Monthly Archives

March 2019

Dr. Jean Bolognia and the Many Faces of Lupus

By | Medical Dermatology, ODAC Sessions | No Comments
Dr. Jean Bolognia presenting at ODAC Dermatology Conference

Source: Next Steps in Derm

This information was presented by Dr. Jean Bolognia at the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference held January 18th-21st, 2019 in Orlando, FL.  The highlights from her lecture were written and compiled by Dr. Daniel Yanes.

Just as systemic lupus erythematosus (LE) can have protean systemic manifestations, cutaneous LE can present in many different ways. When confronted with the many faces of mucocutaneous LE, the following pearls can be valuable.

1. Be Aware of the SLICC Criteria

In 2012, the Systemic Lupus International Collaborating Clinics (SLICC) developed a set of clinical and immunologic criteria to assist in the diagnosis of systemic LE.

To view the original image full size image, click here.

To meet criteria for systemic LE, a patient must fulfill at least four criteria, with at least one clinical criterion and one immunological criterion OR have biopsy-proven lupus nephritis in the presence of ANA or anti-dsDNA antibodies. Of the 11 clinical criteria, 4 are mucocutaneous: (1) acute or subacute cutaneous LE; (2) chronic cutaneous lupus; (3) non-scarring alopecia; and (4) oral or nasal ulcers. Of note, the dermatologist doesn’t just establish the diagnosis of cutaneous LE, but can also determine the specific types of autoantibodies the patient is forming as well as if the patient has systemic involvement (e.g. hematologic or renal abnormalities). Remember the latter requires a urinalysis in addition to bloodwork. Acute cutaneous LE is more closely associated with systemic LE than subacute cutaneous LE, which in turn is more closely associated with systemic LE than discoid LE. The cutaneous manifestations of LE per the SLICC classification scheme are as follows:

Acute cutaneous lupus

  • Lupus malar rash (does not count if malar discoid)
  • Bullous eruption of systemic LE
  • Toxic epidermal necrolysis variant of systemic LE [also sometimes referred to as acute syndrome of apoptotic pan-epidermolysis (ASAP)]
  • Maculopapular lupus rash
  • Photosensitive lupus rash in the absence of dermatomyositis

Subacute cutaneous lupus

Chronic cutaneous lupus

  • Classic discoid LE
  • localized (above the neck)
  • disseminated (above and below the neck)
  • Hypertrophic (verrucous) LE
  • Mucosal LE
  • Lupus panniculitis (profundus)
  • LE tumidus
  • Chilblain lupus
  • Discoid LE/lichen planus overlap

2. A Positive ANA Does Not Equate to Systemic LE.

While ANA titer is positive in nearly all patients with systemic LE, not all patients with a positive ANA titer have LE.

Continue reading. 

Dermatology Contract Negotiations and Legal Tips

By | ODAC Sessions, Patient Care | No Comments
Dermatology Business deal

Source: Next Steps in Derm

If you are navigating the confusing landscape of contract negotiations or considering partnership in a private practice after years of employment, then take note! Ron Lebow, Senior Counsel in the Health Law practice group at Greenspoon Marder LLP, led a fantastic workshop at the 2019 ODAC conference. He covered common concerns when negotiating employment agreements with dermatology practices, as well as issues to address when it comes time to become a partner.

The most important point and recurring theme of Ron Lebow’s workshop was simply this:

“Make sure everything you want is in writing. Nothing is inferred. Everything is written and agreed upon by both parties.”

This point was stressed time and time again and will continue to be the overarching theme throughout the many parts of contract negotiations. With this in mind, here are some of the main takeaways and important questions we, dermatologists, should constantly keep in mind.

What Do I Do When Searching For A Job?

Surround yourself with experts! Find people who have your back. Make sure you find a lawyer who deals with medical professionals (particularly your specialty) for a living. You may need to find an accountant to work with you depending on your situation. Lastly, it may be in your best interest to work through recruiters. Some recruiters are better than others, and Ron Lebow recommends Dermatology Authority as an organization that provides good recruiting services for dermatologists.

Can I Negotiate When Looking For A Job?

When dealing with negotiations, it is important to recognize the many aspects of the process. With respect to the job you are offered:

  • They expect you to negotiate. It’s not rude to negotiate. It is part of the process.
  • They aren’t doing you a favor by hiring you. They are making a profit on you and therefore, you do have some leverage in the process. You can negotiate because they want you.
  • They will (almost) never take the offer away. The only instance in which they may take an offer away is if you ask for something, they say no, and then you continue to ask for something that is already off the table.
  • Don’t negotiate before you bring a lawyer in to help with the contract and negotiation. It may already be too late for them to be useful.
  • Don’t sign term sheet/offer letter until you have spoken with a lawyer who has reviewed the information. Again, it may already be too late for them to be useful.
  • The term of the contract, the length of time you sign for, is a non-issue. The real term of the contract is actually the notice you have to give before leaving, not the actual term of the contract itself. For example, if you sign a two-year contract but the notice you must give is three months, the term for all intents and purposes is three months from the time you decide you want to break your contact.
  • Make sure it is spelled out when partnership will be happening if that is on the table. Three years is a common timetable for partnership to be offered. If partnership is a possibility, make sure there is something written in the contract in case ownership changes between the time you start and the time you would have been allowed to start buying into partnership (e.g. if the group sells to private equity).

Compensation and Bonuses

Continue reading. 

Actinic Keratosis and Squamous Cell Carcinoma: Pearls from ODAC

By | Medical Dermatology, ODAC Sessions | No Comments
Dr. Patel presenting at ODAC Dermatology Conference

Source: Next Steps in Derm

In a 20-minute lecture presented at the 16th Annual ODAC conference, Dr. Patel reviewed the appropriate management of actinic keratoses and squamous cell carcinoma. Grabbing the attention of the audience early on, Dr. Patel quoted the staggering statistics for squamous cell carcinoma – calling the growing epidemic “a public health crisis.”  He challenged dermatologists to lead the charge in a more sophisticated approach to disease stratification.

Data are conflicting regarding the risk of progression of actinic keratoses to squamous cell carcinoma. Despite Dr. Patel’s expertise, he admitted even he finds it impossible to predict which lesions will progress. Instead, he takes a more astute approach and taking a step back to focus on the burden of disease.

Twenty is the magic number – over 20 actinic keratoses increase the risk of squamous cell carcinoma.

With the groundwork firmly laid, Dr. Patel delved into the crux of his talk. He posed a thought-provoking question to captivated listeners:  Are actinic keratoses a disease or a symptom? In the same way hypertension leads to stroke, actinic keratoses lead to squamous cell carcinoma.

Actinic keratoses are a field disease, as such we should focus on field treatment.

Dr. Patel drove his point home with several instructive clinical cases. With each patient, Dr. Patel calls dermatologists to first discern field disease from invasive disease. Once invasive disease has been excluded, hyperkeratotic lesions should be debrided, and a strict regimen of topical 5-fluorouracil instituted for 4 weeks. This regimen should be followed by photodynamic therapy in 3 months.

Continue reading. 

Facial Anatomy: ODAC Coverage with Susan Weinkle, MD

By | Aesthetic Dermatology, ODAC Sessions | No Comments
Patient receiving injections

Source: Next Steps in Derm

This information was presented by Dr. Susan Weinkle at the 16th Annual ODAC Dermatology, Aesthetics and Surgical Conference held January 18th-21st, 2019 in Orlando, FL. The highlights from her lecture and live demonstrations were written and compiled by Dr Nikhil Shyam.

Dr. Susan Weinkle, an expert in the field of aesthetic and surgical dermatology, shares important anatomical concepts to consider when using neurotoxins and fillers safely.

The face can be split into 3 zones – the upper 1/3rd, the middle 1/3rd and the lower 1/3rd. Knowing the important vessels and nerves in each zone as well as their corresponding depth in the skin is crucial in order to minimize injury and utilize a safe technique when injecting neurotoxins and fillers.

Figure 1: D corresponds to areas where deeper injections are safer to avoid vasculature and nerves. S corresponds to areas where superficial (intradermal injections) are safer to avoid vasculature and nerves. Vessels shown are cartoon depictions of some of the more common arteries including the supraorbital, supratrochlear, superficial temporal, facial and superior and inferior labial arteries. Also depicted are the supraorbital, infraorbital and mental foramen that are located along the medial limbus.

Important Landmarks for the Upper 1/3rd of the Face

  • A line drawn vertically along the medial limbus denotes the anatomical locations of the supraorbital, infraorbital and mental foramen.
  • The supraorbital notch or foramen is the exit aperture for the supraorbital neurovascular bundle (NVB). While the vessels here initially lie deep in the skin, they become more superficial about 1.5 cm superior to the supraorbital foramen as they supply the forehead.
  • The supratrochlear NVB lies about 8-12 mm medial to the supraorbital NVB. The vessels are similarly deep initially and gradually become more superficial as they traverse superiorly to supply the forehead.
  • The supraorbital nerve, after exiting through its foramen, runs laterally and then superiorly about 1 cm medial to the temporal fusion line. It lies deep within the skin in this region.

Key Concepts for Upper 1/3rd Facial Injections and more.