I Won't Miss That One Next Time…

Home , Dermatofibroma, Granuloma, Granuloma annulare, Halo nevus, Seborrheic keratosis

“I Won’t Miss That One Next Time…” Richard E. Johnson, DO

I WON’T MISS THAT ONE NEXT TIME…..

JANUARY 29, 2018

RICHARD E JOHNSON, DO, FAAD, FAOCD

OBJECTIVES

• A couple of days away from the office, cell phones off please • A little time with friends, family, and colleagues • Obtain required CME in a relaxed, no-stress venue • Recognize some commonly seen dermatologic entities • Getting through winter with minimal use of the snowblower • Reinforcing your visual-diagnostic skills with the requisite dermatology pics • Win the powerball…..but only if it’s more than $800 million

RISK MANAGEMENT— PATIENT SAFETY

From POMA website…. “12 CME credit hours in the areas of patient safety or risk management (either Category 1 or Category 2).”

For Florida licensees: “medical errors” requirement

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 1 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

Activities in patient safety and risk management may include the following topics:

Patient safety Risk management Improving medical records and record keeping Reducing medical errors Professional conduct and ethics Improving communications Preventative medicine Health-care quality improvements

DISCLOSURES…………. 1. I’m old 2. I can be opinionated at times 3. I still use paper charts 4. I don’t think “we” have a health care problem in the United States ……..”we” have a health INSURANCE COMPANY problem in the United States (see #2 above) 5. I attempt, as best as I can, to be a patient advocate: cost effective treatments, prior authorizations fights on the patients’ behalf, follow-up care (……hey, that’s an osteopathic approach.) 6. I attempt to provide useful, relevant, and fun lectures with information that can be used to fulfill #5 above 7. Oh, and I have no drug company affiliations, but I do tend to slip in brand names occasionally (see #1 above)

IF IN DOUBT

• Biopsy • Refer

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 2 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

Patient-initiated Physician-initiated i.e. pt’s reason for i.e. incidental finding visit

I don’t Changes Change Not sure •size like it noted… Obvious of •shape diagnosis diagnosis, •color but… •symptoms

Cosmetic Refer Reassure •bx cost •tx cost •path fees •scar •results you want? bx-tx Pt bx refer returns right then

tx refer bx refer or tx

No this is not an insurance company lecture

A BASS-ACKWARDS LECTURE

• My first attempt

• May be my last attempt

• Get your clickers ready…..participant input from the get-go

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 3 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

• Get the brain cells started before going into the room • Each case presented as if medical assistant gave you a brief raison d’etre for the next patient • Pick from group of possible diagnoses • Add more into • What’s a derm lecture without pictures • Whittle down the list of usual suspects and “possibles” • Make the final, and of course, the correct diagnosis • Maybe some treatment pearls

• Repeat with the next patient’s saga

7 YEAR OLD MALE WITH MOM AND DAD

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 4 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

7 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. Acne 1. Tinea corporis 1. Molluscum 2. Warts 2. Granuloma annulare 2. Tinea corporis 3. Tinea corporis 3. Seborrheic dermatitis 3. Impetigo 4. Psoriasis 4. Psoriasis 4. Granuloma annulare 5. Granuloma annulare 5. Flea bites 5. Warts 6. Molluscum 6. Scabies 6. Pyogenic granuloma 7. Flea bites 7. Impetigo 7. Bed bugs 8. Scabies 8. Bed bugs 8. Psoriasis

USE CLICKERS HERE

DF DX #1

1. Acne 2. Warts 3. Tinea corporis 4. Psoriasis 5. Granuloma annulare 6. Molluscum 7. Flea bites 8. Scabies

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 5 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

Df Dx #2

1. Tinea corporis 2. Granuloma annulare 3. Seborrheic dermatitis 4. Psoriasis 5. Flea bites 6. Scabies 7. Impetigo 8. Bed bugs

Df Dx #3

1. Molluscum 2. Tinea corporis 3. Impetigo 4. Granuloma annulare 5. Warts 6. Pyogenic granuloma 7. Bed bugs 8. Psoriasis

All three groups are correct at this point………

Let’s get some info from the patient…….

(I try to converse directly with the patients; if possible and when applicable)

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 6 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

HISTORY • Present for 6 months • No symptoms, just there • Prior treatments = no help • Topical antifungal • Triple antibiotic • OTC hydrocortisone

• No other family members with it • No family history of same

7 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3

1. Acne 1. Tinea corporis 1. Molluscum 2. Warts 2. Granuloma annulare 2. Tinea corporis 3. Tinea corporis 3. Seborrheic dermatitis 3. Impetigo 4. Psoriasis 4. Psoriasis 4. Granuloma annulare 5. Granuloma annulare 5. Flea bites 5. Warts 6. Molluscum 6. Scabies 6. Pyogenic granuloma 7. Flea bites 7. Impetigo 7. Bed bugs 8. Scabies 8. Bed bugs 8. Psoriasis

7 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. Tinea corporis 1. Tinea corporis 1. Molluscum 2. Psoriasis 2. Granuloma annulare 2. Tinea corporis 3. Granuloma annulare 3. Seborrheic dermatitis 3. Impetigo 4. Molluscum 4. Psoriasis 4. Granuloma annulare 5. Impetigo 5. Pyogenic granuloma 6. Psoriasis

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 7 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

USE CLICKERS HERE

PHYSICAL EXAM

• Several round/ovoid lesions • Raised rubbery/firm rim with essentially clear center • No scale • Flesh colored • No inflammation

7 YEAR OLD MALE

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 8 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

7 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. Granuloma annulare 1. Granuloma annulare 1. Molluscum 2. Molluscum 2. Granuloma annulare 3. Pyogenic granuloma

WHAT’S A DERM LECTURE WITHOUT PICTURES

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 9 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 10 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

GRANULOMA ANNULARE

• Generally children and young adults—but, diseases don’t read the textbooks

• Generally self-limiting—but, diseases don’t read the textbooks

• Etiology: trauma, insect bites, viral induced, ? medications (allopurinal), sun exposure…….

TYPES OF GRANULOMA ANNULARE

• Localized lesions • Generalized • Subcutaneous • Perforating • Patch • Actinic

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LOCALIZED

• Most commonly seen type • Raised rubbery edge • Centrally, surface normal color/texture, may be slightly depress/hyperpigmented • More than half of the patients have single lesion

……but diseases don’t read the textbooks

GENERALIZED GRANULOMA ANNULARE

• About 10-15% of patients have more than 10 lesions • More in <10yo and >50yo • Generally truncal in distribution • Generally rings are <5cm • ???may be a marker for diabetes

SUBCUTANEOUS GRANULOMA ANNULARE

• BB sized to “large” painless papules/nodules • Elbows, knees, and ankles most common sites • ??may be a marker for diabetes or abnormal glucose tolerance

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PERFORATING GRANULOMA ANNULARE

• Superficial small papules • Hands and fingers • May develop umbilication (?? MC’s) • Ulceration rarely occurs, but is possible • 1/3 +/- patients have diabetes

PATCH GRANULOMA ANNULARE

• Subtle pink patches without induration or scale • Women > men • Proximal extremities most common sites • Localized and generalized variants have been described

ACTINIC GRANULOMA

• Large annular plaques develop on face or other actinically damaged skin • May be quite large and elevated

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 13 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

TREATMENT

• Rarely needs biopsy • Perhaps with less common variants, but with classic GA, no biopsy needed • Benign neglect • Topical steroids—with or without occlusion • Atrophy potential • Intralesional steroids • Cryotherapy • Oral retinoids—isotretinoin with iPledge “hassles” vs acitretin • Seems to be effective, but relapses expected when d/c med

CAVEATS

• Not all round rashes are ringworm • Firm-edged asymptomatic annulare lesion dorsum of foot/hand think GA • Biopsy rarely needed for classic GA, but if done for confirmation, sometimes lesions resolves with biopsy—”therapeutic biopsy” • Generalized, “sudden onset” GA, consider any new meds started …..?allopurinol

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75 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. BCC/SCC 1. Tinea 1. BCC/SCC 2. Seborrheic keratosis 2. Seborrhea 2. Tinea 3. Tinea 3. Seborrheic dermatitis 3. Eczema 4. Psoriasis 4. Rosacea 4. Onychomycosis 5. Eczema 5. Stasis dermatitis 5. Psoriasis 6. Stasis dermatitis 6. Actinic keratosis 6. Bateman’s purpura 7. Bateman’s purpura 7. Eczema 7. Seborrheic keratosis

CLICKER RESPONSE PAGE

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ONCE AGAIN, ALL CORRECT

HISTORY AND PHYSICAL WILL HELP

HISTORY

• Present for “awhile” • “Patient-speak”: anywhere from this morning to “I was born with it. • After conversing with the patient: about 8 months • Itchy at first, now, not at all • Prior treatments • OTC: Benadryl cream and hydrocortisone 1% • Rx: betamethasone for 3 months and since then, about 4 months fluocinolone • Was size of quarter, now whole back of hand

DF DX 1

1. BCC/SCC 2. Seborrheic keratosis 3. Tinea 4. Psoriasis 5. Eczema 6. Stasis dermatitis 7. Bateman’s purpura

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DF DX 1

1. SCC 2. Seborrheic keratosis 3. Tinea 4. Psoriasis 5. Eczema 6. Stasis dermatitis 7. Bateman’s purpura

DF DX 1

1. SCC 2. Tinea 3. Psoriasis 4. Eczema

DF DX 2

1. Tinea 2. Seborrhea 3. Seborrheic dermatitis 4. Rosacea 5. Stasis dermatitis 6. Actinic keratosis 7. Eczema

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DF DX 2

1. Tinea 2. Eczema

DF DX 3

1. BCC/SCC 2. Tinea 3. Eczema 4. Onychomycosis 5. Psoriasis 6. Bateman’s purpura 7. Seborrheic keratosis

DF DX 3

1. SCC 2. Tinea 3. Eczema 4. Onychomycosis 5. Psoriasis 6. Bateman’s purpura 7. Seborrheic keratosis

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 18 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

DF DX 3

1. SCC 2. Tinea 3. Eczema 4. Psoriasis

75 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3

1. SCC 1. Tinea 1. SCC 2. Tinea 2. Eczema 2. Tinea 3. Psoriasis 3. Eczema 4. Eczema 4. Psoriasis

ALL THREE PRETTY MUCH THE SAME

LET’S SEE WHAT THE PATIENT HAS

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POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 20 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 21 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

75 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3

1. SCC 1. Tinea 1. SCC 2. Tinea 2. Eczema 2. Tinea 3. Psoriasis 3. Eczema 4. Eczema 4. Psoriasis

TINEA INCOGNITO

• Remember, diseases don’t read the textbook….. • Generally: scaly edged, clear center…..tinea scaly throughout…..eczema • One hand only…..probably not eczema • Any onychomycotic nails? • Check the feet…………. two foot, one hand syndrome • Biopsy, if in doubt.

TREATMENT

• Topical may do it, but not wrong adding short-term oral • Majocchi’s granuloma-type needs oral and topical • Wrestlers………shampoo?

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PATIENT IN ROOM #3

• Was here an hour before his appointment time …… “to beat the crowd”

• Has another appointment across town scheduled for 30 minutes after his scheduled appointment was to start here.

68 YEAR OLD MALE ?

68 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. BCC/SCC 1. Changing mole 1. BCC/SCC 2. Seborrheic keratosis 2. Seborrhea 2. Tinea 3. Tinea 3. Seborrheic dermatitis 3. Scabies 4. Psoriasis 4. Rosacea 4. Hair loss 5. Warts 5. Lichen simplex 5. Psoriasis 6. Lichen simplex chronicus 6. Lichen simplex chronicus 6. Scabies chronicus 7. Tags 7. Lyme disease 7. Seborrheic keratosis

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 23 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

CLICKERS

No fooling you…… all acceptable.

Let’s get some history

68 YEAR OLD MALE

• Itchy rash in groin for last 6 months • Scrubbing with antibacterial soap • No Rx treatments • OTC hydrocortisone 1% and clotrimazole creams, …..on and off use • “I think it started this summer with “crotch-rot”

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 24 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

68 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. Tinea 1. Changing mole 1. BCC/SCC 2. Psoriasis 2. Seborrhea 2. Tinea 3. Lichen simplex 3. Seborrheic dermatitis 3. Scabies chronicus 4. Rosacea 4. Hair loss 5. Lichen simplex 5. Psoriasis chronicus 6. Lichen simplex 6. Scabies chronicus 7. Lyme disease 7. Seborrheic keratosis

68 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. Tinea 1. Seborrheic dermatitis 1. BCC/SCC 2. Psoriasis 2. Lichen simplex 2. Tinea 3. Lichen simplex chronicus 3. Scabies chronicus 3. Scabies 4. Hair loss 5. Psoriasis 6. Lichen simplex chronicus 7. Seborrheic keratosis

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 25 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

68 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. Tinea 1. Seborrheic dermatitis 1. Tinea 2. Psoriasis 2. Lichen simplex 2. Scabies 3. Lichen simplex chronicus 3. Psoriasis chronicus 3. Scabies 4. Lichen simplex chronicus

EXAM TIME

• Red inflamed lichenified scrotum with minimal crease or thigh involvement • Some excoriations noted • No nodules noted • No other body areas

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 26 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

68 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. Tinea 1. Seborrheic dermatitis 1. Tinea 2. Psoriasis 2. Lichen simplex 2. Scabies 3. Lichen simplex chronicus 3. Psoriasis chronicus 3. Scabies 4. Lichen simplex chronicus

CLICKERS

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 27 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

68 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. Tinea 1. Seborrheic dermatitis 1. Tinea 2. Psoriasis 2. Lichen simplex 2. Scabies 3. Lichen simplex chronicus 3. Psoriasis chronicus 3. Scabies 4. Lichen simplex chronicus

68 YEAR OLD MALE

DF DX 1 DF DX 2 DF DX 3 1. Lichen simplex 1. Lichen simplex 1. Lichen simplex chronicus chronicus chronicus

RASS

• Red Angry Scrotum Syndrome • Much more common in males………… females get it too, but LSC only name they get • Lichen Simplex Chronicus • Also seen ankles, elbows; anywhere chronic friction/scratching

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 28 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

TREATMENT

• Long term care • Often recurrent • Castle moat analogy—rebuilding barrier function • Sprained thumb analogy—wash to wash, not wash to wash rash • Patient education key to treatment success • 2/2/2 dosing of topical steroids

32 YEAR OLD FEMALE

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 29 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

32 YEAR OLD FEMALE

DF DX 1 DF DX 2 DF DX 3 1. Acne 1. Tags 1. Rosacea 2. Annoying mole 2. Onychomycosis 2. Tinea 3. Eczema 3. Hair loss 3. Shingles 4. Psoriasis 4. Warts 4. Hair loss 5. Warts 5. BCC 5. Annoying mole 6. Rosacea 6. Scabies 6. Eczema 7. Shingles 7. Tinea 7. Tags

CLICKER PAGE

HISTORY

• Present for about 3 years • Regularly/occasionally shaves to bleed • No symptoms • Was flatter, now more raised • Other similar lesions on legs and arms, but not in the way • Tried wart medicine for a couple of days, but “never bothered me, so I stopped using it.”

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 30 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

32 YEAR OLD FEMALE

DF DX 1 DF DX 2 DF DX 3 1. Annoying mole 1. Tags 1. Rosacea 2. Warts 2. Onychomycosis 2. Tinea 3. Hair loss 3. Shingles 4. Warts 4. Hair loss 5. BCC 5. Annoying mole 6. Scabies 6. Eczema 7. Tinea 7. Tags

32 YEAR OLD FEMALE

DF DX 1 DF DX 2 DF DX 3 1. Annoying mole 1. Warts 1. Rosacea 2. Warts 2. BCC 2. Tinea 3. Shingles 4. Hair loss 5. Annoying mole 6. Eczema 7. Tags

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 31 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

32 YEAR OLD FEMALE

DF DX 1 DF DX 2 DF DX 3 1. Annoying mole 1. Warts 1. Annoying mole 2. Warts 2. BCC

PHYSICAL EXAM

• Firm pink/red nodule • Small surface scab

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 32 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

32 YEAR OLD FEMALE

DF DX 1 DF DX 2 DF DX 3 1. Annoying mole 1. Warts 1. Annoying mole 2. Warts 2. BCC

32 YEAR OLD FEMALE

DF DX 1 DF DX 2 DF DX 3 1. Annoying mole 1. BCC 1. Annoying mole

If in doubt, biopsy

ANNOYING MOLE

• Dermatofibroma • Trauma induced ?? • Firm • Flat or domed • Dimples • Not easily traumatized, as opposed to BCC .…..remember, diseases don’t read the textbook.

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 33 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

TREATMENT

• Benign neglect • Surgery • Cryosurgery • IL injections

Lightening Round

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 34 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

3 SECOND VISUAL

• Pick your diagnosis • Review picture • Discuss

PICK YOUR POISON

1. Vasculitis 2. Zoster 3. Contact dermatitis 4. Erythema ab igne 5. Urticaria 6. Leprosy

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 35 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

CLICKERS

Erythema ab igne

…..also known as hot water bottle rash, fire stains, laptop thigh, granny's tartan and toasted skin syndrome

…..caused by long-term exposure to heat (infrared radiation)

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 36 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

READY?

HERE’S THE PITCH…..STRIKE 2

HHHMMMMMMMMM?

1. Melanoma 2. Eclipse mole 3. Tinea capitis 4. Bug bite site 5. I don’t know, but I’m going to biopsy it 6. I don’t know, but I’m going to refer

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 37 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

CLICKERS

ECLIPSE MOLE

• Nevus en cocarde • Benign

• biopsy/refer certainly an option

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 38 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

HERE’S THE WINDUP

…..STRIKE 3

AND………….

1. Onychomycosis 2. Psoriasis 3. Onychomadesis 4. Oops, be more careful with closing the car door 5. Paronychia

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 39 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

CLICKERS

ONYCHOMADESIS

• Proximal, complete separation of the nail plate from nail bed • Results from full, but temporary, arrest of nail growth • Stressful events, commonly seen after Hand-Foot-Mouth Disease

• Beau’s lines—transverse grooves cause be partial arrest of nail growth

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BOTTOM OF THE NINTH

TWO OUTS, 3-2 COUNT

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WELL……………..?

1. Melanoma 2. Halo nevus 3. Lyme disease 4. Bateman’s purpura

CLICKERS

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 42 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

HALO NEVUS

Central lesion characteristics and symmetry of halo may determine decision tree

1. If benign appearing and centrally placed nevus with symmetrical depigmentation is noted, need not be removed….patient’s age?? Periodic evaluation of lesion and patient recommended 2. Biopsy/refer: Atypical appearing central nevus asymmetrical halo eccentric placement of nevus in halo personal or family hx of atypical nevi and/or melanoma

OOPS, LOOKS LIKE EXTRA INNINGS

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 43 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

WHAT’S IT GONNA BE?

1. Psoriasis 2. Tinea versicolor 3. Pityriasis alba 4. Vitiligo 5. Tinea faciale and corporis

CLICKERS

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 44 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

PITYRIASIS ALBA

-- more common in children than adults -- often seen in atopic patients -- most common sites are face and upper lateral arms -- usually begins with non-specific erythema and gradually becomes scaly and hypopigmented -- caused by transient and mild dermal inflammation

TREATMENT

emollient moisturizers -- mild inflammation treated with anti-inflammatory

Protopic® and Elidil® probably work better than topical steroids

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 45 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

POST-LECTURE QUESTIONS

1. This “reverse” lecture format was a bust 2. This “reverse” lecture format was okay 3. Some of the lecturer’s objectives were met

(sorry, no powerball winning today) 4. Enough with winter already! 5. Yea!! The end.

CLICKERS

POMA District VIII 31st Annual Educational Winter Seminar January 25‐28, 2018 46 “I Won’t Miss That One Next Time…” Richard E. Johnson, DO

DISCLOSURES…………. 1. I’m old 2. I can be opinionated at times 3. I still use paper charts

4. I don’t think “we” have a health care problem in the United States

……..”we” have a health INSURANCE COMPANY problem in the United States (see #2 above)

5. I attempt, as best as I can, to be a patient advocate: cost effective treatments, prior authorizations fights on the patients’ behalf, follow-up care (……hey, that’s an osteopathic approach.) 6. I attempt to provide useful, relevant, and fun lectures with information that can be used to fulfill #5 above

5. Oh, and I have no drug company affiliations, but I do tend to slip in brand names occasionally

(see #1 above)

…….JUST SAYIN’

PAPER CHART EMR

• Diagnosis made in about 5 seconds • Meaningful use entries: 5 minutes • Chart note: same • Entry of history: 3 minutes • Patient education: 2 minutes • Look at patient/diagnosis: 5 seconds • Chit-chat time: 2 minutes • Entry of PE: 3 minutes • Visit complete: 4+ minutes • Patient education: 2 minutes • Entry documenting same: 3 minutes • Chit-chat time: not allowed, no time • Visit complete: 16+++ minutes

How many visits per day/week/month/year are like this for EVERY specialty……. Where are our national organizations?

See # 2 under “DISCLAIMERS”

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