8/5/2013

Teledermatolgy and Primary Care Integrating common diseases into a system where teledermatology triaging is used

Toby Maurer, MD University of California, San Francisco

The Telederm Experiment

• California Health Care Foundation-can we make it happen in the Bay Area? • La Clinica-first group in the Bay Area • Primary care provider has any derm question or wants to refer to derm • ALL referrals go through telederm-even if it is a pt followed by derm in past

1 8/5/2013

• Obtains verbal consent from pt • Provider or assistant takes picture and uploads picture • Question can be typed in on web based template at the time of pt visit or later that day, etc • Derm group answers question and primary will get notification that derm report is ready

• Provider will get first pass advice-what is it, how to treat, when he/she should see pt back or when to refer OR • Provider will be alerted that pt needs derm appointment and pt will be triaged within an appropriate time to be seen in LIVE CLINIC. • Derm report is part of the electronic medical record

2 8/5/2013

Results to date

• Dermatologists from UCSF read the triage • We have completed around 2000 consults consults and they also staff the live clinics at • 85% of consults have been successfully the primary care providers site treated by primary provider with derm guidance-the GPS system • 15% seen in live derm clinic • Wait time at San Mateo was 9 months to see DERM. Now we get consults back in 2 days and live clinics booked within 1 month

• Primary providers have learned from one on one consults • Primary providers have had to DO some dermatology • Live dermatology clinic –difficult cases but time has been properly apportioned to see them

3 8/5/2013

Acne Topicals

Primary care provider: Pt has recent onset of • BP 5% gel (10% - more drying) bumps on face.What is this and how do I treat. • Retin A 0.025% - 0.1% ( vehicle determines Has used Proactive with minimal change. strength - start with crème) • Cleocin T or erythromycin topically – Use 1 qam and 1qhs – If NO success after 8 weeks, go to p.o.’s

Primary Care Provider: Pt with –used retin A but very irritating. What is the next step?

4 8/5/2013

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

P.O. Antibiotics

• TCN - 500 bid x 8 weeks • Doxycycline - 100 bid x 8 weeks • Minocycline - 100 bid x 8 weeks • Taper - Do NOT STOP ABRUPTLY. Once pt’s skin is clear, taper the dose in ½ for another month and then stop the medication

5 8/5/2013

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

Pt did not get better…… Psoriasis-when topicals don’t work

• New pictures show increased total body • Acitretin -safer to use in liver disease-monitor TG, surface area involvement Chol • Dermatology triage: I see that pt has liver • Methrotrexate-titrate dose, follow LFT’s and CBC, disease (seen on EMR). First choice systemic needs liver biopsy after 1.5 gm-great drug if there drug is acitretin. Please order up baseline is psoriatic arthritis LFT’s , fasting TG and cholesterol. • TNF blockers -good drugs, expensive, subcu • We will book pt for derm clinic in 3 weeks- injections, presecreen for TB and Hep B and cancer risk please order baseline labs and start him on • acitretin 25 qd Ultraviolet light -is pt able to spend the time; is it accessible to pt?

6 8/5/2013

NO PREDNISONE

Atopic Dermatitis Body Treatment

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

7 8/5/2013

Gentle Skin Care discussion

• Steroids are okay to use-not going to thin out the skin • Use steroids with grease-bid • Bathing or showering 1-2x’/wk and don’t even dry off after bathing • Grease up immediately • Antihistamine (benadryl, atarax, doxepin) at night so pt can sleep and break the itch/scratch cycle

Cutaneous Tinea Topicals NOT ENOUGH Here!

• KOH is helpful in distinguishing tinea from eczema • Topical antifungals x 4-6 weeks –your formulary has econazole-apply bid • Just say NO to Lotrisone PLEASE!

8 8/5/2013

Topicals vs orals Tinea Pedis

Orals NEEDED Topicals sufficient Topicals or orals? Topicals or orals?

• Primary Care Provider: weird fungal infection? Not responding to topical or oral antifungals. • Should I add topical steroids-if so, which one? • Won’t I exacerbate the tinea?

9 8/5/2013

• This is corynebacterium- a bacterial infection • Pt notes changing mole-also itchy. Worried that causes pitted keratolysis of the foot and she has has a very bad odor • Use topical erythromycin bid or oral erythromycin for 10 days • You are right that antifungals won’t work – neither will steroids-for this condition

• -reassure-treatment not covered by county services • You can apply cryotherapy 2 x 15 sec thaw cycles or • Private derms in your county will do this for a fee

10 8/5/2013

• 24 year old with new black bump • No others noted

• Looks like seb keratosis but that is unusual in pt under the age of 29. I want to biopsy this • We will contact pt for next live derm clinic • Cc scheduler-book for live derm in 1 week

11 8/5/2013

• Pt notes these get caught on shirt-sometimes • Skin tags-benign get inflamed • Primary can snip them off-services not covered by county

• On pts back-( I can see it from homunculous) • Sometimes wife squeezes out smelly cheese –like material

12 8/5/2013

• Epidermoid -not inflamed. Does not need to be excised unless repeatedly inflamed. • Wife should stop squeezing this-could cause cyst contents to be released into surrounding tissue-causing • If pt wants this excised-please send to surgery for excision-may not be covered by insurance

Inflamed Epidermoid

• Primary Care Provider: pt came in with 2 day • Antibiotics-USELESS-this is abscessed-6 papers and metanalysis shows that antibiotics will not help where an I history of enlarging lesion and increasing pain. and D should be done • Started doxycyline • If just starting to become inflamed and cyst is small( < 1 cm), can try intralesional Kenalog injection but see them back in few days-you can exacerbate the inflammation • This cyst is bigger than 1 cm • INCISE and DRAIN and PACK-send to surgery or ER today • 6 weeks later, inspect for residual cyst and send pt for excision to surgery

13 8/5/2013

Caution

• We may not see this for a couple of days (store and forward) so please don’t send anything acute or if you must-call or write an email to personal account and we will pay special attention

• 30 yr old HIV infected pt started septra 36 hrs • This is toxic epidermal necrolysis. ago-looks like drug reaction. I have stopped • Get him into the ICU with supportive nursing the septra. Should I give him prednisone? care re: burn victim-I will be by later today to do the biopsy/frozen section • No evidence to support that prednisone is helpful • Start IVIg NOW at high dose 2 mg/kg over 3 days-qd infusion-not a lot of evidence to support that this works

14 8/5/2013

• 30 yr old with multiple previous biopsies to rule out melanoma. Here for skin check. • No recent changes in moles • No family history of melanoma • Please see in live derm clinic

• Agree and will book within 1-2 months

15 8/5/2013

• THE PROCEDURES!!!

Keloids Reply from practitioner

• These are • I like to inject keloids-review with me • Did they come from acne-if so-look for other acneiform lesions and let me know-I can discuss systemic acne treatment so that pt does not get new keloids after every acne breakout. • Will need intralesional kenalog-will book with derm clinic for monthly injections-book within next two months

16 8/5/2013

Alopecia areata

• Non-scarring alopecia-we have no idea why it starts and we don’t have preventive treatment in terms of halting future episodes • Inject with intralesional kenalog 10mg/cc q month for at least 6 months to see if there is hair regrowth • Do you want to do this or do you want us to do this in live derm clinic?

• Pt notes and this bald spot x 3 months. No other health problems. Not on any meds

17 8/5/2013

• Hair loss-will need live derm clinic evaluation and possible biopsy for scarring alopecia. • I suspect discoid • Please order CBC and iron, Vit D, TSH, VDRL, ANA • Book within 1 month

• Pt has • Yes-2 x 15 sec thaws –appropriate • Can I freeze it with liquid nitrogen? treatment. Please make sure that you have looked at all sun-exposed areas to rule out non-melanoma skin cancers • Please explain side effects • Please see pt back in 1 month-if lesion not resolved , please biopsy or send pt for biopsy to live derm clinic • Other option-we can book pt for live derm clinic in 4-6 weeks-please let me know

18 8/5/2013

• Likely hyperkeratotic AK but book in derm clinic within 1 month-I need to palpate to r/o Squamous cell cancer

• Likely squamous cell cancer-please book with derm within next month for shave biopsy Next steps: I will biopsy-send to dermatopath at UCSF

If positive-will send to plastics or dermsurgery for excision

19 8/5/2013

• Pt with new lesions around nose-thinks it started when bacon fat hit face • No pain or itching

22 yr old Brazilian 2 wk h/o

• This is sarcoid • I want to make sure that she does not have systemic involvement • Please order Cxray and PFT’s • Order a G6PD in case I need to start sytemic plaquenil • Start clobetasol oint qd to lesions • Would like to see within 2-3 weeks

20 8/5/2013

• Send to derm live clinic next week • As we manage patients in the upcoming years, • We do workup for pempigus with biopsy and triage teledermatology allows primary care direct immunofleurescence providers and dermatologists to effectively • Started prednisone work together • • Came back to derm for f/u -staph - Increased efficiency and access stopped prednisone and started antibiotics • Total cost of specialty service is less • Pt outcomes and satisfaction appear to be better

Many Thanks!

21