet B lamps in the office will also reduce itching and promote healing of the skin.
You might reasonably ask, how could one confuse these two distinct entities? Scabies is an infestation of the skin caused by the sarcoptes mite and poison ivy is an allergic contact dermatitis caused by a resin in the plant. The confusion happens in the layperson and with the inexperienced professional. When I was a dermatology first year resident at NYU, the custom was to have these novice individuals take call at the major metropolitan hospitals of Bellevue and the University. In July of 1978 when I answered one of these calls from the ER, we had not studied these diseases yet, and I had never seen or personally had scabies or poison ivy. I was no different than the ordinary citizen.
The patient in question was a young adult with a very itchy rash, fairly widespread, that consisted of small red bumps and blisters with some distributed in a linear array. I thought of scabies, prescribed the standard regimen at the time which was Kwell lotion, and gave him a follow up visit to our clinic the next week. The lotion irritated his skin, the rash spread, and the itching got worse. The correct diagnosis was poison ivy allergic contact dermatitis, and we then treated him successfully with prednisone.
So let’s talk about the two conditions, and then I’ll tell you about another anecdote that happened soon after the one illustrated above. The scabies mite is so tiny, only 0.4mm, that it is essentially invisible to the naked eye. There is a brand that is specific for us humans and one that specifically befriends our dogs, and rarely do they intermingle. Human scabies is transmitted from casual or intimate contact only with other humans. The rash consists of small red bumps which have a tendency to be located in skin folds such as fingerwebs, wrists, underarms, and groins. The breasts, genitalia, and around the navel may also be affected. These are usually so itchy that the patient has scratched most of the sites making it difficult to see tiny linear burrows that lead to the red bumps.
The best way to be sure of the diagnosis is to make a superficial scraping of the burrow or bump and examine it under the microscope. If you are fortunate you will see the armor-plated creature with four stubby legs and spines. If you not see her, you may see her oval-shaped eggs, or small dark brown fecal pellets.
I have occasionally captured an entire mite in the center of a skin biopsy, but this is rare indeed, because the average number of mites on an infected host is only 8-12! This is hard to believe because the patients itch all over their body and usually can’t localize the itch sensation to a specific spot. We now understand that most of the itching results from an irritant or allergic hypersensitivity reaction to the mites, eggs and feces by the immune system. We know the numbers of mites from experiments performed by intrepid investigators including my friend Dr. Steve Estes (deceased) who intentionally infected themselves and observed the entire life cycle of the scabies mite, rate of migration in the uppermost layer of their own skin, number of eggs laid, etc. The incubation time is about one month and the infestation is quite contagious.
Individual cases are fairly easy to treat once diagnosed, but epidemics are more challenging. Outbreaks are known to occur in conditions of crowding, especially in nursing homes, institutions for handicapped persons, and hospices. The current treatment of choice is permethrin 5% cream by prescription, two full body applications over 5 days, with washing and heat drying of all active clothes, towels and linens because the mite can live off the body for 2-5 days. All household or intimate contacts must be treated simultaneously. That is why the epidemics in institutions are difficult to manage: all the residents, employees, and visitors who touch the patients must be treated.
Kwell, which I used erroneously on the poison ivy patient 30 years ago, is now second line therapy. It is a 1% lindane lotion, a very good insecticide/miticide that got a bad rap because of some neurotoxicity seen due to inappropriate or excessive use in babies and small children. There also have been a few reports of lindane resistance in scabies.
Third line therapy is an oral veterinary drug used to treat worms and the tropical disease that causes river blindness in humans. The drug is called ivermectin and is given as a single dose repeated ten days later.
About a week after the first incident, I was called to our other ER on a Saturday night. We learn best from our mistakes: by now I had read all the textbook chapters and any recent journal articles I could find on the two entities. The patient was a young women who was admitted to the ER for severe pain, swelling and itching in the private area. She was unable to urinate on her own, so the emergency room physician had to place a catheter in her bladder to allow the urine to flow.
I had to question this very uncomfortable patient about the history. The rash and swelling began today. Her boyfriend was unaffected. They went camping last week. She did find herself in the uncomfortable position of having to relieve herself in the wild without having any toilet paper. She used some nearby ivy leaves as a poor substitute. Now I was certain of the diagnosis of allergic contact dermatitis from the resin in the leaves and treated her with intravenous steroids. She eventually made a complete recovery.
The resin called urushiol is present in all parts of the poison ivy, oak and sumac plants, all species of the Toxicodendron genus. This chemical can sensitize up to 85% of people who come into contact with it. If you have never been exposed, the first time you contact it, there may be no rash, or a rash may develop within two weeks making it harder to remember the exposure. Subsequent exposures in the allergic person produce rash and itching within 48 hours, and the reactions can be quite severe if widespread or if they affect the face or genitalia.
The resin can be washed off with simple soap and water immediately after contact, but it can be spread by unwashed hands and clothing. Less obvious exposures occur from handling animals who were exposed, carrying firewood, and from smoke of a campfire, bonfire or forest fire. Poison ivy dermatitis is the most common occupational hazard for the forest fire fighters in the western U.S. Contrary to popular belief, the rash cannot be spread by blister fluid after the first washing because the fluid is sterile and does not contain the allergen.
Treatment of milder localized cases of poison ivy dermatitis may consist of antihistamines like Benadryl and topical treatments like calamine and hydrocortisone. Moderate to severe cases require oral prednisone, Medrol dosepack, or even the intramuscular injection of the steroid called Kenalog.
Of course, prevention is always desirable, so gardeners, joggers, campers, etc. should learn the appearance of their local variant of poison ivy. The plants are ubiquitous weeds and grow everywhere in the continental U.S. They look a little different, but all of them have groups of three leaflets. Thus, the saying leaves of three let it be even if you’re not sure. Similar chemicals may also be found in the sap of the mango tree and the skin of the fruit, in the oil of cashew nut shells, and in fruit pulp of the ginkgo tree. Therefore, a poson ivy-like rash may develop in persons who touch or ingest these substances.
What is psoriasis?
Psoriasis is a common skin disease that results in dry red scaly patches and thicker plaques. These lesions are usually itchy and sometimes painful. Any and all parts of the body may be affected by psoriasis, but the scalp, elbows, knees, and torso are most frequent. Besides the skin discomfort and potential disfigurement, psoriasis can be physically disabling, especially if it affects the hands, feet, face, or genitalia. Many famous people have gone public with their psoriasis. To name a few: John Updike, the author; Jerry Mathers (“the Beaver”); and LeAnn Rimes, country music singer.
Psoriasis affects about 2% of the U.S. population, men and women equally, all races, with an average age of 30 years. It is less common in children. The disease and the tendency to have it are lifelong, although it may sometimes spontaneously clear or flare up. It is unpredictable during pregnancy, as it may worsen, stay the same, or clear up. It does, however, tend to worsen with age.
What causes psoriasis?
The exact cause of psoriasis is unknown, but is believed to be an inherited abnormality of the immune system which leads to inflammation of the skin and joints. The skin inflammation is associated with much more rapid skin cell growth than normal; the joint inflammation leads to swelling, pain, and eventual destruction of the bones. The latter is called psoriatic arthritis and occurs in about one-third of people with psoriasis. The symptoms are similar to the more common affliction called rheumatoid arthritis.
Psoriasis is not a contagious condition, however, it does run in families. Several genes have been closely identified with susceptibility to psoriasis, but there must be other environmental factors. So if one of your parents has psoriasis, you are more likely to get it. If both of your parents have it, then you are very likely to get it. There are some known triggers that bring out psoriasis for the first time or cause flare ups. These triggers include:
How is psoriasis treated?
Treatment of psoriasis depends on how extensive the disease is, as well as which body areas are affected.
Mild cases are treated with lubrication of the skin with products like Vaseline, Aquaphor, Eucerin, or Cetaphil and exposure to natural sunlight.
Mild to moderate cases may be treated with a variety of potent prescription topical medicines, including corticosteroids (e.g. clobetasol), Vitamin D analogues (e.g. Dovonex, Vectical), and Vitamin A derivatives (e.g. Tazorac).
Moderate to severe cases or often treated with ultraviolet light called narrow band UVB or PUVA. These treatments, also known as phototherapy, are given 1-3 times per week in the dermatologist’s office. It may take up to 30 exposures to produce clearing. After that, the frequency of treatments is reduced to the lowest level needed to maintain stability of the disease.
For patients with more severe psoriasis who are unable to make frequent office visits for phototherapy, or who have an intolerable risk for skin cancer, there are FDA-approved pill medicines. Methotrexate and Soriatane reduce inflammation and slow down rapid skin cell growth. Another more potent drug called Cyclosporine is used for very stubborn psoriasis. This immunosuppressive drug, which is also used to prevent rejection of organ transplants, has a number of serious side effects which limit its use in dermatology.
Are there any newer medications for psoriasis?
The newest medications for psoriasis and psoriatic arthritis are the so called “biologics.” Injected directly into the body weekly (or less often), biologics are made up of synthetic proteins and antibodies. You might say that they are “designer molecules” that are more specific in targeting chemicals or sites in the immune system that lead to the inflammation of the skin and joints. A few examples of available biologics include Enbrel, Humira, Remicade, and Simponi. All of these agents are also approved for rheumatoid arthritis and may be associated with serious side effects. Therefore, their use generally requires close monitoring by the specialist. You must realize that although the oral pills and the more sophisticated injectable biologic treatments mentioned are very effective at improving most patients’ psoriasis and arthritis, they do not work for every patient, and they do not provide a cure. In future blogs, I will talk about specific drugs in greater detail.
While there are different levels of severity of psoriasis, it is important for all to maintain a healthful diet including vitamins and minerals, exercise regularly, and stop smoking. A recent journal article from the University of Pennsylvania suggested that severe psoriasis may be an independent risk factor for heart attacks and other cardiovascular diseases at a younger age compared to the general population. Other studies have shown that patients with psoriasis were more likely to be obese and to smoke more than control populations. While these results need confirmation from more research, it should give psoriasis sufferers more motivation to adopt a healthier lifestyle.
Charles Camisa, MD is a dermatologist who specializes in the treatment of psoriasis. All of the treatments listed are available to appropriate candidates at his practice at Riverchase Dermatology in Naples and Fort Myers, FL. His books on psoriasis are available at amazon.com and barnesandnoble.com.
The prognosis for treated actinic keratoses (AK’s) is excellent. However, the patients who have many AK’s have accumulated so much sun damage in their lifetimes that it is very likely they will eventually develop new or recurrent AK’s. Especially if they do not change some habits. The treatments described in the previous blogs may have to be repeated several times and may even fail in some patients. A failure to respond may indicate that the precancerous AK has already progressed into a squamous cell cancer. Moreover, some patients may develop other skin cancer types such as basal cell carcinoma and melanoma directly from sun-damaged skin without first beginning as AK’s. A skin biopsy will help to answer the question and determine the next step in treatment.
Can AK’s and skin cancer be prevented? It is really never too late to begin practicing sun-safety habits.
The three most commonly prescribed topical creams for actinic keratoses (AK’s) are:
1. 5-Fluorouracil (5-FU), “chemotherapy in a cream,” selectively kills the more rapidly dividing skin cells which are generally the precancer and cancer cells. Efudex or Carac cream is applied once or twice daily to the entire affected area of involvement for 2-4 weeks. It can cause quite a bit of redness, swelling, and crusting in the treated areas along with some stinging and burning. The cure rate is high and usually yields an excellent end result.
2. Imiquimod stimulates the patient’s own immune system to produce the natural cancer fighting chemical interferon which destroys the abnormal cells. Aldara cream is applied 2-3 times per week to the affected area for up to 16 weeks. It is recommended to treat more limited areas of skin per course of treatment than with Efudex. Aldara may also cause a significant amount of redness, erosions,and pain, but it is generally well-tolerated and gives good results after healing.
3. Diclofenac (Solaraze gel), a non-steroidal anti-inflammatory drug, is combined with hyaluronic acid, a natural substance in the connective tissue of skin. Its mecanism o f action in treating AK’s is not known, however, it produces much less inflammation in the skin than 5-FU or imiquimod. It also takes much longer to achieve results because it is applied twice daily for 2-3 months. My impression is that the results are inferior to the first two listed here.
What is new?
The latest innovation for treating multiple AK’s is Photodynamic Therapy (PDT), which patients call the “blue light special.” This treatment combines the application of a light sensitizing chemical called Levulan to the affected skin with a special blue light source. Neither treatment used alone would have any effect. After the chemical incubates on the skin for about an hour, it is selectively taken up by the abnormal skin cells. The skin is then exposed to the blue light for about 16 minutes, and the precancer and cancer cells are targeted for destruction. Patients may experience stinging and burning and eventually redness and swelling in the treated areas for a few days. Sun exposure must be strictly avoided for the first 48 hours after the procedure. Healing is usually complete in one week. Results are comparable to 5-FU with the added bonus of some noticeable rejuvenation of the skin.
Actinic keratosis (AK), also known as solar keratosis, are commonly referred to as pre-cancerous skin growths. In fact, they are the most common pe-cancerous growth of any organ in the body. Actinic keratoses (plural) are most commonly found on sun exposed areas, namely, the face, lips, bald scalp, and backs of hands and arms.
What do AK’s look like?
AK’s are usually small red slightly raised bumps with attached dry scaly skin or scab. The scab or crust is usually tightly adherent or concave like a cornflake, such that attempting to remove it yourself might cause pain or bleeding. Some patients report abnormal skin sensations such as pain, itching, burning, or tingling. Some patients only complain about the abnormal feel or texture of their skin such as granular, gritty, or nutmeg-grater-like. AK’s are usually multiple, and sometimes they can be felt more easily than seen.
What is the cause of AK’s?
Based on their typical locations, the most obvious cause of AK’s is chronic excessive sunlight exposure accumulated over a period of years. Less common causes of AK’s are X-rays (radiation) and industrial chemicals such as arsenic.
What is the risk of AK’s?
AK is the first step in the development of squamous cell carcinoma, a type of skin cancer that has the biologic potential to spread. However, the majority of AK’s do not progress to skin cancer. Although it has been estimated that up to 10% of AK’s transform into squamous cell carcinoma, it is virtually impossible to predict which ones will progress, regress, or stay the same. Therefore, it is the dermatologist’s goal to treat all or as many AK’s as possible to prevent cancer.
How are AK’s treated?
We are fortunate that there are many effective treatments for AK’s. For patients who have several scattered well-defined AK’s, liquid nitrogen cryosurgical destruction is usually the treatment of choice. This method is quick, bloodless, and effective. The top layer of skin cells where the precancerous cells reside is killed by the extremely cold temperature of the liquid nitrogen. The only side effects are a temporary burning sensation and some decreased pigmentation of the skin. Healing takes place in about 1-2 weeks, and the local care is straightforward.
There are three different topical creams that have been approved and are marketed for the treatment of AK’s. Each one works well by a different mechanism of action. These medicines are more likely to be prescribed when a patient has too many lesions to count, or an entire area or segment of the body shows obvious severe sun damage (such as face, bald scalp, upper chest, backs of arms or hands), if the AK’s are not easy to delineate from normal skin, or if the patient simply cannot tolerate the discomfort of cryosurgery or declines to receive liquid nitrogen. The three topical drugs are 5-fluorouracil (Efudex, Carac), diclofenac (Solaraze), and imiquimod (Aldara). I will discuss them in the next blog
