LEVEL I SYLLABUS

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ACDT Course Learning Objectives

Upon Completion, Those Enrolled Will Be MODULE Prepared To...

The Language of Dermatology 1. Define and spell the following cutaneous lesions/descriptors: a. Macule b. Patch c. Papule d. Nodule e. Cyst f. Plaque g. Wheal h. Vesicle i. Bulla j. Pustule k. Erosion l. Ulcer m. Atrophy n. Scaling o. Crusting p. Excoriations q. Fissures r. Lichenification s. Erythematous t. Violaceous u. Purpuric v. Hypo­/Hyperpigmented w. Linear x. Annular y. Nummular/Discoid z. Blaschkoid aa. Morbilliform bb. Polycyclic cc. Arcuate dd. Reticular

Collecting & Documenting Patient History Part I 1. Describe the importance of documentation and chart review, while properly collecting dermatology­specific medical history components, including: a. Chief Complaint b. Past Medical History c. Family History d. Medications e. Allergies

Collecting & Documenting Patient History Part II 1. Demonstrate the proper collection of dermatology­specific medical history and explain the significance of the following: a. Social History b. Review of Systems c. History of Present Illness

Anatomy 1. Spell and document the following directional indicators while applying them to the appropriate anatomical landmarks: a. Proximal/Distal b. Superior/Mid/Inferior c. Anterior/Posterior d. Medial/Lateral e. Dorsal/Ventral 2. Spell and identify specific anatomical locations involving the: a. Scalp b. Forehead c. Ears d. Eyes e. Nose f. Cheeks g. Lips h. Chin i. Neck j. Back k. Upper extremity l. Hands m. Nails n. Chest o. Abdomen p. Buttocks q. Hips r. Lower extremity s. Feet

Skin Structure and Function 1. Identify and spell the three primary layers of skin: a. Subcutaneous tissue b. Dermis c. Epidermis 2. Identify the following structures: a. Apocrine sweat glands b. Eccrine sweat glands c. Sebaceous glands d. Collagen e. Elastin f. Melanocytes g. Keratinocytes

Introduction to Coding Part I 1. Explain the significance of the following: a. Evaluation & Management (E/M) codes for consults and new/established patients. b. Current Procedural Terminology (CPT) codes. c. International Classification of Diseases (ICD) diagnosis codes. Introduction to Coding Part II 1. Explain the concepts of “bullet points and time” and its significance in determining visit charges. a. Define bundling and explain how insurances apply this concept to medical billing practice. b. Explain the rationale behind modifiers. c. Identify the proper use of shave removal and shave biopsies.

Intro to ICD­10 1. Explain the fundamental difference between E/M, Procedural, and ICD billing codes. 2. Provide the implementation date for mandatory transition to the ICD­10 system. 3. List the benefits of ICD­10 coding. 4. Define the following terms: a. Granularity b. Laterality 5. Compare and contrast the following: a. The ICD­10­CM Index to Diseases and Injury b. The ICD­10­CM Tabular List of Diseases and Injuries 6. Explain the purpose and use of the following instructions, notes, and terms: a. Includes b. Excludes1 c. Excludes2 d. See e. See Also f. Use Additional Code g. Code First h. Adding the appropriate 7th character 7. Explain the purpose and use of the following ICD­10 punctuation marks: a. Parentheses b. Brackets c. Hyphens 8. Explain the purpose and use of the following abbreviations: a. NEC b. NOS 9. Identify some of the most important considerations for staff members working in medical offices transition to the ICD­10 coding system.

Skin Cancer 1. Differentiate and outline the major risk factors, presentations, subtypes, prognoses, and most common treatment options for the following skin cancers: a. Basal Cell Carcinoma b. Squamous Cell Carcinoma c. Melanoma

Understanding Concentrations 1. Apply the proper ratios needed to dilute IL cortisone to the appropriate concentration.

Prescription Order Entry 1. Provide statistics regarding the impact of medication errors in the United States. 2. Describe the role of medical assistants in prescription order entry. 3. Define the meaning of the acronym CPOE. 4. List, define, and provide common examples of the following components of prescription orders: a. Patient Name b. Medication Name c. Strength d. Formulation e. Quantity (Per Dose) f. Route of Delivery g. Frequency of Dose h. Duration i. Total To Dispense j. Refills 5. Provide relevant examples of pitfalls/mistakes made by those entering the above prescription components into the EMR. 6. List the most important steps needed to prevent errors in medication order entry. 7. Define the meaning, significance, and role of Clinical Decision Support (CDS) alerts with regard to CPOE and avoidance of medication errors.

Intro to Medication Modules 1. Identify the prescription package insert as being the definitive source for explaining the indication, proper use, and potential side effects of a given medication.

Antibiotics 1. Differentiate topical and systemic antibiotics. 2. Contrast the mechanisms of action of bacteriostatic and bactericidal antibiotics. 3. Identify potential and most frequent side effects of the most common antibiotics used in dermatology. 4. Identify the following antibiotic categories and subtypes: a. Tetracyclines b. TMP/SMZ c. Macrolides d. Penicillins e. Cephalosporins f. Fluoroquinolones g. Dapsone h. Clindamycin/Rifampin i. Benzoyl Peroxide j. Clindamycin/Erythromycin k. Sodium Sulfacetamide l. Metronidazole m. Dapsone (Topical) n. Wound Care Antibiotics

Antifungals 1. Identify the most common topical antifungal medications. 2. Identify and spell the following systemic antifungal medications: a. Griseofulvin b. Fluconazole c. Terbinafine d. Itraconazole e. Ketoconazole 3. Contrast the mechanisms of action of fungicidal and fungistatic medications. 4. Provide directions for appropriate use of specific antifungal medications. 5. Identify potential and most frequent side effects of the most common antifungals used in dermatology.

Antihistamines 1. Organize antihistamines into one of the following categories: a. Sedating b. Non­sedating c. H2 Blockers 2. Explain the mechanism of action in antihistamines. 3. List the various methods in which antihistamines can be administered or applied. 4. Identify the most common side effects of antihistamines. 5. Provide appropriate directions and precautions to patients who have been prescribed antihistamines.

Biologics 1. Define the term “Biologic” as it relates to dermatological medications. 2. Identify the biologics most commonly used in dermatology, including: a. Etanercept b. Infliximab c. Adalimumab d. Ustekinumab 2. Explain the mechanisms of action of biologics. 3. Identify the proper administration of biologics. 4. Identify potential side effects of specific biologics. 5. Assist in providing patient education to those who are prescribed biologics.

Corticosteroids 1. Identify misinformation regarding medications classified as “steroids”. 2. Explain the mechanism of action in both systemic and topical steroids. 3. Explain the various methods in which steroids can be administered or applied. 4. Assist in educating patients regarding the appropriate use of steroids.

Hormone Blocking Agents 1. Identify the most commonly used hormone­blocking agents and list the indicated use of each. 2. Explain the mechanisms of action both Spironolactone and Finasteride. 3. Identify potential and most common side effects of both medications. 4. Provide instruction to patients regarding the appropriate use of these medications.

Hydroquinone & Azelaic Acid 1. Provide the mechanisms of action, as well intended use of both Hydroquinone and Azelaic Acid. 2. Identify in which vehicles either medication may be dispensed, and how each should be applied. 3. Identify potential side effects of these medications, both shared and specific.

Keratolytics 1. Define the term “Keratolytic”. 2. List the most common keratolytic ingredients. 3. Describe the mechanism of action of keratolytics. 4. Provide instruction to patients with regard to appropriate use of these medications. 5. Identify potential side effects of keratolytics.

Methotrexate 1. Provide the primary indication of Methotrexate as used in dermatology. 2. Identify and describe the mechanism of action of Methotrexate. 3. List the most common and concerning side effects of this medication. 4. Explain the need for laboratory monitoring while using Methotrexate. 5. Identify medications which should be avoided or used with caution while on Methotrexate.

Non­Steroidal Anti­Inflammatory Medications 1. Define the term “Non­Steroidal Anti­Inflammatory” as it relates to dermatology. 2. Identify the three most common topical Non­Steroidal Anti­Inflammatory medications used in dermatology. 3. Explain the mechanisms of action of these medications 4. Describe the proper use and potential side effects of these medications. 5. Provide instruction to patients regarding the appropriate use of these medications.

Retinoids 1. Define the term “Retinoid”. 2. Identify the most commonly used topical and systemic retinoids. 3. Describe the mechanism of action in retinoids. 4. Explain how to appropriately use these medications, while identifying and avoiding potential side effects.

Topical Antipruritics 1. Define the term “Topical Antipruritic”. 2. Identify the most commonly used topical antipruritics. 3. Describe the different mechanisms of action in various topical antipruritics. 4. Identify potential side effects of these medications. 5. Explain how to appropriately use topical antipruritics.

Topical Chemotherapies 1. Identify the two most common ingredients used used in topical chemotherapies. 2. Describe the mechanisms of action in both topical chemotherapies. 3. Provide examples of the most common frequency and duration of application. 4. List potential and expected side effects of topical chemotherapies.

Psoriasis 1. Explain the Psoriasis disease process. 2. Identify potential precipitating and exacerbating factors of Psoriasis. 3. Describe the various physical presentations of Psoriasis 4. Determine how Psoriasis is graded with regard to severity. 5. Describe the general treatment approaches used for Psoriasis.

UV Light, Sunscreen, Skin Type 1. Describe the three types of UV radiation. 2. Identify sources of possible UV exposure. 3. Explain the process of tanning as a physiological response. 4. Identify the various sunscreen ingredients, and categorize each as either organic or inorganic. 5. Define SPF and explain how this rating is determined. 6. Identify and describe which sunscreen ingredients act as UVA blockers. 7. Provide recommendations to patients regarding selection and appropriate use of sunscreen. 8. Define the concept of skin typing. 9. Assign skin type utilizing the Fitzpatrick scale.

iPledge 1. Provide the purpose of the iPledge program. 2. List the general requirements necessary to use Isotretinoin under the iPledge program. 3. Explain the acronyms FCBP and FNCBP, and the importance of these identifications to the iPledge program. 4. Describe the registration, confirmation, and discontinuation processes for FCBP. 5. Describe the registration, confirmation, and discontinuation processes for males and FNCBP.

Most Common Benign Lesions 1. Identify, spell, and provide the etiology (if known) of the following benign cutaneous lesions: a. Seborrheic Keratoses b. Cherry Hemangiomas c. Milias d. Solar Lentigines e. Chondrodermatitis Nodularis Helicis (CNH) f. Cysts g. Dermatofibromas h. Neurofibromas i. Sebaceous Hyperplasia j. Idiopathic Guttate Hypomelanosis k. Lipomas l. Lichenoid Keratoses m. Venous Lakes n. Skin Tags o. Fibrous Papules p. Keloids & Hypertrophic Scars q. Cafe­au­Lait Spots

Warts & Molluscum 1. Define and explain the viral etiologies of both warts and molluscum. 2. List the various risk factors associated with both warts and molluscum. 3. Identify the presentation of the various “types” of warts. 4. Describe the presentation of molluscum. 5. Explain the available treatment options, as well as treatment expectations, for both warts and molluscum.

Phototherapy & PDT 1. Describe the potential benefits of light treatment with respect to the associated risk of UV exposure. 2. Identify the various types and subtypes of light treatment. 3. Provide the names of the conditions for which specific light treatments are indicated. 4. Explain the concept of PUVA, and the routes through which this treatment may be delivered. 5. Describe the effects of PUVA and NB­UVB with regard to the skin’s immune system. 6. Compare and contrast NB­UVB to PUVA. 7. Explain the significance of Skin Type and Minimal Erythema Dose (MED) in determining a specific treatment protocol. 8. Define the term “Photodynamic Therapy”. 9. Describe the relation between Blue Light and Levulan, and the effects which their interaction produce in both Actinic Keratoses and Acne. 10. Identify the conditions in which light treatments would generally be contraindicated. 11. Provide the potential and expected side effects of each form of light treatment, both during and after completion of treatment.

Moisturizers & Medication Vehicles 1. Explain the different methods through which the skin maintains hydration. 2. Identify the most common moisturizer ingredients and the purpose for each. 3. Describe the correlation between dry skin and sensitive skin. 4. Provide patient education regarding proper skin moisturizer selection. 5. Define the term “medication vehicle”. 6. Identify the available medication vehicles, and describe the intended purpose of each.

Eczema 1. Define the term “Eczema” and identify its various presentations. 2. Explain the role of genetic predisposition and environmental factors. 3. Describe the Eczema disease process. 4. Discuss the general treatment approach while providing recommendations for prevention of future flares.

Acne & Rosacea 1. Discern truths from misinformation with regard to the various treatments for both Acne and Rosacea. 2. Describe the following components of Acne, as well as their contribution to the Acne process: a. Pilosebaceous unit b. Open comedo c. Closed comedo d. Microcomedo e. P. acnes bacteria f. Androgens 3. Describe the various treatment approaches for acne, including: a. Killing Bacteria b. Prevention/Treatment of Comedones c. Hormonal d. Isotretinoin 4. Provide comprehensive acne­specific patient education. 5. Define the term “Rosacea,” and identify the condition by its various presentations. 6. Discuss the various factors which may precipitate Rosacea. 7. Identify the various treatment methods for Rosacea, including: a. Avoidance of triggers b. Antibiotics c. Topical Anti­Inflammatories d. Retinoids e. Laser & Light Treatments f. Alternative Treatments

AK & Dysplastic Nevi 1. Define the terms Actinic Keratosis and Dysplastic Nevus, and provide their respective etiologies. 2. Describe the potential for malignant degeneration of both Actinic Keratoses and Dysplastic Nevi. 3. Describe the typical presentation of Actinic Keratoses and Dysplastic Nevi. 4. Describe the causes and contributing factors in the development of Actinic Keratoses. 5. Discuss the various treatment options available for Actinic Keratoses and Dysplastic Nevi. 6. Explain how Dysplastic Nevi are classified in accordance with their severity. Common Rashes & Conditions Part I 1. Describe the etiologies, presentations, prognoses, and treatment options available for the following common rashes and cutaneous conditions: a. Alopecia Areata b. Androgenetic Alopecia c. Asteatotic Eczema d. Contact Dermatitis e. Drug Eruptions f. Dyshidrotic Eczema g. Granuloma Annulare h. Intertrigo i. Keratosis Pilaris j. Lichen Planus k. LSC & Prurigo Nodularis l. Melasma

Common Rashes & Conditions Part II 1. Describe the etiologies, presentations, prognoses, and treatment options available for the following common rashes and cutaneous conditions: a. Notalgia Paresthetica b. Nummular Eczema c. Perioral Dermatitis d. Pityriasis Alba e. Pityriasis Rosea f. Pseudofolliculitis g. Seborrheic Dermatitis h. Stasis Dermatitis i. Tinea Versicolor j. Urticaria k. Vitiligo

Infections & Infestations 1. Describe the risk factors, preventative measures, prognoses, and treatment options available for the following infections and infestations: a. Staphylococcus b. Streptococcus c. Pseudomonas d. Tinea Pedis e. Tinea Cruris f. Tinea Capitis g. Tinea Unguium h. Onychomycosis i. Candidiasis j. Herpes Simplex k. Varicella Zoster l. Herpes Zoster m. Head Lice n. Scabies

Autoimmune Conditions 1. Compare and contrast healthy immune function with that which occurs in autoimmune disease. 2. Describe the etiologies, presentations, diagnostic measures, prognoses, and treatment options available for the following autoimmune conditions: a. Bullous Pemphigoid b. Pemphigus c. Lupus d. Dermatomyositis e. Morphea f. Epidermolysis Bullosa Acquisita

Most Common Labs 1. Describe the purpose, processing procedures, and most common scenarios in which the following labs may be ordered: a. Biopsies b. CBC c. Lipid Panel d. Hepatic Function Panel e. BUN/Creatinine f. CMP g. Hepatitis Panel h. hCG i. Bacterial Culture j. Fungal Culture k. KOH Prep l. Wet Mount m. ANA n. PAS Stain 2. Explain the significance of the ICD code V58.69 with regard to ordering labs.

Most Common Procedures Part I 1. Describe the purpose, and various methods/techniques employed in performing the following procedures: a. Cryosurgery b. Biopsy c. ED&C d. Shave Removal e. Excision (Traditional)

Most Common Procedures Part II 1. Describe the purpose, and various methods/techniques employed in performing the following procedures: a. Mohs Surgery b. Incision & Drainage 2. Identify the following instruments used in a clinical setting: a. Mayo Stand/Tray b. Needle Driver c. Forceps d. Hemostats e. Scissors f. Scalpel Blades/Handles 3. Describe and distinguish the various types of sutures materials and sizes.

Principles of Cosmetic Dermatology 1. Explain the physiological principles behind skin aging and damage. 2. Describe the categories of cosmetic treatments. 3. Define and discuss the etiologies, preventative and exacerbating factors, and treatment options for: a. Rhytids b. Loss of “Fullness” c. Irregular Surface Texture d. Irregular Surface Tone

A few reminders… A few reminders…

• The purpose of this syllabus is to serve as an • You may print the syllabus. “outline” only! – However, you should strongly consider printing in – Because our training is video-based, it’s literally black-and-white only and on “draft” setting as the impossible for these slide images to represent all sheer amount of color and detail within the slides information reviewed through the program audio would quickly deplete most printer cartridges! and/or animation. – Also remember that you can choose to only print • Unfortunately, some slides are impossible to represent in print. those pages which you find most beneficial. • In an effort to provide you with a syllabus that is most “representative” of the content reviewed, certain slides in the syllabus may not exactly match those within a given module.

A few reminders…

• You may print the syllabus. – However, you should strongly consider printing in black-and-white only and on “draft” setting as the sheer amount of color and detail within the slides would quickly deplete most printer cartridges! – Also remember that you can choose to only print those pages which you find most beneficial.

1 The Language of Dermatology The Language of Dermatology

“Flat” Lesions • Macule Before we begin…. • Patch

Macule Macule

• “Textbook” Definition – A flat lesion which is no larger than 0.5 cm in diameter. • “Real World” Definition – A flat lesion which is up to 1.5 cm in diameter.

1 Patch Patch

• “Textbook” Definition – A flat lesion which is larger than 0.5 cm in diameter. • “Real World” Definition – A flat lesion which is at least 1 cm in diameter. – Also, although overall “flat”, they can be scaly or have slight texture.

“Raised” Lesions Papule • Papule • “Textbook” Definition – A raised lesion which is no larger than 0.5 • Nodule cm in diameter. • Cyst • “Real World” Definition • Plaque – A raised lesion which is up to 1 cm in diameter (or even slightly larger). • Wheal

Papule Nodule

• Definition – A solid, relatively spherical lesion which is at least 0.5 cm in diameter.

2 Nodule Cyst

• Definition – A spherical lesion which is filled with semi- solid material.

Cyst Plaque

• “Textbook” Definition – A solid, plateau-like elevation measuring at least 0.5 cm in diameter. • “Real World” Definition – A solid, plateau-like elevation measuring at least 1 cm in diameter (or larger).

Plaque Wheal

• “Textbook” Definition – Lesion resulting from swelling of the skin caused by the escape of plasma fluid from within the vessels of the upper dermis. • “Real World” Definition – A hive. • Instead of “wheal”, some dermatologists say… – Urticarial papule (“hive-like” papule), or… – Urticarial plaque (“hive-like” plaque).

3 Wheal “Fluid-Filled” Lesions • Vesicle • Bulla • Pustule

Vesicle Vesicle

• “Textbook” Definition – Fluid-filled cavity measuring less than 0.5 cm in diameter. • “Real World” Definition – Fluid-filled cavity measuring up to 1 cm in diameter.

Bulla Bulla

• Definition – Fluid-filled cavity measuring at least 0.5 cm in diameter. • Spelling can be confusing – Bulla (singular). – Bullae (plural).

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Pustule Pustule

• Definition –A thin-walled, pus-filled papule.

“Depressed” Lesions Erosions and Ulcers • Erosion • Erosion – A defect of the skin resulting from the loss or • Ulcer breakdown of the epidermis only. – Heals without scarring. • Atrophy • Ulcer – A defect of the skin resulting from the loss or breakdown of the epidermis and at least the upper portion of the dermis. – Heals with scarring.

Erosion Ulcer

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Atrophy Atrophy

• Definition –Loss of normal thickness of the skin.

Surface Changes Scaling • Scaling • Definition • Crusting –Describes the small, dry particles which arise from the outermost layer • Excoriations of the epidermis. • Fissures • Lichenification

Scaling Crusting

• Definition –Describes the hardened deposits resulting from dried fluid.

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Crusting Crusting

Excoriation Excoriation

• Definition –Injury to the surface of the skin resulting from scratching.

Fissure Fissure

• Definition –Vertical separation of the skin surface, resulting from excessive tension or decreased elasticity. • Essentially a “crack” in the skin.

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Lichenification Lichenification

• Definition –Thickening of the skin with accentuation of the surface markings. • Think “leather”.

Lichenification Adjectives of Color

• Erythematous • Violaceous • Purpuric • Hypopigmented/Hyperpigmented

Erythematous Erythematous

• Definition –Simply means “red”. –For example….

“Erythematous papule” = “Reddish papule”

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Violaceous Violaceous

• Definition –Means “violet” in color. • Used to describe lesions which are overall erythematous, but have shades of “bluish-purple” within. –Unique to certain conditions, such as Lichen Planus.

Purpuric Purpuric

• Definition –Means “bruised” or “bruise-like”. –For example….

“Purpuric patch” = “Bruise-like patch”

Hypopigmented/Hyperpigmented Hypopigmented

• Definition –Hypopigmented • “Lighter” in color as compared to the patient’s normal skin tone. –Hyperpigmented • “Darker” in pigment as compared to the patient’s normal skin tone.

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Hyperpigmented Shape/Configuration of Lesions • Linear • Annular • Nummular/Discoid • Blaschkoid • Morbilliform • Polycyclic • Arcuate X • Reticular

Linear Linear

• Definition –Means “line-like”. –For example….

“Linear cluster of verrucae” = “Cluster of warts arranged in a line-like fashion”

Annular Annular

• Definition –Means “ring-shaped”. –Most often seen with fungal “ringworm” infections.

10 Nummular/Discoid Nummular/Discoid

• Definition –Both mean “round” or “coin-shaped”. –For example….

“Nummular eczematous patches” = “Round eczematous patches”

Blaschkoid Blaschkoid

• Named after Dr. Blaschko. • “Blaschko’s Lines” - Invisible lines within the skin which are believed to trace the pattern of embryonic skin development. • “Blaschkoid” lesions and rashes follow these lines which are “whorled”, thus… – “Blaschkoid” means “whorled” in appearance.

Morbilliform Morbilliform

• Definition –Means “measles-like”. –“Morbilliform” rashes are those which are comprised of numerous erythematous macules and papules.

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Polycyclic Polycyclic

• Definition –“Comprised of numerous rings”.

Arcuate Arcuate

• Definition –“Curved”.

Reticular Reticular

• Definition –Means “Lace-like”.

12 Summary

• Remember…

– Expectations are not that you know when/how to use these, but you should at least be “familiar” with their use and spelling.

13 Collecting Patient History Collecting and Documenting Patient History Part I

Collecting Patient History Collecting Patient History

The efficient collection of patient history ensures Stages of preparing the patient for their visit that…. with the dermatologist include… 1) The patient’s concerns are fully addressed. – “Pre-Visit” Chart Review 2) No harm is done to the patient by treatments – Determining Chief Complaint which may conflict with his/her preferences, – Reviewing/Clarifying… allergies, or other medical conditions. • PMH/FH 3) Your supervising physician can fulfill his/her • Current Medications duties in a timely, stress-free, and efficient • Allergies manner. • Social History – Gathering the HPI

Chart Review

New Patients –Is the patient a consult? Chart Review –If so, have the prior records and/or consult request been received?

1 Chart Review Chart Review

Established (Follow-Up) Patients Established (Follow-Up) Patients –Why is the patient being seen? –Some patients will express resentment • Patients’ “perceptions” of why they were if it seems that we don’t know why scheduled for follow-up are sometimes they were scheduled to return. different from the intended purpose of the visit. “How can we help you today?”

Chart Review Chart Review

Established (Follow-Up) Patients Established (Follow-Up) Patients –Some patients will express resentment –Review the last note or two. if it seems that we don’t know why –See if they have a PMH of skin cancer. they were scheduled to return. If so, is this their scheduled f/u? –Was another problem addressed at last “Well, you all told me to come back…don’t you visit and they were asked to return remember?” today for follow-up?

Chart Review Chart Review

Why this important…. Why this important…. – Prior to calling the patient back, you look – Prior to calling the patient back, you look over the last few notes and discover: over the last few notes and discover:

Example Example

Patient had surgery one week ago, at which Patient was seen 6 weeks ago for Acne, at time he was asked to return in a week for which time she was asked to return in 6 suture removal. weeks to follow-up.

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Chart Review Chart Review

Consider the different responses you “How’s everything going?” might get if you were to ask…

Chart Review Chart Review

“I see we prescribed Minocycline at “I see that Differin was prescribed. Has it your last visit. Are you remembering to been causing any irritation? Are you take it as directed?” remembering to use it?”

Chart Review Chart Review

Why this important…. Why this important…. – Prior to calling the patient back, you look – Prior to calling the patient back, you look over the last few notes and discover: over the last few notes and discover:

Example Example

Patient has a history of melanoma and today’s Patient called earlier in the day, asked to be visit is his scheduled 6 month skin exam. worked in for “an emergency”. Once in the room, she pulls out a “list” of concerns.

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Chief Complaint/Concern

Definition Chief Complaint/Concern The primary reason that a patient is there to see the dermatologist.

Chief Complaint/Concern Chief Complaint/Concern

Things to consider… Things to consider… • Did “we” call the patient back for follow-up, or • Asking the CC also provides you with the first did the patient initiate the appointment? opportunity to discover if the patient has • Remember it’s the primary reason they made unusual or unrealistic expectations. Such the appointment. expectations may include: – • Don’t be afraid to use quotes! Patient may have a “list” of concerns. – Patient who is being seen for the first time may think he’s Chief Complaint: having surgery that day. “I have bugs crawling in my skin”. – Patient made appointment with the wrong specialist.

Past Medical History

History of skin cancer is the Past Medical History most important past medical history we gather from the patient.

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Past Medical History Past Medical History

Ascertaining Skin CA History Ascertaining Skin CA History • Did patient genuinely have a skin cancer? • Melanoma or NMSC? – It is very common for patients to believe they have – How “serious” was the diagnosis presented to the had skin cancer when they really haven’t! patient? • Usually, skin cancers aren’t “just frozen off”. • “Best kind” = Basal Cell CA • Clarify what type of skin cancer they’ve had. • “Worst kind” = Melanoma At the very least, was it melanoma or non- – Were lymph nodes checked? melanoma skin cancer (NMSC)? – How big is the scar? – What did the original lesion look like?

Past Medical History Past Medical History

Ascertaining Skin CA History Ascertaining Skin CA History

• Melanoma or NMSC? • Patients who report a history of “melanoma”, but – When there is doubt about a patient’s reported are uncertain, should be reminded of the history of skin cancer, reflect that in your potential implications of their uncertainty. documentation. – Life insurance may be difficult or more costly to obtain for Example those who report a history of melanoma. – Health insurance is much more expensive and potentially PMH: “Melanoma”(?) excised from LT arm around limited in coverage. 1998 (patient uncertain). – Dermatologists may be much more likely to biopsy lesions on a patient with a history of melanoma than they would on a patient without such history.

Past Medical History Past Medical History

• Three elements are key to properly • Type of Skin CA documenting skin cancer history… • Date of Treatment – Most important to know if within 5 years. – Many patients cannot provide greater specificity Type of Skin CA than within a year or two. Date of Treatment – Do NOT document “___ years ago”! • Instead, you should always indicate an actual year, even How Treated if it’s the patient’s best guess. • How Treated

5 Past Medical History Past Medical History

Documenting Non-Melanoma Skin CA Documenting Melanoma Skin CA

“BCC excised from RT forearm in 2008”. “Melanoma, Level III, 1.2 mm depth. Excised from the RT thigh in 2007. SLN negative”.

“Sentinel Lymph Node”

Past Medical History Past Medical History

Other Important PMH Other Important PMH (cont.) – Dermatology-specific PMH. – Conditions which require pre-medication, – Currently pregnant or trying to conceive. such as artificial joints or Atrial Fibrillation. – History of immune suppression. – History of recurrent Staph (MRSA) infections. – History of infectious disease. – Significant developmental, neurological, or – Conditions which may affect healing, such as psychological history. bleeding disorders or diabetes. – Any other condition which patient indicates in – Conditions which may affect surgical their registration should still be documented. treatment, such as implanted defibrillator or pacemaker.

Family History

Most important FH to know… • Family history of skin cancer? Family History – Melanoma risk does increase if positive FH. – Only FIRST DEGREE family members count! • Parents • Brothers/Sisters • Children – Unfortunately, patients use the term “melanoma” just as loosely with FH as they do for their own personal history of skin cancer.

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Family History

Most important FH to know… • Other Important FH – Besides a skin cancer history, Family History is really “patient-specific”. For example… Medications • FH of Psoriasis would be important to document if patient being worked up for Psoriasis. • FH of Lupus would be important if your doctor suspects that a patient may have an autoimmune disease.

Medications Medications

• Dermatological Medications • Dermatological Medications – We need as many details as possible. – Strength • Non-dermatological Medications • Concentration (if topical) – We generally don’t need the same degree of details. • Milligrams (if systemic) – Formulation • Gel, Cream, Ointment, Solution, Foam, Shampoo, etc. – Frequency of Use • QD, BID, etc.

Medications

• Non-Dermatological Medications – Specifics are usually not as important! – In many offices, you simply need to know the name of the medication (dosage is usually unnecessary). Allergies – Don’t forget vitamins and “supplements”! – The most important of the non-dermatological medications that should always be documented include… • Heart Medications • Immunosuppressant Medications • Pain Medications (esp. ASA and most NSAIDs)

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Allergies Allergies

• One of the most important items to document for • Erroneous belief that a medication allergy exists patient safety! (when it does not) can significantly and unnecessarily • Patients often mistake a past “intolerance” of a limit a patient’s available treatment options. medication for a true “allergic” reaction. • All allergies reported by patients should be qualified. – True “allergic” reactions to a medication typically Example present as a widespread and often hive-like rash. “Keflex – Rash” – Medication “intolerance” includes side effects such as “Erythromycin – Stomach Upset” stomach upset, nausea, dizziness, and diarrhea. • These ARE NOT allergic reactions! • Food and environmental allergens generally don’t belong here! – Latex allergy is an exception!

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Collecting and Documenting Social History Patient History Part II

Social History

• Think “habits” – especially those which may influence the patient’s health. – Smoking – Drinking Review of Systems – Outdoor/Sun Exposure History – Tanning Bed Use – Frequency of Sunscreen Use – Bathing Habits – Any others your supervising physician feels are appropriate!

Review of Systems Review of Systems

• Documenting ROS is important because… Definition – It’s a requirement to satisfy the “bullet” components necessary for coding. An inquiry in which the patient is asked about the – “Negative” ROS are important to document for presence, or absence, of symptoms produced by the patient safety and medicolegal reasons. various organ systems. • Isotretinoin patients should be asked about symptoms of depression at each visit. • Melanoma patients should be asked about any symptoms which might suggest melanoma metastasis.

1 Review of Systems Review of Systems

Example A few key points about ROS…

• Ultimate responsibility for performing ROS belongs ROS (for hypothetical “Isotretinoin follow-up” visit) to your supervising physician. Integumentary • See to it that this information gets documented! Dry Skin – Yes, using moisturizer, Hair Loss - Denies • Work with your supervising physician to see what he Psychiatric or she expects your role to be with gathering ROS. Depression – Denies, Mood Changes – Denies

GI Nausea - Denies

History of Present Illness

Definition

HPI A detailed account of the history of a lesion, rash, or other dermatological concern.

History of Present Illness History of Present Illness

Key points about HPI… Key points about HPI… • It is considered “subjective” in nature. • It is considered “subjective” in nature. – “Subjective” information incorporates ones – We should still strive to include as much “factual” feelings, beliefs, perspectives, and emotions. information as possible in the HPI. – “Objective” information is fact-based and without – Using quotes allows us to indicate that consideration to feelings, beliefs, perspectives, or information is coming from directly from the emotions. patient, and provides a “hint” to those reading • It’s a patient’s right to be “subjective”. that there may be question regarding its accuracy. • It’s our duty to be “objective”.

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History of Present Illness History of Present Illness

Key points about HPI… Key points about HPI… • It is considered “subjective” in nature. • It is considered “subjective” in nature. Example Example

HPI #1: Patient has had a rash x 6 weeks. Her PCP has tried HPI: Patient presents with a concerning lesion on the everything to treat it but he doesn’t know what he’s doing. nose. He thinks it’s been there for “2 weeks”, but his wife “knows it’s been there for over a year”. VS. HPI #2: Patient has had a rash x 6 weeks. Her PCP “has tried

everything to treat it but he doesn’t know what he’s doing”.

History of Present Illness History of Present Illness

• Understanding your physician’s “mindset” will • The most important variable which affects the help you understand the importance of a good type of information needed in the HPI… HPI. – Dermatology visits are very fast-paced. Rash/Condition – Your physician will form a “mental game-plan” to address the patient’s issues based on the HPI that or you provide to him or her. Lesion – The better your initial HPI, the faster and more efficiently your physician will be able to address the patient’s concerns.

History of Present Illness History of Present Illness

• Rashes/Conditions (Initial Work-Up) • Rashes/Conditions (Initial Work-Up) – Duration – Symptoms • Constant/Ongoing, or… • Does it itch, burn, hurt, etc., or… • Waxed/Waned • Is it asymptomatic? – When did first episode begin? – How long do the episodes usually last? – After it goes away, how long does it stay resolved until it flares up again?

3 History of Present Illness History of Present Illness

• Rashes/Conditions (Initial Work-Up) • Rashes/Conditions (Initial Work-Up) – Aggravating/Alleviating Factors – How Treated • Do certain factors cause it to get worse, or does it • What has the patient used to treat it and how has occur spontaneously without rhyme or reason? it responded to those treatments? • What, if anything, seems to help? • It is common for patients to not remember the names/types of treatment they’ve used. – Prescription or over-the-counter (OTC)? – If prescription, most dermatologists prefer that you make an effort to determine the name of the medication used. » Consider calling the patient’s pharmacy or PCP.

History of Present Illness History of Present Illness

• Rashes/Conditions (Initial Work-Up) • Rashes/Conditions (Initial Work-Up) – How Treated – Is anyone else around the patient similarly • Calling the Pharmacy affected? – Before calling the pharmacy, be sure to ask the • Infectious rashes or conditions such as Scabies, patient… Impetigo, and Tinea (and others) are all contagious. » Which pharmacy? » Around what date? » By whom? » What “type” of medication was it?

History of Present Illness History of Present Illness

• Rashes/Conditions (Follow-Up) • Lesions (Initial Work-Up) – Always review the patient’s last note or two prior – Duration to calling them back! – Symptoms – How are they doing? – Changes in Appearance – Is the patient using the medication as prescribed? – Prior Treatments • If not, why? – Patient Desire for Treatment – Forgets to use it?

– Purposely quit because “it was not helping”.

– Side effects? – Medication too costly?

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History of Present Illness History of Present Illness

The “truth” about the HPI for “lesions”… • Lesions (Initial Work-Up) – Duration • “How long has the lesion been present?” The HPI is often entirely unnecessary in order – Days for your supervising physician to accurately – Weeks diagnose a lesion. – Months – Years – Patient “uncertain” – “Long time” – “It’s been there for a while”

History of Present Illness History of Present Illness

• Lesions (Initial Work-Up) • Lesions (Initial Work-Up) – Symptoms – Changes in Appearance • ALWAYS document symptoms! • Darker – Asymptomatic • Lighter – Bleeds • Scalier – Itches • Any other change reported by the patient! – Burns – e.g., “Has fallen off before” (common w/ SKs) – Stings – “Gets caught on clothing” – “Irritated by jewelry”

History of Present Illness History of Present Illness

• Lesions (Initial Work-Up) • Lesions (Initial Work-Up) – Prior Treatments – Patient Desire for Treatment • Already treated? If so, how? • Most simply want reassurance, while others want • What happened after treatment? the lesion treated. – Did it go away and come back, or it never went away? • Document patient’s wishes if they want treatment. • Always let your supervising physician know if a patient wants their lesion treated. Follow your office’s ABN protocol with these patients!

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History of Present Illness History of Present Illness

• Lesions (Initial Work-Up) • Lesions (Follow-Up) – Patient Desire for Treatment – Lesion Monitoring (For Changes in Appearance) • What is an ABN? • Ask these patients if they’ve noticed any changes in – ABN stands for “Advance Beneficiary Notice”. appearance or symptoms since last visit. – Medicare and other insurances require that patients are • If biopsy was previously recommended, but they told in advance and in writing that certain services may not declined, ask them how they feel about that now. be covered by insurance. • – Common scenarios include skin tag removal, benign mole Whenever a patient expressly indicates that they removal for cosmetic reasons, and treatment of non- decline having a biopsy, you ALWAYS want to inflamed seborrheic keratoses. document the patient’s sentiment. Example BOTTOM LINE – IF A PATIENT INSISTS ON TREATMENT OF A LESION, BUT INSURANCE WILL NOT COVER IT, THEY SHOULD BE TOLD IN ADVANCE! Patient states he “still doesn’t want it biopsied”.

History of Present Illness History of Present Illness

• Lesions (Follow-Up) • Lesions (Follow-Up) – Lesion Monitoring (For Changes in Appearance) – Lesion Monitoring (Response to Treatment) • If pictures were taken at the prior visit, always have • Treatment was performed in the office. them out (or pulled up on the computer) and – How did the patient do in the post-treatment period? available for review by the dermatologist. – Did they experience any significant pain or discomfort? – How effective do they think the treatment was?

History of Present Illness A few final points before we finish….

• Lesions (Follow-Up) • Always confirm with the patient that you’ve covered all – Lesion Monitoring (Response to Treatment) of the issues that they wish to address! • Treatment was performed by the patient at home. • Besides the patient’s medical concerns, is there – Were they able to get the prescription filled? anything else your doctor should know? – How do they think they responded? • Is the patient in a bad mood? Rude? – Were there any problems or significant side effects? • Is the patient very demanding? • Is the patient hard of hearing? • Is the patient an amputee and is unable to shake hands? • These are just examples. The bottom line is that anything you would want to know before meeting someone is something your physician would also like to know as well!

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. Dermatologists are very specific in describing locations. . For example, for the same lesion… Anatomy . A PCP may simply use the location of “nose”. . A dermatologist would say “right lateral nasal tip”. . Precise locations avoid confusion!

. Right or Left . Usually abbreviated (e.g., “RT” and “LT”)

RIGHT LEFT SIDE SIDE

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. Right or Left . Proximal/Distal . Usually abbreviated (e.g., “RT” and “LT”)

. Superior/Mid/Inferior

. Anterior/Posterior LEFT RIGHT SIDE SIDE . Medial/Lateral

. Dorsal/Ventral (aka “Volar”)

. Describes location on an appendage in relation to . Describes location on an appendage in relation to the point of origin of the appendage itself. the point of origin of the appendage itself.

. Primarily used for describing locations on the limbs. . Primarily used for describing locations on the limbs.

. Any appendage (such as nose/fingers) can have proximal and distal regions.

PROXIMAL DISTAL

. Describes location on an appendage in relation to . These terms can apply to any body part which has a the point of origin of the appendage itself. single point of origin.

. Primarily used for describing locations on the limbs. NASAL ROOT

PROXIMAL NOSE

DISTAL NOSE

DISTAL PROXIMAL

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. “Proximal to…” and “Distal to…” add specificity: . “Superior” = on or near the “uppermost” or “highest” part.

. “Mid” = on or near the “middle”.

. “Inferior” = on or near the “lowest” part or area closest to the base.

SUPERIOR LT HELIX . Sometimes common “lay” terms are used in place of “Superior” or “Inferior”. INFERIOR LT HELIX . “Superior” can also be described as “Upper”. . e.g., “Upper Back” instead of “Superior Back”.

. “Inferior” can also be described as “Lower”.

. e.g., “Lower Back” instead of “Inferior Back”.

. Simply indicate “front” or “back”. . Simply indicate “front” or “back”.

. Anterior = On the “front” side of the body. . Anterior = On the “front” side of the body.

. Posterior = On the “back” side of the body. . Posterior = On the “back” side of the body.

There is no “interior” when INTERIOR describing anatomical locations!!

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. Simply indicate “front” or “back”. . Simply indicate “front” or “back”.

. Anterior = On the “front” side of the body. . Anterior = On the “front” side of the body.

. Posterior = On the “back” side of the body. . Posterior = On the “back” side of the body.

POSTERIOR ANTERIOR NECK NECK

. Medial = “toward the middle” or “closer to the middle”. . Medial = “toward the middle” or “closer to the middle”.

. Lateral = “toward the side” or “closer to the side”. . Lateral = “toward the side” or “closer to the side”.

RT LATERAL LT LATERAL MEDIAL FOREHEAD FOREHEAD FOREHEAD

. Dorsal = “top surface”. Dorsal Forearm . Ventral = “bottom surface”.

. Ventral = Volar (synonyms).

Ventral Forearm

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. Before we begin… . Ultimate responsibility for naming locations belongs to your physician. . Don’t stress! You don’t have to be an expert! . Also keep in mind… . The same anatomical location can be named in more than one way!

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PROPERTIES PROPERTIES Allow user to leave interaction: Anytime Allow user to leave interaction: Anytime Show ‘Next Slide’ Button: Show always Show ‘Next Slide’ Button: Show always Completion Button Label: Next Slide Completion Button Label: Next Slide

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PROPERTIES PROPERTIES Allow user to leave interaction: Anytime Allow user to leave interaction: Anytime Show ‘Next Slide’ Button: Show always Show ‘Next Slide’ Button: Show always Completion Button Label: Next Slide Completion Button Label: Next Slide

PROPERTIES PROPERTIES Allow user to leave interaction: Anytime Allow user to leave interaction: Anytime Show ‘Next Slide’ Button: Show always Show ‘Next Slide’ Button: Show always Completion Button Label: Next Slide Completion Button Label: Next Slide

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. There are multiple ways to name the same location. . Always use the terminology preferred by your supervising physician. . Keep your mind open – the study of anatomy is an ongoing process!

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8 Skin Structure & Function Skin Structure & Function

Skin Structure & Function

EPIDERMIS • Essentially the “fatty tissue” beneath the skin. • Contains the blood vessels and nerves. DERMIS • Cutting into this layer carries the risk of damaging these blood vessels and nerves. SUBCUTANEOUS TISSUE

Did You Know…

• Loses volume as we grow Sensory nerves damaged during deep excision into older. • This loss of volume contributes the subcutaneous tissue can regenerate. Provided to the bruising (“Solar Purpura”) damage isn’t severe and regeneration is possible, commonly seen on elderly nerves heal at a rate of about 1 mm/day. patients’ forearms and hands.

1 Skin Structure & Function

EPIDERMIS HAIR FOLLICLES • Phases of Hair Growth • Anagen (Growth Phase) DERMIS • >85% of hairs in anagen. • Lasts for years.

SUBCUTANEOUS TISSUE

HAIR FOLLICLES HAIR FOLLICLES • Phases of Hair Growth • Phases of Hair Growth • Catagen (Regression Phase) • Telogen (Dormant Phase) • ~1-2% of hairs in catagen. • 10-15% of hairs in telogen. • Lasts for a few weeks. • Lasts for several months. • Telogen Effluvium results from too many hairs prematurely entering this phase (and subsequently shedding).

Did You Know… Did You Know…

The average person has about 100,000 The typical rate of hair growth for healthy hairs on their scalp. adults is about ½ inch per month.

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Did You Know…

HAIR FOLLICLES • Types of Hair Growth On average, we normally shed about • Terminal Hair • Long, thick, dark hair (e.g., 100 hairs/day. scalp, pubic, axillary regions). • Vellus Hair • Very fine, light-colored hair. • Think “peach fuzz”.

SWEAT GLANDS SWEAT GLANDS • Apocrine Glands • Eccrine Glands • Found primarily within the • Found throughout virtually axillary, genital, and anal all skin surfaces. regions of the body. • Essentially odorless. • Most associated with body • Primary function is to help odor. regulate body temperature. • Their true function remains a mystery. • “Hidradenitis” causes chronic inflammation of these glands.

Did You Know…

What we perceive as body odor is the result of bacteria interacting with sweat and epidermal skin cells. Most perspiration is not inherently odorous. Instead, it simply serves as a catalyst for the bacterial interaction which SEBACEOUS GLANDS causes the body odor. • The “oil” glands. • Produce “sebum”. The clinical diagnosis of body odor is Bromhidrosis. Controlling the catalyst (perspiration) through the use of • Connected to the hair antiperspirants can help. However, so can antibiotics. It’s follicles. • Together, referred to as the not uncommon for dermatologists to prescribe topical “pilosebaceous unit”. products such as Clindamycin Lotion to help control • Because of this connection, hair excessive body odor. follicle inflammation and acne look very similar.

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SEBACEOUS GLANDS COLLAGEN & ELASTIN • Hormonally sensitive. • Collagen • Genetics, location on body, • Protein fibers which provide and age all play a role. strength. • Typical “teenage” acne • Helps skin to resist tearing. occurs throughout the face, • Skin which is lacking in healthy chest, and back. collagen easily tears and bruises. • Adult females tend to breakout on lower cheeks and upper neck.

Skin Structure & Function

EPIDERMIS COLLAGEN & ELASTIN • Elastin • Protein fibers which allow the skin to stretch but then return to position. DERMIS

SUBCUTANEOUS TISSUE

Skin Structure & Function

Basal Layer • Melanocytes found here. • Where skin cells are produced • Cells which provide pigment and developed. (color) to our skin. • Divided into layers. • “Melanin” is the name of that pigment. • Home to a few very important • Cancer of the melanocytes is types of skin cells- called “melanoma”. • Keratinocytes • Melanocytes

EPIDERMIS

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Skin Structure & Function Skin Structure & Function

Basal Layer Basal Layer • Melanocytes found here. • Keratinocytes begin here. • Damaged or destroyed anytime • Make up 95% of the epidermis. the dermis is injured. • They are what soaks up • Excision, deep shave removal, or moisturizer when you apply it. even deep cryosurgery always • They are what shed when we risks damaging the melanocytes and causing permanent rub our skin and bathe. hypopigmentation. • Form a barrier against infection. • “Surface” procedures (skin tag • Help our body to retain water. removal, light cryosurgery, etc.) generally don’t damage the melanocytes. EPIDERMIS EPIDERMIS

Skin Structure & Function Skin Structure & Function

Basal Layer Beyond the Basal Layer • Keratinocytes begin here. • Keratinocytes migrate • The basal layer is where upward, through the... keratinocytes are born. Stratum Spinosum • These earliest versions of Stratum Granulosum epidermal skin cells are called Stratum Corneum basal cell keratinocytes. • Protein (“keratin”) increases in • Cancer of the basal cell concentration as cells migrate keratinocytes is called “Basal upward. Cell Carcinoma”. • Keratin increases their resilience to damage. EPIDERMIS • Eventually, cells die and shed off. EPIDERMIS

Skin Structure & Function Did You Know…

Beyond the Basal Layer • The process of skin cell maturation is sometimes Skin cell "turnover" is the process in which called “squamatization”. epidermal skin cells are created in the lowest • Cancer of keratinocytes outside (basal) layer of epidermis, mature, migrate of the basal layer (undergoing upward, and eventually slough. On average, this squamatization) is called “Squamous Cell Carcinoma”. process typically takes about one month.

EPIDERMIS

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Did You Know… Did You Know…

Because it doesn’t “turn over” like the Since Basal Cell Carcinomas (BCC) are comprised of epidermis, any pigment which makes its way to cells which haven’t undergone significant the dermis will be permanent. Tattoos are the keratinization, they usually (but not always) tend to most obvious example, but even longstanding appear more fragile and prone to bleeding. Melasma, in which excess melanin has “leaked” Since Squamous Cell Carcinomas (SCC) are into the upper dermis, can cause permanent comprised of cells undergoing “squamatization”, (and unwanted) discoloration. they usually (but not always) tend to have a tougher, scalier appearance.

Skin Structure & Function

CONCLUSION

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Coding is…

A standardized method of communicating with a patient’s insurance company, using numeric codes, to indicate which billable services were performed during a patient’s office visit.

E/M CPT ICD E/M Codes CODES CODES CODES

Traditional New E/M Codes Patients & Consults

• E/M stands for “Evaluation and Management”. • Used to bill the office visit (not procedures or labs!). “New Patient” Definition: • Represent the charges for diagnosing the problem(s) and counseling the patient. • A patient who has never been seen by any providers in your office before OR… E/M • A patient who has not been seen (or provided medical Traditional New care or advice via communication) for at least 3 years. Codes Established Patients & Patient Visits Consults

1 Traditional New Consult Patients & Consults

What Is A “Consult”? • A “consult” occurs when a physician specifically seeks input or assistance in the management of a patient’s condition by referring that patient to another provider who has more expertise in that area of medicine.

Established Important “Caveat” About Consults: Patient Visits

Some insurances, including Medicare, are E/M no longer providing coverage for Consults. Traditional New Codes Established Patients & Instead, when billing to these insurances, Patient Visits Consults you must instead use “traditional” new patient visit codes.

Established Patient Visits E/M Codes

ESTABLISHED NEW PATIENT CONSULTS “Established Patient” Definition: PATIENTS 99201 99241 99211 • A patient who has been formally seen, treated, or provided medical advice within the past 3 years. 99202 99242 99212 • It does not matter if the patient’s paper charts 99203 99243 99213 are in storage. Less than 3 years = Established. 99204 99244 99214 VISIT OF COMPLEXITY 99205 99245 99215 VISIT OF COMPLEXITY

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In General…. In General….

• The overwhelming majority of visit codes used are: • The lowest level new patient codes 99201 and 99241 are New Patients rarely used by most dermatologists. • The new patient codes (99204 – 99205 and 99244 – 99245) 99202 – 99203 are also rarely used by most dermatologists. Consults • Amongst the established patient codes, 99214 is 99242 – 99243 occasionally used for a very complex visit, but it’s quite rare to charge a level 99215. Established Patients • The “level one” established patient code 99211 can be 99212-99214 used for nurse-only visits.

https://www.cms.gov/medicarefeeforsvcpartsab/04_medicareutilizationforpartb.asp Average Utilization of NEW PATIENT Codes E/M Codes (Dermatology 2009) 700000

ESTABLISHED NEW PATIENT CONSULTS 600000 PATIENTS 500000 99201 99241 99211 400000 99202 99242 99212 300000 99203 99243 99213 200000 99204 99244 99214 100000

COMPLEXITY OF VISIT OF COMPLEXITY VISIT OF COMPLEXITY 0 99205 99245 99215 99201 99202 99203 99204 99205

https://www.cms.gov/medicarefeeforsvcpartsab/04_medicareutilizationforpartb.asp https://www.cms.gov/medicarefeeforsvcpartsab/04_medicareutilizationforpartb.asp Average Utilization of CONSULT Codes Average Utilization of ESTABLISHED PATIENT Codes (Dermatology 2009) (Dermatology 2009) 250000 5000000 4500000 200000 4000000 3500000 150000 3000000 2500000 100000 2000000 1500000 50000 1000000 500000 0 0 99241 99242 99243 99244 99245 99211 99212 99213 99214 99215

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CPT Codes

CPT Codes • CPT stands for Current Procedural Terminology. • E/M Codes are actually a type of CPT Code, though in practice, the term “CPT Code” is generally used to reference “procedure codes”. • Dermatology-specific CPT procedure codes range from 10040 to 19499.

Most Common CPT Codes: Destruction of AKs

• Destruction of AKs IF 1-14 LESIONS ARE TREATED • Destruction of ISKs/Warts/Molluscum 17000 for the first AK. PLUS • Biopsies 17003 for each additional AK up to 14. • Skin Tags OR IF 15 OR MORE TREATED

17004 by itself regardless of how many over 15.

Destruction of AKs Destruction of ISKs/Warts/Molluscum

For Example: IF 1-14 LESIONS ARE TREATED

17110 by itself regardless of how many up to 14.

OR IF 15 OR MORE TREATED

17111 by itself regardless of how many over 15.

4 Destruction of ISKs/Warts/Molluscum Biopsies

FIRST BIOPSY For Example: 11100

EACH ADDITIONAL BIOPSY 11101 (x however many units)

LOCATION SPECIFIC BIOPSIES 40490 - Lip 69100 – Biopsy of Ear 67810 - Eyelid

Skin Tags Skin Tags

IF 1-15 TAG ARE TREATED For Example:

11200 by itself regardless of how many up to 15.

EACH “ADDITIONAL” 10 TAGS BEYOND 15

11201

Introduction To Coding

ICD Codes

ICD Codes • Stands for International Classification of Diseases. • They are numeric values which represent the various diagnoses. • Currently “ICD-9” is in use. – “ICD-10” was due for implementation by late 2013, but the deadline for its use now pushed back. • Easiest of coding fundamentals to understand.

5 Introduction To Coding Introduction To Coding

ICD Codes “Location-Specific“ ICD Codes – xxx.0 – LIP

– xxx.1 – EYELID Examples – xxx.2 – EAR – xxx.3 – FACE Acne - 706.1 – xxx.4 – SCALP/NECK – xxx.5 – TRUNK Psoriasis - 696.1 – xxx.6 – UPPER EXTREMITY Actinic Keratosis - 702.0 – xxx.7 – LOWER EXTREMITY – xxx.8 – OTHER SPECIFIED SITE – xxx.9 – SITE UNSPECIFIED

That concludes Part I of Introduction To Coding. Please proceed to…

Introduction To Coding PART II

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We’ll Be Reviewing…

• “Bullet Points” and “Time” • Bundling • Modifiers • Biopsy vs. ?

Introduction To Coding

“Bullet Points” and “Time” (a brief introduction) BULLET TIME POINTS

LEVEL OF E/M CODE

Coding Based On “Time” Coding Based On “Time”

• A key advantage is that the sometimes The Center for Medicare and Medicaid burdensome and bureaucratic requirements Services (CMS) states…. of coding by “bullet points” are not required. • Physicians may determine the code for the • Documentation of “time spent” is required, though. office visit (E/M) based on time alone if at • “Time” documentation example – least 50% of the total visit duration was • “Today’s visit was a total duration of 30 minutes, at spent on direct (face-to-face) patient least 50% of which was spent on direct patient counseling.” counseling.

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“COUNSELING TIME” REQUIREMENTS “Bullet Point” System of Coding ESTABLISHED LEVEL OF VISIT NEW PATIENT CONSULTS PATIENTS • System of coding office visits which Level I 10 Minutes 15 Minutes 5 Minutes takes into consideration the number of Level II 20 Minutes 30 Minutes 10 Minutes elements documented for a given visit. Level III 30 Minutes 40 Minutes 15 Minutes

Level IV 45 Minutes 60 Minutes 25 Minutes

Level V 60 Minutes 80 Minutes 40 Minutes

HPI ROS • Psychiatric • Rash on RT arm. -Denies • Started yesterday. depression. • It itches. • Integumentary -Experiencing dry lips.

“Bullet Points” “Bullet Points”

• Represent elements of the office note. For example, in order to justify a 99213, the • Auditors count the number of “bullet points” note should have… within each section of the note. HPI • Each code has its own number of “bullet 1-3 elements (“bullet points”) point” requirements. ROS Components of at least 1 systems review

2 “Bullet Points”

• You do not need to memorize how many Bundling elements (or “bullet points”) each section needs to have documented. • You do need to understand that documenting elements within a given section of the note may be a requirement for fulfilling the criteria of a given code.

Introduction To Coding Introduction To Coding

Bundling Bundling

Definition: CPT code “11100” includes reimbursement for….

Bundling is the inclusion of multiple procedures Cost of Biopsy Supplies or services under a single billing code. Performing the Biopsy Time and Effort Needed To Submit Specimen To Lab

Introduction To Coding Introduction To Coding

Unbundling

Definition: $1.75

Charging separately for services or procedures $1.75 which should have been included together $3 under a single code.

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Introduction To Coding

Modifiers Cost of Biopsy Supplies $30 Performing the Biopsy $70

Time and Effort Needed To Submit Specimen To Lab $25

Introduction To Coding Introduction To Coding

Modifiers Modifiers

Definition: “LOL” (“modifier” used in e-mail and text)

– Means “laughing out loud”. Modifiers are two digit codes which provide – It’s essentially a 3-digit modifier added to the clarification regarding a submitted E/M or end of a sentence which tells the reader that this CPT (procedure) code. is something that makes the author of the e-mail (or text) laugh.

Introduction To Coding Introduction To Coding

Modifiers Modifiers

Insurance Company Assumption -25 Modifier – Added to E/M code when a procedure code is also billed Any procedure, unless clarified otherwise, is being performed on the same date of service. on a lesion or condition which has already been “worked-up”, • Clarifies to the insurance company that the E/M service that was therefore an E/M charge, in addition to the procedure charge, performed on the same date as the procedure was necessary. isn’t justified. • The most common modifier used in dermatology! • BOTTOM LINE: – Any time an E/M charge is submitted on the same day that a procedure is performed, we add a “-25” modifier to the office visit.

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Introduction To Coding

“Global Period” Modifiers

Definition Insurance Company Assumption

Time period after a procedure in which all routine and necessary Any office visit or procedure performed within a “global services associated with that procedure are “bundled” (included) with period” must be related to the original procedure which set the original reimbursement for that procedure. off the “global period” in the first place. If an E/M or procedure code is submitted during a “global” EXCISION period, the doctor must be trying to “unbundle” and therefore the charges aren’t justified. 10- DAY GLOBAL PERIOD July 1st July 5th July 10th

Introduction To Coding Introduction To Coding

Modifiers Modifiers

-24 Modifier -79 Modifier – Added to E/M code when an office visit is performed – Added to the procedure code when a procedure is during a post-op “global” period. performed during a “global” period. • Must be unrelated to the routine care of the procedure which • Must be unrelated to the routine care of the procedure which initiated the “global period”. initiated the “global period”. – For example, patient has a BCC excised, but then 2 days later comes in for – For example, patient has a BCC excised, but then 2 days later comes in for evaluation of Poison Ivy. cryosurgery of a wart. • BOTTOM LINE: • BOTTOM LINE: – Any time an E/M charge is submitted within a “global” period, we add a – Any time a procedure code is submitted within a “global” period, we add a “-24” modifier to the office visit. “-79” modifier to the procedure code.

Modifiers

• There are a number of additional modifiers, but an Biopsy vs. ? in-depth review of them is far beyond the scope of this program. • Some modifiers (like the -59 modifier) are so confusing that even professional coders need computer programs and reference manuals to know how/when to use them!

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Biopsy vs. ? A patient comes in because of a mole on her thigh. It’s been there for years, but her razor nicks it when she shaves. Your doctor evaluates the lesion, and reassures • A biopsy is a procedure. the patient that it looks completely harmless, but if • Its purpose is to obtain a specimen of tissue which can be she’d like to have it removed, he’d be happy to do so. submitted to the lab, so that the lab can provide us with So, it’s shaved off, and you send the lesion to the lab for the diagnosis of the lesion, rash, or condition. evaluation. • Simply submitting a specimen to the lab for evaluation does not constitute a biopsy!!! Is this coded as a biopsy, a shave removal, or both?

Remember “Bundling”? Shave Biopsy vs. Shave Removal

Biopsy “Bundle” Shave Removal Excision “Bundle” INTENTION MAKES THE DIFFERENCE! “Bundle”

1) Sampling The 1) Removing The 1) Removing The Shave Biopsy Lesion/Rash Lesion Via Lesion Via Shave Excision • Intention is to simply obtain a sample for 2) Preparing & 2) Preparing & 2) Preparing & laboratory evaluation. Submitting Submitting Submitting Specimen To Specimen To Specimen To Shave Removal The Lab For The Lab For The Lab For • Intention is to remove the lesion. Evaluation Evaluation Evaluation • Whether or not it’s sent to pathology for evaluation makes no difference!

Conclusion

Resources:

6 ICD-10 for Dermatology Introduction to ICD-10 DISCLAIMER The purpose of this video is to serve as an for Are youintroduction ready to forICD-10. ICD -10? Those who play a significant role in the coding process will certainly need additional training – both Dermatology in preparation for the implementation of ICD-10 as well as ongoing training as the ICD-10 code set evolves and is updated.

ICD-10 for Dermatology ICD-10 for Dermatology International Classification of Diseases • We’re currently using version ICD-9-CM. • ICD codes serve as a “universal language” PROCEDUREVISIT E/MICD CODESCODES allowing diagnoses to be easily understood CHARGESCODES throughout the world. • Created by the World Health Organization.

ICD-10 for Dermatology ICD-10 for Dermatology International Classification of Diseases October 1, 2015 • ICD-10 has been in use elsewhere in the world – US Department of Health & Human Services since the 1990s! has mandated that everyone covered by the Health Insurance Portability and Accountability • ICD-10-CM Act (HIPAA) must implement ICD-10 for – Contains outpatient clinical diagnosis codes. medical coding effective October 1, 2015. – “CM” stands for “Clinical Modification”. – Claims will literally switch overnight from using • ICD-10-PCS ICD-9-CM codes on September 30, 2015 to – Only for inpatient procedure codes. ICD-10-CM codes on October 1, 2015. – Average derm clinic will not use ICD-10-PCS!

Why The Change To ICD-10? • Epidemiologists study the patterns and causes of health issues within the population. – By monitoring such patterns, attention can be given to Why The Change certain diseases/conditions that warrant increased research and concentration. • For example… To ICD-10? – The incidence of melanoma has increased significantly over recent decades. – Because epidemiologists have noticed this trend, there has been an increase in melanoma research.

Why The Change To ICD-10? Using Psoriasis As An Example… • Epidemiologists (and others) would like to see detailed statistics on every disease and injury. – ICD codes provide the easiest way of doing that! – Too many unique variations of diseases, conditions, or injuries share the same ICD-9 code.

Why The Change To ICD-10? • ICD-10 also greatly reduces “code sharing” between totally unrelated diagnoses. – For example… • With ICD-9, both Melasma and Solar Lentigines share Key Features of the same code (709.09), even though they’re two very different diagnoses. • With ICD-10, most (but not all) unique conditions ICD-10 and/or lesions have their own code. – Melasma L81.1 – Solar Lentigines L81.4 Key Features of ICD-10 • ICD-10 codes will provide much greater detail. – Granularity • The state or quality of being composed of many individual pieces or elements.

Key Features of ICD-10 • ICD-10 codes will provide much greater detail. – In order to reflect this greater detail, codes will have up to six or (rarely) seven characters! • Most dermatology codes will be 4-6 characters long. • For example…

Key Features of ICD-10 Key Features of ICD-10 • Laterality (right or left side) will be indicated • Certain diagnoses will need to be described in certain codes. using more than one code. – For example… – For example… Key Features of ICD-10 Key Features of ICD-10 • Certain codes may describe more than just • Diagnoses can be marked as resulting from a one diagnosis. preceding infection, injury, or illness. – “Combination Codes” – “Late Effect” (Sequela) Codes – For example… – For example…

Key Features of ICD-10 • Greatly expanded coding to describe unique “situations and circumstances”. – When a person who may not be sick receives health services for some specific purpose. ICD-10 Index & – When a circumstance influences a person's health status but is not in itself a current illness or injury. Tabular List

ICD-10 Index & Tabular List ICD-10 Index & Tabular List • All ICD-10 codes are officially found in… • Once ICD-10 is implemented, we will feel very – ICD-10-CM Index to Diseases and Injuries fortunate that we work in dermatology! • Similar to any other alphabetical index and provides a – The same coding rules (“conventions”) will affect us “quick reference” to the various code categories. all to some degree. • We’re advised to avoid using the index for final code • However, the most complicated of these rules will affect selection! dermatology relatively little. – ICD-10-CM Tabular List of Diseases and Injuries • Other specialties (esp. those that deal with orthopedics, • Contains the full, comprehensive listing of codes, injuries, and chronic illness) will have it much harder! including special notations and instructions. • Broken into various chapters, often by “body system”. – e.g., Chapter 12 is Diseases of the skin and subcutaneous tissue. ICD-10 Index & Tabular List ICD-10 Index & Tabular List • It’s all about following the instructions! • It’s all about following the instructions! – “Includes” Notes – “Excludes” Notes • Generally provide clarification. • Excludes1 – Tell us that we cannot code the listed diagnoses at the same time!

ICD-10 Index & Tabular List ICD-10 Index & Tabular List • It’s all about following the instructions! • It’s all about following the instructions! – “Excludes” Notes – “See” Notes • Excludes2 • Simply point you in the right direction. – Clarify that the listed diagnoses aren’t part of the represented code, and… – If applicable, diagnoses in the “Excludes2” list can be coded at the same time!

ICD-10 Index & Tabular List ICD-10 Index & Tabular List • It’s all about following the instructions! • It’s all about following the instructions! – “See Also” Notes – “Use Additional Code” Notes • Often used to provide alternative locations where the • Instruct us that another code should also be used. most appropriate code might be found. • Unless presented as an option (e.g, “if applicable”), the use of the additional code will be a requirement. ICD-10 Index & Tabular List ICD-10 Index & Tabular List • It’s all about following the instructions! • It’s all about following the instructions! – “Code First” Notes – “Add The Appropriate 7.th Character” Notes • Instruct us that another code must also be used, and… • Sometimes a 7th character is required to provide added • The additional code must be listed first on the superbill. details about a given visit. • These codes will be very rare in dermatology, but extremely common for “injuries and accidents”.

ICD-10 Index & Tabular List ICD-10 Index & Tabular List • It’s all about following the instructions! • It’s all about following the instructions! – “Add The Appropriate 7.th Character” Notes – Punctuation Marks • Sometimes a 7th character is required to provide added • “( )” details about a given visit. – Often used to provide additional descriptive terms. • These codes will be very rare in dermatology, but extremely common for “injuries and accidents”.

ICD-10 Index & Tabular List ICD-10 Index & Tabular List • It’s all about following the instructions! • It’s all about following the instructions! – Punctuation Marks – Punctuation Marks • “[ ]” • “-” – Often used to provide synonyms or explanatory – Most significant when seen as “.-” (“point dash”). phrases. » Represents the more specific codes that exist following the decimal point of the listed category. ICD-10 Index & Tabular List • It’s all about following the instructions! – Abbreviations Important • NEC – Means “Not Elsewhere Classified”. – Used to describe the rare circumstance when you Considerations have a specific diagnosis, but that diagnosis just isn’t found anywhere in the tabular listing. • NOS – Means “Not Otherwise Specified”. For Staff – Often means that we aren’t able to provide further specificity for a given diagnosis.

Important Considerations For Staff Important Considerations For Staff • ICD-10 coding will be associated with certain • We must code to the highest degree of requirements that must be followed or the available specificity! claim will not get processed! – For example….

Important Considerations For Staff Important Considerations For Staff • Visit documentation must support the added • All instructions provided to us within the specificity of the ICD-10 codes we use! tabular list must be followed! – Examples include Excludes1, Excludes2, Code First, Use Additional Code, etc. Conclusion Conclusion • It’s time for you to check it out for yourself! • It’s time for you to check it out for yourself! – ICD-10-CM Index to Diseases and Injuries – ICD-10-CM Index to Diseases and Injuries – ICD-10-CM Tabular List of Diseases and Injuries – ICD-10-CM Tabular List of Diseases and Injuries • Other Important Resources… • Other Important Resources… – Center for Medicare and Medicaid Services (CMS) – Center for Medicare and Medicaid Services (CMS) – American Academy of Dermatology – American Academy of Dermatology – Inga Ellzey Practice Group – Inga Ellzey Practice Group – American Academy of Professional Coders (AAPC) – American Academy of Professional Coders (AAPC) – AHIMA – AHIMA

Skin Cancer

• Screening for, diagnosing, and treating skin cancer is… – One of the most important tasks your supervising Skin Cancer physician performs. – One of the most common tasks performed. • Clinical support staff members like you play a vital role in this process.

Skin Cancer

The “big three” skin cancers are…

• Basal Cell Carcinoma Basal Cell “Non-Melanoma Skin Cancer” (NMSC) Carcinoma • Squamous Cell Carcinoma

• Melanoma

Skin Cancer Skin Cancer

BASAL CELL CARCINOMA BASAL CELL CARCINOMA • Background • Risk Factors – Most common cancer (of any type) in the world. – Ultraviolet Light • >1,000,000 occur every year in the United States alone. – Fair Skin – 75-80% of skin cancers are Basal Cell Carcinomas. • Inability to tan • Light-colored eyes • Light-colored hair – Advanced Age

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Skin Cancer Skin Cancer

BASAL CELL CARCINOMA • Presentation – Can occur almost anywhere on the body. • Face, ears, and neck most common. – Patients often think they are a “pimple”, abrasion, or even an insect bite that just wouldn’t heal. • Usually does NOT present as a “dark mole”.

Skin Cancer Skin Cancer

Skin Cancer Skin Cancer

BASAL CELL CARCINOMA • Most Common Subtypes – Superficial – Nodular – Pigmented – Infiltrative • Morpheaform • Micronodular – Basosquamous

2 Skin Cancer BASAL CELL CARCINOMA • Prognosis – Often referred to as “the best kind of skin cancer Squamous Cell to have”. • Metastasis is exceedingly rare (<1%). • Tend to grow very slowly. Carcinoma – Eventually will destroy surrounding tissue if left untreated. • Vital structures such as the eyes, ears, and nose are particularly vulnerable to damage and/or disfigurement.

Skin Cancer Skin Cancer

SQUAMOUS CELL CARCINOMA SQUAMOUS CELL CARCINOMA • Background • Risk Factors – Ultraviolet Light – Second in frequency behind Basal Cell Carcinoma. – Fair Skin • Est. 200,000 diagnosed annually in United States alone. – Advanced Age – Actinic Keratoses – Immunosuppression – Radiation Exposure – Burn Scars – Human Papilloma Virus

Skin Cancer Skin Cancer

SQUAMOUS CELL CARCINOMA • Presentation – Can occur almost anywhere. • Face, ears, dorsal hands, and forearms most common. • SCC can also occur on the oral mucosa. • SCC on legs is not uncommon in elderly females who used to play golf, tennis, or sunbathe. – Often presents as a non-healing, scaling or crusting “sore” that just doesn’t go away.

3 Skin Cancer Skin Cancer

Skin Cancer Skin Cancer

SQUAMOUS CELL CARCINOMA SQUAMOUS CELL CARCINOMA • Most Common Subtypes • Prognosis – Superficial – SCC does have a real potential to metastasize! • aka, “Bowen’s Disease” or “SCC In Situ” • However, the overwhelming majority do not. – Keratoacanthoma-type – The greatest risk of metastasis occurs in…. • Very deep lesions (extending to bone, muscle, or nerve tissue). – Typical SCC often classified by “differentiation” • Immunosuppressed patients. • Well-differentiated (least atypical) • Lesions which are “poorly-differentiated”. • Moderately-differentiated • Lesions arising within a scar (e.g., “burn scar”). • Those which arise on the lip (~14%). • Poorly-differentiated (most atypical)

Skin Cancer

Most Common NMSC Treatments – Traditional Excision – Mohs Surgery – Electrodessication and Curettage Melanoma – Topical Chemotherapy – Radiation Therapy (aka, “XRT”) – Erivedge® (BCC Only)

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Skin Cancer Skin Cancer

MELANOMA MELANOMA • Background • Facts – To the public, it’s the most “familiar” of all – The ACS estimates over 75,000 new cases of skin cancers. melanoma are diagnosed every year. • Many mistakenly believe that all skin cancers • Over 9,000 will die! are “melanoma”. – The overall lifetime risk of melanoma: – Even though it accounts for only 5% of skin • 1 in 50 for whites. cancers, it is responsible for nearly 80% of • 1 in 200 for Hispanics. skin cancer deaths! • 1 in 1,000 for blacks.

Skin Cancer Skin Cancer

MELANOMA MELANOMA • Risk Factors • Risk Factors (cont.) – Fair Skin – Personal History of Melanoma – Light-Colored Eyes • BCC/SCC do not turn into melanoma! – Red or Blonde Hair – Family History of Melanoma (1° Relative) – Presence of > 100 Nevi – Xeroderma Pigmentosum – Any Dysplastic Nevi – Certain Gene Mutations (e.g., “P16”) – Large Congenital Nevus –ULTRAVIOLET LIGHT!!

Skin Cancer Skin Cancer

MELANOMA MELANOMA • Risk Factors (cont.) • Presentation –ULTRAVIOLET LIGHT!! – Can occur anywhere on the body. • Both chronic and intense intermittent • Slightly more common on the legs in women. exposure increase melanoma risk. • Slightly more common on the back in men. –Just one blistering sunburn during childhood can double chance of melanoma later in life! • Tanning beds, and even PUVA and UVB in dermatology office can increase risk.

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Skin Cancer A – Asymmetry MELANOMA • Presentation – ABCDs of Melanoma • Meant to serve as a screen for lesions which may be suspicious for melanoma. • NOT a perfect screening tool! – It’s very sensitive, but not very specific.

B – Border (irregular) C – Color (very dark or varied)

C – Change (constant/ongoing) D – Diameter (> 6 mm)

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Skin Cancer Skin Cancer

MELANOMA MELANOMA • Presentation • Presentation – There will always be exceptions to the rule! – The majority of melanomas do not arise • Amelanotic melanoma is the most notable. from within a mole. – Have no pigment, therefore aren’t dark. • All lesions should be monitored, but melanoma more – Very difficult to diagnose using traditional ABCD likely to be found in newly-forming lesions. criteria. • Many patients think moles “must” be raised/elevated. » However, screening techniques used for – If only raised/elevated lesions are monitored, then BCC/SCC can help to discover them. melanoma in its earliest stages can be missed.

Skin Cancer Skin Cancer

MELANOMA MELANOMA • Most Common Subtypes • Most Common Subtypes – Superficial Spreading Melanoma – Nodular Melanoma

Skin Cancer Skin Cancer

MELANOMA MELANOMA • Most Common Subtypes • Most Common Subtypes – “Growth Pattern” – Level of “Invasion” • Superficial Spreading Melanoma • Melanoma In Situ • Nodular Melanoma – Confined to the epidermis only . • “Invasive” Melanoma – Any melanoma which isn’t “in situ”. » Melanoma which has moved beyond the epidermis and has “invaded” at least the underlying dermis.

7 Skin Cancer Skin Cancer

MELANOMA MELANOMA • Other Common Subtypes • Prognosis – Lentigo Maligna – Good News • Simply a melanoma in situ which formed within a pre- • The vast majority of melanomas are easily excised and existing “lentigo”. never metastasize. – Lentigo Maligna Melanoma – Bad News • “Invasive” version of a “Lentigo Maligna”. • A significant minority of patients who are diagnosed – Acral Lentiginous Melanoma with melanoma will have metastasis and eventually die. – Of 75,000 patients diagnosed, over 9,000 will die. • Name given to melanoma which arises on the palms, soles, beneath the nails, or on the mucosal surfaces.

Skin Cancer Skin Cancer

MELANOMA MELANOMA • Prognostic Considerations • Prognostic Considerations – Clark’s Level – Breslow Depth I 1 mm

II 2 mm

3 mm III 4 mm IV V 5 mm

Skin Cancer Skin Cancer

MELANOMA MELANOMA • Prognostic Considerations • Prognostic Considerations – 5-Year Survival Rate – 5-Year Survival Rate Example Example

Breslow Depth < 1 mm Breslow Depth 4.5 mm Non-Ulcerated Ulcerated 95% 5-Year Survival Rate 45% 5-Year Survival Rate

8 Skin Cancer Skin Cancer

Melanoma Treatment Melanoma Treatment – Surgical – Adjuvant • Margins always taken. • Chemotherapy – As little as 0.5 cm to as much as 2 cm. – Dacarbazine • Sentinel Lymph Node (SLN) Biopsy? • Immunotherapy NONE have been shown – Blue dye and radioactive “technetium-99” solution – Interleukin-2 to significantly affect injected into the tissue surrounding melanoma site. • Vaccines (various) long-term survival! – Draining node(s) are removed and tested for any • New Medications sign of metastatic melanoma. – Ipilimumab – Vemurafenib

Skin Cancer

CONCLUSION

9

Understanding Concentrations & Dilutions

Concentration

Amount of Medication Total Amount of Solution

5 mg/ml 2 ML 1 CC

= 1 MG OF KENALOG SAME 10 MG WE HAD BEFORE

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3.3 mg/ml 2.5 mg/ml 3 ML 4 ML

SAME 10 MG SAME 10 MG WE HAD WE HAD BEFORE BEFORE

It’s all about the “ratio”!

Parts of Original Undiluted Concentration Plus This Many Equal Results In A Dilution (Any Concentration/ Parts of Water Which Is This Fraction of Any Amount) the Original 1 1 1/2 1 2 1/3 1 3 1/4

For Example:

.1 CC Kenalog 10 + .3 CC Water = .4 CC Kenalog 2.5 MG/ML

It’s all about the “ratio”! It’s all about the “ratio”!

Parts of Original Parts of Original Undiluted Concentration Plus This Many Equal Results In A Dilution Undiluted Concentration Plus This Many Equal Results In A Dilution (Any Concentration/ Parts of Water Which Is This Fraction of (Any Concentration/ Parts of Water Which Is This Fraction of Any Amount) the Original Any Amount) the Original 1 1 1/2 1 1 1/2 1 2 1/3 1 2 1/3 1 3 1/4 1 3 1/4

For Example: For Example:

.25 CC Kenalog 10 + .25 CC Water = .5 CC Kenalog 5 MG/ML .15 CC Kenalog 10 + .45 CC Water = .6 CC Kenalog 2.5 MG/ML

2 It’s all about the “ratio”! It’s all about the “ratio”!

Parts of Original Parts of Original Undiluted Concentration Plus This Many Equal Results In A Dilution Undiluted Concentration Plus This Many Equal Results In A Dilution (Any Concentration/ Parts of Water Which Is This Fraction of (Any Concentration/ Parts of Water Which Is This Fraction of Any Amount) the Original Any Amount) the Original 1 1 1/2 1 1 1/2 1 2 1/3 1 2 1/3 1 3 1/4 1 3 1/4

For Example: .2 CC Kenalog 40 + .2 CC Water = .4 CC Kenalog 20 MG/ML

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Prescription Order Entry • Transcription of your supervising physician’s verbal orders into the patient’s medical records may be one of the most frequent tasks you perform! Prescription • Many MAs now act as a type of “medical scribe”. – Prescription information verbalized by the provider is in turn entered into the medical record by staff. Order Entry • For practices utilizing electronic medical records (EMR), this process is known as “CPOE”. – Computerized Physician Order Entry • Major focus of Meaningful Use!

Prescription Order Entry Prescription Order Entry Why Is This Important? Written Prescription Components • As many as 1 in 4 ambulatory care (outpatient) clinic • Patient Name patients suffer an Adverse Drug Event (ADE).1 • Medication Name • • Cost of medication errors occurring in outpatient Strength • Formulation clinics alone is estimated at nearly $5 billion/year. 2 • Quantity (Per Dose) • Estimated 7,000 deaths occur every year as a result of • Route of Delivery preventable medication errors.3 • Frequency of Dose

• Duration 1) Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med 2003;348:1556–1564. • Total To Dispense 2) Berwick DM, Winickoff DE. The truth about doctors' handwriting: a prospective study. BMJ 1996;313:1657–1658. 3) Institute of Medicine (IOM). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999. • Refills

Prescription Order Entry Prescription Order Entry Written Prescription Components Written Prescription Components • Patient Name • Patient Name – Date of birth (DOB) is typically the best method of – Date of birth (DOB) is typically the best method of distinguishing “same name” patients from one another. distinguishing “same name” patients from one another. • Other considerations include: • Other considerations include: – Middle Initial – Middle Initial – Address – Address – Date of Last Visit – Date of Last Visit

WHAT IF “SULFA-ALLERGIC MARY WILLIAMS” WERE MISTAKENLY WHAT IF “SULFA-ALLERGIC MARY WILLIAMS” WERE MISTAKENLY PRESCRIBED BACTRIM? PRESCRIBED BACTRIM?

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Prescription Order Entry Prescription Order Entry Written Prescription Components Written Prescription Components • Medication Name • Strength – In dermatology, we’re fortunate to only prescribe a – Systemic Medications fraction of the thousands of medications available. • Pills, Tablets, Etc. – Almost always milligrams (mg).

– e.g., Doxycycline 100 mg • Liquids – Generally measured in mg/ml. – e.g., Cetirizine 5 mg/5 ml – Topical Medications • Almost always as percentage/concentration. – e.g., Tretinoin 0.025%

Prescription Order Entry Prescription Order Entry Written Prescription Components Written Prescription Components • Formulation • Quantity (Per Dose) – Systemic Medications – Systemic Medications • Pill, Capsule, Liquid, etc. • Pills/Capsules • e.g., Fluconazole 150 mg Capsules – The number taken per dose. – Topical Medications – e.g., “Take One”, or “Take Two”, etc. • • Ointment, Cream, Lotion, Solution, Foam, etc. Liquids – The volume of medication per dose, usually as “tsp” or “ml”. – aka, “Medication Vehicle” (reviewed elsewhere in the – e.g., “Take ½ Teaspoon”, or “Take 2 ML”. ACDT course). • Injectables • e.g., Clindamycin 1% Solution – The volume of medication per dose, usually as “ml” or “cc”. • Formulation of topical medications is always important. – e.g., “Inject 0.5 ml”.

Prescription Order Entry Prescription Order Entry Written Prescription Components Written Prescription Components • Quantity (Per Dose) • Route of Delivery – Topical Medications – Systemic Medications • A specific “quantity per dose” is usually not indicated. • Oral – General terms often used instead. – “Orally”, “By Mouth”, and “PO” all mean the same! – e.g., “Apply As Directed” – “PO” is an abbreviation for the Latin per os, meaning “by way of the mouth”. • Sometimes more specific instructions are indicated. – e.g., “Take One PO”. – e.g., “Apply One Pea-Sized Drop” • Injectables – “Subcutaneously”, “SQ”, Sub-Q”, and “SC” are all used to describe injections under the skin. » e.g., “Inject 0.5 ML SQ”. – “Intramuscularly” or “IM” means within the muscle.

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Prescription Order Entry Prescription Order Entry Written Prescription Components Written Prescription Components • Frequency of Dose • Duration – “Plain English” Method – How long is the prescribed quantity supposed to last? • e.g., “Once Daily”, “Twice A Day”, “Three Times/Week”, etc. • e.g., “14 Days”, “30 Day Supply”, etc. • This method is increasingly favored since it provides least ambiguous method of describing how often a medication is to be used. – Latin Abbreviations • QD (quaque die) means “once a day”. • BID (bis in die) means “twice a day”. • TID (ter in die) means “three times a day”. • QID (quater in die) means “four times a day”. • QAM (quaque die ante meridiem) means “every morning”. • QHS (quaque hora somni) means “every evening”.

Prescription Order Entry Prescription Order Entry Written Prescription Components Written Prescription Components • Duration • Total To Dispense – How long is the prescribed quantity supposed to last? – How much medicine should be provided? • e.g., “14 Days”, “30 Day Supply”, etc. – For example… • An antibiotic to be taken BID for one month would be written to dispense “60 Tablets” (#60). • An Efudex prescription to be applied QD x 3 weeks to the face may be written to dispense “40 GM”. • A patient receiving a Stelara injection every 3 months may be prescribed a dispense quantity of “0.5 ML”.

Prescription Order Entry Written Prescription Components • Refills Medication – Always confirm the number of refills authorized by your supervising dermatologist before sending prescription! – What if too many refills were authorized for a patient who Error then becomes noncompliant with f/u visits or lab monitoring? • TOPICAL STEROIDS – Steroid Atrophy • SYSTEMIC ANTIFUNGALS Avoidance – Liver Damage • DAPSONE – Anemia

3 Prescription Order Entry Prescription Order Entry Medication Error Avoidance Medication Error Avoidance As a medical assistant, you… To Prevent Errors, You Should… • Are not responsible for exercising independent clinical • Enter medication name and directions precisely judgment with regard to medication selection. as described by your supervising physician. • Are responsible for- – Pay attention while your SP is describing the 1) Accurately entering the prescription details as treatment plan and directions. communicated by your supervising physician. – Don’t be afraid to ask if you’re not sure! 2) Recognizing and acting upon any Clinical Decision Support (CDS) alerts intended to prevent errors.

Prescription Order Entry Prescription Order Entry Medication Error Avoidance Medication Error Avoidance To Prevent Errors, You Should… To Prevent Errors, You Should… • Beware of “sound-alikes”! • Beware of “sound-alikes”! – Pay attention and don’t be afraid to ask if unsure! – Pay attention and don’t be afraid to ask if unsure!

Prescription Order Entry Prescription Order Entry Medication Error Avoidance Medication Error Avoidance To Prevent Errors, You Should… To Prevent Errors, You Should… • Avoid confusing terminology. • Avoid “trailing zeros”. – Abbreviations, acronyms, and “shorthand” were – e.g., Entering 25.0 MG may be confused for 250 MG designed to speed up the handwriting process! – For example- • Instead of entering “QD”, write “Once Daily”. • Rather than write “TIW”, say “Three Times Per Week”.

4 Prescription Order Entry Prescription Order Entry Medication Error Avoidance Medication Error Avoidance To Prevent Errors, You Should… To Prevent Errors, You Should… • Include “leading zeros”. • Recognize and Take Action When Presented – e.g., Entering .1% may be confused for 1% Important Clinical Decision Support (CDS) Alerts! – These are the “pop-up” alerts we sometimes see after a prescription is entered. – Unfortunately, not all CDS alerts are equally important, which can lead to “pop-up fatigue”. • Your practice should establish a protocol which ensures patient safety while avoiding unnecessary concern over insignificant CDS alerts!

Prescription Order Entry Prescription Order Entry Medication Error Avoidance Medication Error Avoidance To Prevent Errors, You Should… To Prevent Errors, You Should… • Recognize and Take Action When Presented • Recognize and Take Action When Presented Important Clinical Decision Support (CDS) Alerts! Important Clinical Decision Support (CDS) Alerts! – These are the “pop-up” alerts we sometimes see – These are the “pop-up” alerts we sometimes see after a prescription is entered. after a prescription is entered. – Unfortunately, not all CDS alerts are equally – Unfortunately, not all CDS alerts are equally important, which can lead to “pop-up fatigue”. important, which can lead to “pop-up fatigue”. • Your practice should establish a protocol which ensures • Your practice should establish a protocol which ensures patient safety while avoiding unnecessary concern over patient safety while avoiding unnecessary concern over insignificant CDS alerts! insignificant CDS alerts!

Prescription Order Entry Prescription Order Entry Medication Error Avoidance Medication Error Avoidance To Prevent Errors, You Should… To Prevent Errors, You Should… • Recognize and Take Action When Presented • Recognize and Take Action When Presented Important Clinical Decision Support (CDS) Alerts! Important Clinical Decision Support (CDS) Alerts! – These are the “pop-up” alerts we sometimes see – These are the “pop-up” alerts we sometimes see after a prescription is entered. after a prescription is entered. – Unfortunately, not all CDS alerts are equally – Unfortunately, not all CDS alerts are equally important, which can lead to “pop-up fatigue”. important, which can lead to “pop-up fatigue”. • Your practice should establish a protocol which ensures • Your practice should establish a protocol which ensures patient safety while avoiding unnecessary concern over patient safety while avoiding unnecessary concern over insignificant CDS alerts! insignificant CDS alerts!

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Prescription Order Entry Prescription Order Entry Medication Error Avoidance Medication Error Avoidance To Prevent Errors, You Should… To Prevent Errors, You Should… • Recognize and Take Action When Presented • Recognize and Take Action When Presented Important Clinical Decision Support (CDS) Alerts! Important Clinical Decision Support (CDS) Alerts! – These are the “pop-up” alerts we sometimes see – These are the “pop-up” alerts we sometimes see after a prescription is entered. after a prescription is entered. – Unfortunately, not all CDS alerts are equally – Unfortunately, not all CDS alerts are equally important, which can lead to “pop-up fatigue”. important, which can lead to “pop-up fatigue”. • Your practice should establish a protocol which ensures • Your practice should establish a protocol which ensures patient safety while avoiding unnecessary concern over patient safety while avoiding unnecessary concern over insignificant CDS alerts! insignificant CDS alerts!

Prescription Order Entry THE BOTTOM LINE

Although you aren’t expected to make independent clinical decisions, you are expected to responsibly enter medication orders. This means that you must:

• Accurately transcribe the Rx order as verbalized by your supervising MD. • Heed any important CDS alerts.

6

Medications

• The days in which “only the doctor” really needs to know about medication use and side MEDICATIONS effects are gone! – When a patient has a question, who are they (INTRODUCTION) going to ask first? – When your doctor is the one who answers the question, who do you think they’re going to ask to “relay” that message back to the patient?

Medications Medications

In these modules, we’ll be reviewing… • Corticosteroids • Antibiotics • Basic Mechanism of Action • Antifungals • How Used • Antihistamines • Side Effects • Retinoids • What Patients Should Know • Hydroquinone & Azelaic Acid • Keratolytics

Medications Medications

• Non-steroid Anti-Inflammatories DISCLAIMER • Topical Antipruritics The full range of uses and potential side effects of any of • Topical Chemotherapies the medications we discuss can only be found through • Hormone Blocking Agents lengthy review of the prescription package inserts.

• Methotrexate : The discussion we have here is meant to introduce you • Biologics to the background and use of these medications, but by no means is intended as a replacement for the

information within the FDA -approved monographs.

1

Antibiotics

• Used for a variety of conditions. • From a patient-education perspective, they Antibiotics are also one of the more “high maintenance”.

Antibiotics Antibiotics

• We’ll be reviewing only the most common, • We’ll be reviewing only the most common, which include… which include… – Topical Antibiotics – Systemic Antibiotics • Benzoyl Peroxide • Tetracycline, Doxycycline, and Minocycline • Clindamycin/Erythromycin • Trimethoprim/Sulfamethoxazole (Bactrim® or Septra®) • Sodium Sulfacetamide • Erythromycin and Azithromycin • Metronidazole • Amoxicillin, Ampicillin, and Dicloxacillin • Dapsone (Aczone®) • Cephalosporins (such as Keflex®) • Neomycin, Bacitracin, Mupirocin (Bactroban®), and • Ciprofloxacin and Levofloxacin Retapamulin (Altabax®) • Dapsone • Clindamycin/Rifampin

Antibiotics Antibiotics

• Basic Mechanism of Action • How Used • Bactericidal – Directly kill the bacteria. – Benzoyl Peroxide – Use depends on the formulation prescribed. – Penicillins – Cephalosporins • Oral Antibiotics – Neomycin, Bacitracin, and Retapamulin (Altabax®) – Metronidazole – Taken by mouth as a “pill” or “syrup”. • Bacteriostatic – Prevent replication. – Exact frequency varies significantly depending on the – Tetracyclines condition treated and how your supervising physician – Clindamycin – Sodium Sulfacetamide prescribes. • Both bactericidal and bacteriostatic. • Topical Antibiotics – Erythromycin and Azithromycin – Ciprofloxacin – Applied in a “vehicle” base ranging from ointments to – Mupirocin (Bactroban®) solutions. • Neither – Instead used for “anti-inflammatory” effects. – Exact frequency again depends on the condition and – Low-dose Doxycycline – Dapsone preferences of your supervising physician.

1

Antibiotics Antibiotics

• Side Effects • Side Effects – Topical Antibiotics – Systemic Antibiotics • Allergic reactions almost always limited to the skin. • Allergic Reactions – Neosporin and Bacitracin are the most common culprits. – PCN and SULFA most common. • Irritant reactions are also a possibility, but usually due • GI Upset/Diarrhea to the base rather than the medication itself. • Yeast Infection (Women) – Gels and solutions are more likely to cause irritation on • Pregnancy? cracked/broken skin. – Some antibiotics should not be taken while pregnant! – Only “Rifampin” has been documented to affect OCPs. » If a woman is concerned, we recommend that she use a secondary method of contraception.

Antibiotics Antibiotics

• What Patients Should Know • What Patients Should Know – Tetracyclines – Tetracyclines (cont.) • Calcium interferes with absorption. • Tetracyclines should be avoided while pregnant or by – Don’t take at the same time as calcium-containing food or young children whose teeth are still developing. supplements! • All Tetracyclines can cause sun-sensitivity, but – Take 30 minutes before or 2 hours after ingesting calcium. Doxycycline is the most likely to do so. • Minocycline is known to cause headache and/or dizziness • Doxycycline is notorious for causing stomach-upset. in some patients. – Patients can take it with a meal, just not one which is • Minocycline also associated with causing bluish rich in calcium. discoloration of the skin or teeth if taken for a prolonged period of time.

Antibiotics Antibiotics

• What Patients Should Know • What Patients Should Know – TMP/SMZ (Bactrim®/Septra ®) – Erythromycin and Azithromycin • Quit taking at first sign of a rash! • Allergy is rare. – “SULFA” antibiotics are infamous for causing bad • Stomach-upset is very common with Erythromycin. allergic reactions! – Stomach acid (if taken w/ meal) can decrease the – Patients who stop taking it immediately upon potency, but most doctors will still tell patients to take seeing the rash and seek treatment usually do fine. with food to avoid stomach ache. – Enteric-coated versions are available. – Those who don’t recognize it as a reaction to the medicine and keep taking it can experience a life- • Rarely, patients will report transient “hearing loss”. threatening reaction called Stevens-Johnson. • Known to interact with other medications. • Can rarely cause anemia and lowered WBC.

2

Antibiotics Antibiotics

• What Patients Should Know • What Patients Should Know – Amoxicillin, Ampicillin, and Dicloxacillin – Cephalosporins (such as Keflex®) • Penicillin allergy is common! • Allergy Risk – Discontinue at first sign of a rash. – Allergy risk in general population is low (1-2%). • Ampicillin and Dicloxacillin are best absorbed in a low- – As high as 15% in those allergic to Penicillin! acidity environment (empty stomach). » Because 85% of those allergic to PCN aren’t allergic • May cause diarrhea, sometimes serious, by altering the to Cephalosporins, your doctor may choose to use natural intestinal flora. them in those patients! – Patients should eat yogurt or take “probiotics”.

Antibiotics Antibiotics

• What Patients Should Know • What Patients Should Know – Ciprofloxacin and Levofloxacin – Dapsone (Systemic) • Allergic reaction is always a possibility. • Usually prescribed because of its anti-inflammatory effects • GI upset is the most common side effect. and not its antibiotic properties! • Supplements containing Ca, Al, Mg, Iron, or Zinc can – When prescribed as an anti-inflammatory, let patients know interfere with absorption. ahead of time so they don’t get too surprised reading the pharmacy insert. • Spontaneous tendon rupture and Peripheral • Anemia is not uncommon while taking it. Neuropathy have been reported in patients who have taken either. • Doctors may test for “G6PD” enzyme deficiency. • Headache and dizziness occur in some patients. – Anemia risk is much greater in those who are G6PD- deficient. • Peripheral neuropathy another potential side effect.

Antibiotics Antibiotics

• What Patients Should Know • What Patients Should Know – Clindamycin/Rifampin – Benzoyl Peroxide • Combination used to treat “Staph carriers”. • Can cause dryness and irritation. • Clindamycin can cause a serious intestinal inflammation – Some patients simply cannot tolerate it. called Pseudomembranous Colitis, caused by • Can “bleach” clothing and towels. overgrowth of the bacteria C. difficile. – Yogurt and/or probiotics can help prevent. – Patients should stop taking medication immediately at first sign of GI upset or diarrhea. • Rifampin can cause the tears and urine to temporarily turn reddish-orange in color.

3

Antibiotics Antibiotics

• What Patients Should Know • What Patients Should Know – Clindamycin/Erythromycin (Topical) – Sodium Sulfacetamide • If paired with Benzoyl Peroxide, patients should be • Often paired with “Sulfur” which has both keratolytic warned about potential irritation and bleaching. and antibacterial qualities. • By themselves (without Benzoyl Peroxide), they rarely – If paired with Sulfur, may have a faint “rotten egg” smell. cause irritation. • By itself, Sodium Sulfacetamide is fairly odorless and non-irritating. • “SULFA” allergic patients should avoid. – Some doctors may still prescribe to these patients if their allergy history is questionable.

Antibiotics Antibiotics

• What Patients Should Know • What Patients Should Know – Metronidazole (Topical) – Dapsone (Topical) • Fairly non-irritating. • Very well-tolerated. – “Cream” version is less irritating than the “Gel”. – Dryness, redness, oiliness, or peeling rarely reported. • There are two concentrations: – 1% approved for “QD” application. – 0.75% usually prescribed for “BID” application, though some patients do fine using it only once/day.

Antibiotics

• What Patients Should Know – Neomycin, Bacitracin, Mupirocin (Bactroban®), and Retapamulin (Altabax®) That concludes the module on Antibiotics. • Allergy is the single greatest concern. – More common with Neomycin and Bacitracin. Please proceed to the next topic. – Risk increases with prolonged use under occlusion. – Patients should stop using them if they experience signs of allergy including increased redness, itching, or blister formation.

4 Antifungals

• Used for to treat skin and nail infections caused by either fungus or yeast. • Available in both topical and systemic Antifungals formulations.

Antifungals Antifungals

• The most common topical antifungals • The most common systemic antifungals include…. include…. – Creams/Lotions/Gels/Sprays/Powders, etc. – Griseofulvin (Gris-Peg®, Grifulvin®, etc.) • These range from OTC Clotrimazole (Lotrimin®) to – Fluconazole (Diflucan®) prescriptions such as Naftin® or Oxistat®. – Terbinafine (Lamisil®) – Nail Lacquer – Itraconazole (Sporanox®) • Penlac® (generic is called Ciclopirox) – Ketoconazole (Nizoral®)* – Oral Preparations • Nystatin Suspension *On July 26, 2013, the FDA announced new safety warnings regarding the use of systemic Ketoconazole. • Clotrimazole (Mycelex®) Troches

Antifungals Antifungals

• Basic Mechanism of Action • How Used • Fungicidal – Directly kill the fungus/yeast. – Terbinafine (Lamisil®) – Creams, Gels, Lotions, Sprays, etc. – Nystatin – Butenafine (Mentax® and Lotrimin Ultra®) • Applied QD-BID. – Naftifine (Naftin®) • Total frequency and duration of treatment is • Fungistatic – Prevent replication. determined by your supervising physician. – Clotrimazole (Lotrimin® and Mycelex®) – Ketoconazole (Nizoral®) – Econazole (Spectazole®) – Oxiconazole (Oxistat®) – Fluconazole (Diflucan®) – Itraconazole (Sporanox®) – Griseofulvin (Gris-Peg®, Grifulvin®, etc.) • Both fungistatic and fungicidal. – Ciclopirox (Loprox® and Penlac®)

1

Antifungals Antifungals

• How Used • How Used – Nail Lacquer (Penlac® or its generic) – Nystatin Suspension • Applied daily, layer upon layer. • Being a “suspension” would suggest that it’s to be • Every 7 days, patients should remove the used systemically, but its action is topical. accumulated layers of lacquer using alcohol and • Patients are to place ½ of the prescribed dose in file away nail debris using an emery board before each side of their mouth, swish for at least 30-60 beginning the next week’s cycle of daily seconds, and then either spit it out or swallow. application.

Antifungals Antifungals

• How Used • How Used – Mycelex® (Clotrimazole) Troches – Griseofulvin • Formulated as a “lozenge”. • Available as either a pill or a suspension. • Usually prescribed to be used 5x/day x 1 week. – Comes in standard, micronized, and ultra- • Patients are to slowly dissolve the troche on their micronized. tongue, while swirling it around in their mouth. – MAKE SURE you’re clear on which form your doctor is prescribing before you write it down or enter into the EMR! • Often prescribed for children with Tinea Capitis. – Treatment for at least 6 weeks (or longer) is not uncommon.

Antifungals Antifungals

• How Used • How Used – Fluconazole (Diflucan®) – Systemic Ketoconazole (Nizoral®) • Best known for the treatment of vaginal or oral yeast • Now restricted to the treatment of rare fungal infections. infections when alternatives are either not available – Most often taken just “one time” as-needed. or tolerated – including Blastomycosis, • Because of the FDA warnings regarding systemic Coccidioidomycosis, Histoplasmosis, Ketoconazole, we’re likely going to see a Fluconazole Chromomycosis, and Paracoccidioidomycosis. used more often in the treatment of a wider variety – Topical Ketoconazole of fungal and yeast infections. • Still widely used in creams and shampoos for a multitude of fungal and yeast infections.

2 Antifungals Antifungals

• How Used • How Used – Terbinafine (Lamisil®) – Itraconazole (Sporanox®) • Usually prescribed in 250 mg tablets. • Available in 200 mg capsules or oral solution. • Durations vary… • It was the first to be prescribed as “pulse” therapy… – Tinea Corporis (i.e., “Ringworm”) – Two capsules (400 mg) are taken BID x 1 week only. • 250 mg QD x 2-3 weeks. – An entire month of treatment is taken in just 7 days. – Onychomycosis • 250 mg QD x 3 months (or longer). – Tinea Capitis • Partial tablet mixed w/ food x 4, 6, or 8 weeks.

Antifungals Antifungals

• Side Effects • Side Effects – Topicals – Griseofulvin • Very well-tolerated. • Most common SE is headache. • Rarely patients may report redness or irritation at • Occasionally patients may report GI upset or application site. drowsiness.

Antifungals Antifungals

• Side Effects • Side Effects – Fluconazole (Diflucan®) – Ketoconazole (Nizoral®) • Nausea, vomiting, and rash can rarely occur. • GI upset is most common side effect. • Hepatitis is rare. • Androgen hormone production can decrease. – If patient is taking a prolonged course, your – Men can experience gynecomastia, decreased libido, supervising physician may order bloodwork. and impotence. – Women can experience menstrual irregularities. • Can cause hepatoxicity and adrenal insufficiency! – If/when it’s prescribed, bloodwork (esp. hepatic) will likely be performed.

3 Antifungals Antifungals

• Side Effects • Side Effects – Terbinafine (Lamisil®) – Itraconazole (Sporanox®) • GI Upset, headache, and rash are the most common. • GI upset, rash, hypertension, edema, and headache • Taste disturbances also rarely reported. may occur. • Elevated liver enzymes, hepatitis, and decreased • Elevated liver enzymes and hepatitis have occurred blood count (neutropenia) have occurred. in some patients. – CBC and Hepatic Function testing is recommended – Bloodwork (inc. Hepatic Function Panel) may be for patients taking a prolonged course. ordered.

Antifungals Antifungals

• What Patients Should Know • What Patients Should Know – Topicals – Griseofulvin • If a follow-up is not made, patients should contact • Has a number of potential interactions, so patients the office if they don’t see the expected results! need to be sure to have provided your doctor with – Some fungal infections ultimately need to be a complete list of current medications. treated with a systemic medication. • Absorption is improved if taken with fatty meals. • Some of the prescription topical antifungals are • Alcohol should be avoided as it can potentiate quite expensive. Patients should call the office if (strengthen) its effects. they can’t afford their medicine so that a suitable alternative can be recommended.

Antifungals Antifungals

• What Patients Should Know • What Patients Should Know – Fluconazole (Diflucan®) – Ketoconazole (Nizoral®) • It’s not dependent on stomach acidity for absorption, • Should be avoided in those with a history of liver so it can be taken with or without a meal. disease! • Bloodwork, if ordered, should be performed as • Has a number of potential interactions, so patients directed. need to be sure to have provided your doctor with a complete list of current medications. • Bloodwork, if ordered, should be performed as directed.

4

Antifungals Antifungals

• What Patients Should Know • What Patients Should Know – Terbinafine (Lamisil®) – Itraconazole (Sporanox®) • Patients should call the office should they • Has a number of potential interactions. experience any unusual side effects. – Is their medication list complete/accurate? • Bloodwork should be performed in a timely • Absorbed better in an “acidic” stomach environment. manner. – Patients should take with a meal.

– Avoid taking it with an antacid. • Bloodwork, if ordered, should be performed as directed.

That concludes the module on Antifungals. Please proceed to the next module.

5 Antihistamines

• “Sedating” Antihistamines – Diphenhydramine (Benadryl®) – Hydroxyzine (Atarax®) – Cyproheptadine (Periactin®) Antihistamines – Doxepin • “Non-Sedating” Antihistamines – Fexofenadine (Allegra®) – Loratadine (Claritin®)/Desloratadine (Clarinex®) – Cetirizine (Zyrtec®)/Levocetirizine (Xyzal®) • “H2 Blockers” – Cimetidine (Tagamet®) – Ranitidine (Zantac®) – Famotidine (Pepcid®)

Antihistamines Antihistamines

• Basic Mechanism of Action • Basic Mechanism of Action

HISTAMINE

BLOOD VESSEL BLOOD VESSEL BLOOD BLOOD VESSEL BLOOD VESSEL BLOOD

MAST CELL MAST CELL

Antihistamines Antihistamines

• Basic Mechanism of Action • How Used – Systemically • Pill/Syrup ANTIHISTAMINE • Parenteral (Injection) – Diphenhydramine (Benadryl®) HISTAMINE RECEPTORS – Hydroxyzine (Atarax®) – Topical • Benadryl® Cream/Lotion

BLOOD VESSEL • Doxepin (Zonalon®) Cream/Lotion

1

Antihistamines Antihistamines

• Side Effects • Side Effects – Older “Sedating” Antihistamines – Newer “Non-Sedating” Antihistamines • Including Diphenhydramine (Benadryl®), Hydroxyzine • Including Fexofenadine (Allegra®), Loratadine (Atarax®), Cyproheptadine (Periactin®), and Doxepin. (Claritin®), Desloratadine (Clarinex®), Cetirizine – SEDATION (or the opposite – “Excitability”) (Zyrtec®), Levocetirizine (Xyzal®). – Dry Mouth – Drowsiness (or the opposite – “Excitability”) – Urinary Retention – Dry Mouth – Uncoordination – Urinary Retention – Blurred Vision – Uncoordination – Tachycardia (Increased Pulse Rate) – Blurred Vision – Tachycardia (Increased Pulse Rate)

Antihistamines Antihistamines

• Side Effects • What Patients Should Know – “H2 Blockers” – “Older” Sedating Antihistamines • Ranitidine (Zantac®) and Famotidine (Pepcid®). • Including Diphenhydramine (Benadryl®), Hydroxyzine – May occasionally report headache, dizziness, (Atarax®), Cyproheptadine (Periactin®), and Doxepin. diarrhea, and muscular pain. – Patients MUST be warned about the potential • Cimetidine (Tagamet®) for sedation!! – Same potential for headache, dizziness, diarrhea, • Doxepin and muscular pain, but more importantly… – Originally created as an antidepressant. – Ongoing use can inhibit androgen hormones, and – Patients should be told this before they go to the can cause gynecomastia and decreased sperm pharmacy to pick up their prescription! count in men.

Antihistamines Antihistamines

• What Patients Should Know • What Patients Should Know – “Newer” Non-Sedating Antihistamines – “H2” Blockers • Including Fexofenadine (Allegra®), Loratadine (Claritin®), • Including Cimetidine (Tagamet®), Ranitidine (Zantac®), and Desloratadine (Clarinex®), Cetirizine (Zyrtec®), Famotidine (Pepcid®). Levocetirizine (Xyzal®). – Patients should be made aware that it’s being prescribed for – Sedation is very uncommon but still worth mentioning to its antihistamine properties and not as a stomach acid patients just to be safe. treatment. – Patients should speak to the pharmacist about the effect any » Cetirizine (Zyrtec®) the most likely to cause. of these could have on their other medications. – Majority of these are available OTC and generic. » Cimetidine in particular can affect the levels of blood – Clarinex® and Xyzal® may not be covered by insurance. thinners and seizure meds. – Patients should always be told to call the office if cost or – All of these are now available OTC, which may be less coverage of medications is an issue. expensive for the patient.

2 Biologics

Definition

Biologics Medications consisting of concentrated, naturally-occurring (biologic) components of our immune system which have been modified such that, upon administration, they favorably alter the natural course of a disease process.

Biologics Biologics

Medications in this category include…. • Basic Mechanism of Action

• Etanercept (Enbrel®) Anti-Tumor Necrosis Factor (TNF) Agents • Infliximab (Remicade®) • Etanercept (Enbrel®) • Adalimumab (Humira®) • Infliximab (Remicade®) • Adalimumab (Humira®) • Ustekinumab (Stelara®) Anti-Interleukin 12/23 (IL-12/23) • Ustekinumab (Stelara®)

Biologics Biologics

Adalimumab (Humira®) Ustekinumab (Stelara®)

1

Biologics Biologics

• How Used Adalimumab (Humira®) Injection Instructions

–All biologics are administered by injection. • These medications are proteins which mimic naturally occurring components of our blood. –Taking these orally would never work.

Biologics Biologics

• How Used • Side Effects

– Frequency varies product to product. – Most Common • For example…. • Redness, itching, and/or swelling of the –Enbrel® is generally self-administered by injection site. patients once or twice per week. –Remicade® (administered intravenously) –Stelara® is administered by a healthcare may cause fever, chills, hives, or provider every 12 weeks (after two initial cardiopulmonary symptoms (chest pain, “starter doses”). hypo- or hypertension) within hours of administration.

Biologics Biologics

• Side Effects • Side Effects – Less Common (Though Potentially Serious) – Less Common (Though Potentially Serious) • Serious infection or malignancy. • TNF blockers are also associated with –Tuberculosis and/or Hepatitis can be increased risk of “demyelinating disorders” reactivated. (such as Multiple Sclerosis). • Congestive Heart Failure (CHF) can be –Stelara® has been rarely associated with exacerbated w/ TNF blockers. Reversible Posterior Leukoencephalopathy Syndrome (RPLS).

2 Biologics Biologics

• What Patients Should Know • What Patients Should Know

–Side effects should be fully explained. –Baseline testing (TB and Hepatitis • The responsibility for discussing the side effects screening, etc.) typically must be is primarily that of your supervising physician’s. completed before medication can be –Biologics are expensive. prescribed. • Typically $20K-40K/year. • Some insurance companies won’t even • Medication assistance programs are available. consider providing coverage until all baseline testing has been performed.

Biologics Biologics

• What Patients Should Know • What Patients Should Know

–Patient should be completely honest –Live vaccines (aka, “attenuated” and thorough in providing their past vaccines) should be avoided. medical history. • Typical (“killed”) vaccines may be taken but the –Generally, biologics are only prescribed biologic may limit the effectiveness. to reliable, trustworthy patients. – All biologics are Pregnancy Category B. • Safe to use in pregnancy, but of course only used if absolutely necessary.

That concludes the module on Biologics. Please proceed to the next topic.

3 Corticosteroids

• The most common medication that dermatologists prescribe! • “Steroid” is simply a chemistry term which Corticosteroids refers to the chemical structure only. – The steroid “family” includes compounds ranging from Testosterone to Prednisone to Cholesterol. – Anabolic steroids increase muscle size. • Corticosteroids (which we prescribe in dermatology) work in an entirely different manner.

Corticosteroids Corticosteroids

• Basic Mechanism of Action • Basic Mechanism of Action – Absorbed into our body’s tissue cells where they – A number of immune system cells, and the substances cause a decrease in the inflammatory response. they produce, are responsible for causing inflammation. The most common include…. • If “systemic” (like Prednisone or Kenalog®), these effects occur throughout our body. • If “topical” (like Clobetasol or Desonide), these effects only occur on the skin where the medication is applied.

Corticosteroids Corticosteroids

• How Used • How Used – Use depends on how the medication is – Oral Steroids administered to the patient. • Usually Prednisone or Methylprednisolone. • Systemic Steroids • Often prescribed in a “tapering dose”. – Administered as a “pill”… – e.g., 40 mg QAM x 3d, then 30 mg QAM x 3d, then 20 mg » Prednisone QAM x 3d, then 10 mg QAM x 3d. » Methylprednisolone (“Medrol®”) – Our body already produces cortisol in the adrenals. – Administered as an injection… – Adrenal glands can get “lazy” after not having to produce their own cortisol, and cause an “adrenal crisis”. » Kenalog® • Some doctors may choose not to taper if only • Topical Steroids prescribing a short course. – Administered topically as creams, gels, ointments, etc.

1 Corticosteroids Corticosteroids

• How Used • How Used – Parenterally-Administered Steroids – Topical Steroids • Parenteral = Not delivered by mouth (injection). • Ointments • Kenalog® is the most common. • Emollient Creams • Given intramuscularly, usually in the gluteus. • Creams • Gels • Foams • Solutions • Tape

Corticosteroids Corticosteroids

• Side Effects • Side Effects – Systemic Steroids – Topical Steroids • Increased blood pressure. • Burning/Stinging – Depends on the “base”. • Increased blood sugar. • THINNING OF THE SKIN!!!! • Decreased calcium uptake in bones. – Also known as “steroid-induced atrophy”. • Increased risk of cataracts. – A risk with repeated or prolonged steroid use. • Increased fluid retention. – Skin becomes very fragile and prone to bruising • Plus many other “potential” side effects…. and tearing. – Most patients take a short round of steroids and feel completely fine. – Risk of serious side effects increases with repeated treatments or prolonged duration.

TOPICAL STEROID POTENCY CHART CLASS I Corticosteroids Clobetasol, Halobetasol, Diflorasone Diacetate CLASS II • What Patients Should Know Betamethasone Diproprionate, Fluocinonide CLASS III – Systemic Steroids

Amcinonide, Fluticasone, Desoximetasone • Their doctor needs to know about all of their other CLASS IV medical conditions! Hydrocortisone Valerate, Triamcinolone, Mometasone • They shouldn’t be overused. CLASS V • Sleep cycle can be disturbed. Betamethasone Valerate, Flucinolone Acetonide – Most doctors ask patients to take their entire dose in P O E PC N T Y CLASS VI the AM. Desonide, Alcometasone Diproprionate • Some patients feel “anxious” while taking them. CLASS VII

• Others experience increased appetite. OTC Hydrocortisone

2 Corticosteroids

• What Patients Should Know – Topical Steroids • Avoid overuse! That concludes the module on Corticosteroids. – As a general rule, patients should avoid continuous use of topical steroids for more than 2-3 weeks in a row Please proceed to the next topic. without taking a break. – For chronic conditions, some doctors will prescribe that a medication can be used a “certain number of days/month”. – Talk to your supervising physician about his/her protocol and educate your patients! • Steroid atrophy is completely avoidable!

3 Hormone Blocking Agents

• The most common agents include…. Hormone – Spironolactone (Aldactone®) – Finasteride (Propecia®) Blocking Agents • Neither of these were originally created for the treatment of skin conditions.

Hormone Blocking Agents Hormone Blocking Agents

Spironolactone (Aldactone®) Finasteride (Propecia®) – Originally created as a diuretic. – Originally created for the treatment of – Used in patients with Congestive Heart Benign Prostatic Hyperplasia (BPH). Failure and/or Hypertension. • But also discovered to have other benefits as well, such as the ability to regrow hair. – Allows kidneys to excrete more sodium which in turn decreases the total volume of fluid the body retains. • But also discovered to have other benefits as well, such as ability to decrease Acne and unwanted facial hair.

Hormone Blocking Agents Hormone Blocking Agents

• Basic Mechanism of Action • Basic Mechanism of Action – Spironolactone (Aldactone®) – Finasteride (Propecia®) • Found to have an affinity for the “androgen • Inhibits an enzyme called “5α-reductase”. receptors” in the skin. – 5α-reductase converts Testosterone to – Androgens include hormones such as Testosterone, “dihydrotestosterone” which is what prostate tissue DHEA, DHEA-S, and DHT. and hair follicles are sensitive to. • By blocking androgens, it’s able to prevent one • By blocking this conversion, Finasteride greatly of the driving forces behind conditions such as minimizes one of the most important driving Acne, Hirsutism, Androgenetic Alopecia, as well forces behind hormone-sensitive hair loss. as others.

1 Hormone Blocking Agents Hormone Blocking Agents

• How Used • Side Effects – Spironolactone (Aldactone®) – Spironolactone (Aldactone®) • Available in 25, 50, and 100 mg. • Fairly well-tolerated. – • Most women report no side effects, though Finasteride (Propecia®) occasionally some patients will experience… • Propecia® is FDA-approved as 1 mg QD. – Increased urination. – Generic Finasteride is available in 5 mg size tablets. – Breast tenderness. » The 5 mg size is used for the treatment of – Irregular menses. Benign Prostatic Hyperplasia (BPH). Because it’s • Men can experience enlarged breast tissue and cheaper (per dose), some doctors will prescribe impotence while taking. this size and ask patients to take ¼ tablet QD. – In dermatology, it’s generally prescribed for women only.

Hormone Blocking Agents Hormone Blocking Agents

• Side Effects • What Patients Should Know – Finasteride (Propecia®) – Spironolactone (Aldactone®) • Minimal reported side effects. • Don’t take while pregnant. • Very rarely patients will report sexual • May elevate serum K+ levels. dysfunction. – Bloodwork should be performed if ordered by the dermatologist. – OCPs containing “drospirenone” (e.g., Yaz®) may increase this potential. • Patients should be aware that we’re not prescribing it as a diuretic!

Hormone Blocking Agents

• What Patients Should Know – Finasteride (Propecia®) • Don’t take while pregnant. That concludes the Hormone Blocking Agents • May lower Prostate-Specific Antigen (PSA) levels. module. Please proceed to the next topic. – Let your doctor decide if this is something worth discussing. • Must be taken at least 6 months before the patient can judge its effectiveness!

2 Hydroquinone & Azelaic Acid

Hydroquinone Hydroquinone & • The primary Rx “fading cream” ingredient. • Too many brand names to list. Also available generically. Azelaic Acid Azelaic Acid • Found in Finacea®, Azelex®, Finevin®, and also available generically.

Hydroquinone & Azelaic Acid Hydroquinone & Azelaic Acid

• Basic Mechanism of Action • Basic Mechanism of Action –Hydroquinone –Azelaic Acid • Inhibits tyrosinase. • Inhibits tyrosinase. –Tyrosinase is the enzyme which converts – Helps to decrease hyperpigmentation. tyrosine to melanin. • Antibacterial effects. »Melanin is the pigment which gives the – Helps with Acne and Rosacea. skin its color. • Mild “retinoid” qualities. – Provides some of the benefits of products like Retin-A® and Differin ®.

Hydroquinone & Azelaic Acid Hydroquinone & Azelaic Acid

• How Used • How Used –Hydroquinone –Azelaic Acid • Available as either cream or gel. • Available as both 15% gel or 20% cream. • OTC concentration usually around 2%. • Applied QD-BID. • Most prescriptions are 4% concentration. – Some compounded versions can be found in up to 8-10% concentration. • Applied QD-BID.

1 Hydroquinone & Azelaic Acid Hydroquinone & Azelaic Acid

• Side Effects • Side Effects –Hydroquinone & Azelaic Acid –“Ochronosis” (Hydroquinone only) • Both very well-tolerated. • Caused by buildup of homogentistic acid. • Occasionally patients report…. – Rather than fading the skin, the homogentistic acid actually causes hyperpigmentation. –Redness • This is a VERY RARE complication in USA. –Irritation – Most cases caused from excessive use of –Peeling higher-than-average concentration • Either may increase photosensitivity. Hydroquinone for years on end.

Hydroquinone & Azelaic Acid Hydroquinone & Azelaic Acid

• What Patients Should Know • What Patients Should Know –Hydroquinone & Azelaic Acid – Hydroquinone Safety? • Hydroquinone has been shown to increase the • Neither works “overnight”. risk of cancer in laboratory mice. – Results generally not seen until at least 4-6 – It has been in use for decades and there is NO weeks into treatment. evidence to suggest that it increases the risk of cancer in humans. • Consider using sunblock-containing face • It has been banned in some countries. lotion QAM, especially during summer. – The overuse of Hydroquinone, resulting in • Fading effects of either product are gradual Ochronosis, likely played a significant role in other and reversible. countries banning the product.

That concludes the module on Hydroquinone & Azelaic Acid. Please proceed to the next topic.

2 Keratolytics

Definition

Medications which assist in the removal of Keratolytics problematic, excess, or unwanted scaling/thickness of the epidermis.

KERATIN PROTEIN IN THE EPIDERMIS WHICH FORMS SCALING “LYSE” TO “BREAK UP”

Keratolytics Keratolytics

Definition • Topical Keratolytics–

– Salicylic Acid Medications which assist in the removal of – Urea problematic, excess, or unwanted – Glycolic Acid scaling/thickness of the epidermis. – Lactic Acid

KERATOLYTIC = “SUBSTANCE WHICH BREAKS UP KERATIN”

Keratolytics Keratolytics

• Topical Keratolytics– • Topical Keratolytics–

– Salicylic Acid – Urea • OTC washes, pads, shampoos, etc. • Both OTC and Rx – Neutrogena®, Proactiv®, Stridex®, etc. (up to 2%) – OTC Carmol® 10, Eucerin® Repair Lotion, etc. (10%) – Neutrogena® T-Sal, DHS®, etc. (up to 3%) – OTC Carmol® 20, Gormel® Crème, etc. (20%) • Rx Only – Rx Carmol® 40, Umecta®, and generics (40%) – Salex® Cream/Lotion/Shampoo (up to 6%) » OTC Topix® Urix Cream (40%) – Generics also available

1 Keratolytics Keratolytics

• Topical Keratolytics– • Topical Keratolytics–

– Glycolic Acid – Lactic Acid • OTC washes, creams, lotions, toners, etc. • Often sold in the form “Ammonium Lactate”. – Wide variety of concentrations • Both OTC and Rx – Wide variety of brands (MD Forte®, Glytone®, etc.) – OTC Lac-Hydrin® 5, as well as others (5%) » There are probably hundreds of brands on the – Rx Lac-Hydrin® Cream and generics (12%) market which contain glycolic acid – in dozens of » OTC Amlactin® Cream (12%) concentrations!

Keratolytics Keratolytics

• Basic Mechanism of Action • How Used

– Keratolytics help to “break the bond” which holds – Straightforward older, built-up skin cells in the outer epidermis. • Creams used as cream, shampoo used as shampoo, etc. This helps to…. • Just remember…. • Remove cosmetically unappealing rough, dead skin. – For cleansers (shampoos/washes), the active • Decrease the “barrier” of thickened epidermis which ingredient is within the cleanser. compromises the absorption of medications and » When possible, patients should allow the cleanser to moisturizers. remain on the skin for at least a few moments (face) or a few minutes (scalp or body) before rinsing off.

Keratolytics Keratolytics • What Patients Should Know

• Side Effects

– Redness Patients should… – Irritation – Discontinue if they experience any significant discomfort. – Take appropriate precautions (avoidance of ultraviolet – Stinging/Tingling light, wearing sunblock, etc.) if using on a UV-exposed – Sun Sensitivity area. – Allow for the keratolytic process to occur gradually. • Generally speaking, mechanical exfoliation (scrubbing) should be avoided! – Avoid Salicylic Acid products if allergic to aspirin!

2 Keratolytics • What Patients Should Know

Patients should… – Avoid using “excessive” quantities of Salicylic Acid Creams/Lotions. That concludes the module on Keratolytics. • Can cause “salicylism” – similar to aspirin poisoning. Please proceed to the next topic. • Children should avoid using more than 2 GM of Salicylic Acid 6% Cream/Lotion per day. • Adults may use quite a bit more, but to be safe, should avoid regularly using Salicylic Acid Cream/Lotion as moisturizer for the entire body.

3 Methotrexate

• Methotrexate (MTX) is used primarily for the treatment of Psoriasis, but helpful in a number of other conditions as well. Methotrexate • Used in dermatology since the 1950s. • One of the more “serious” medications we use. • Safely managing patients on MTX takes a team approach.

Methotrexate Methotrexate

• Basic Mechanism of Action • How Used – Inhibits an enzyme called dihydrofolate – Available in injectable form as well as reductase (DHFR). 2.5 mg size tablets. • DNA must be replicated in order for skin cells to • Most dermatologists prescribe MTX in the tablet form. multiply. • Average dosages range from 7.5 mg to 15 mg/week. • Folate is a necessary component of this process. • With reduced DHFR, folate use is greatly limited, DNA production slows, and skin cells can’t rapidly divide.

Methotrexate Methotrexate

• How Used • Side Effects

– Full dose typically prescribed to be taken –Gastrointestinal once/weekly. For example…. • Nausea, vomiting, diarrhea. • Methotrexate 2.5 mg – Take six tablets by mouth QFriday. –Anemia – “Alternative” is to split dosage 3 ways, • Feeling tired or “run down”. separating each by 12 hours. For example…. –Mouth Sores • Methotrexate 2.5 mg – Take two tablets QFriday morning, two tablets QFriday evening, then two –Hair Loss tablets QSaturday morning.

1 Methotrexate Methotrexate

• Side Effects • What Patients Should Know

–Cirrhosis (Liver) – Patients must be informed of the potential • Liver biopsy may be needed if patient needs to side effects. stay on MTX beyond a certain “total dosage”. – Labwork is a mainstay of treatment with –Renal (Kidney) Damage Methotrexate. • Every physician’s preferred protocol for lab testing is –Pulmonary Toxicity (rare) different. Learn your physician’s protocol. • Patients must understand the importance of having lab testing and comply with having labwork performed as directed.

Methotrexate Methotrexate

• What Patients Should Know • What Patients Should Know – Clarify to patients exactly how – MTX is teratogenic! Methotrexate is to be taken. • Contraindicated during pregnancy. – If prescribed, Folic Acid should be taken. • Used with caution, if at all, in fertile females – Avoid overuse of Acetaminophen (Tylenol®) who still plan to have children. and NSAIDs (Aleve®, Motrin®, etc.) while on • Even men should wait 6 months after finishing MTX before attempting to conceive a child. MTX. – Avoid taking MTX while sick or if actively infected.

That concludes the module on Methotrexate. Please proceed to the next topic.

2 Non-Steroid Anti-Inflammatories

Definition Non-Steroid Anti-Inflammatories Topical medications which decrease inflammation without the use of corticosteroids.

Non-Steroid Anti-Inflammatories Non-Steroid Anti-Inflammatories

• Basic Mechanism of Action Tacrolimus (Protopic®) – 0.1% Ointment (adults) – Tacrolimus (Protopic®)/Pimecrolimus (Elidel®) – 0.03% Ointment (children 2-15) • Inhibit “calcineurin”. Pimecrolimus (Elidel®) – Exactly how this helps is complicated. » Decreasing the effects of “calcineurin” helps to – 1% Cream (2 years and older) decrease the overactive immune response seen in conditions like Eczema, Contact Dermatitis, Calcipotriene (Dovonex®) and Seborrheic Dermatitis. – 0.005% Cream, Ointment, and Solution – Some generics now available

Non-Steroid Anti-Inflammatories Non-Steroid Anti-Inflammatories

• Basic Mechanism of Action • How Used

– Calcipotriene (Dovonex®) – Tacrolimus (Protopic®), Pimecrolimus (Elidel®), & Calcipotriene (Dovonex®) • Synthetic form of Vitamin D3. – Exact mechanism of action is also complicated. • All are applied topically. » By binding to “vitamin D receptors” in the skin, • Usually applied QD-BID. it helps to decrease the excessive production of – Exact frequency determined by your supervising skin cells that occurs in Psoriasis, and also helps physician. to decrease inflammation.

1 Non-Steroid Anti-Inflammatories Non-Steroid Anti-Inflammatories

• Side Effects • Side Effects

Tacrolimus (Protopic®)/Pimecrolimus (Elidel®) Calcipotriene (Dovonex®) – Stinging – Skin irritation – Burning – Itching – Irritation – Redness – Lymphoma & Malignancy (?) – Hypercalcemia

• Malignancies have been reported in patients using either. • Remember, Calcipotriene acts like Vitamin D3.

– The incidence, however, has not yet been shown to be – Because Calcipotriene mimics Vitamin D3, it can statistically significant. increase Ca+ absorption and raise serum levels. • Until further studies prove otherwise, FDA has issued a • Patients should avoid using ≥ 100 GM/week. “Black Box Warning” informing patients of the potential.

Non-Steroid Anti-Inflammatories Non-Steroid Anti-Inflammatories

• What Patients Should Know • What Patients Should Know

– Tacrolimus (Protopic®)/Pimecrolimus (Elidel®) – Tacrolimus (Protopic®)/Pimecrolimus (Elidel®) • May experience burning/stinging upon application. • Black Box Warning – Consider using topical steroid to initially calm the – How the issue is addressed depends on the acute inflammation before starting either preferences of your supervising physician. Tacrolimus or Pimecrolimus. – Even the manufacturers are unable to provide – Keep the medicine in the refrigerator. specific guidelines. » Ointments and creams absorbed more slowly » They simply state that patients “shouldn’t use when they’re cold. (the product) continuously for a long time”.

Non-Steroid Anti-Inflammatories

• What Patients Should Know

– Calcipotriene (Dovonex®) That concludes the module on • May experience irritation, itching, redness, etc. Non-Steroid Anti-Inflammatories. • If patient has a lot of surface area to treat, let them know about the recommendation to avoid using Please proceed to the next topic. more than 100 GM/week. • Some generic availability.

2 Retinoids

Definition

Retinoids Any chemical compound whose actions in the skin mimic that of Vitamin A.

Retinoids Retinoids

The most common Retinoids used in • Basic Mechanism of Action dermatology include… – Topicals After activating the “retinoid receptors” in the skin • OTC “Retinol” (RoC®, Oil of Olay®, SkinCeuticals®, etc.) cells, Retinoids… • Tretinoin (Retin-A®, Renova®, Atralin®, etc.) • Adapalene (Differin®) 1) Affect skin cell growth and differentiation. • Tazarotene (Tazorac®) 2) Alter the adhesiveness of skin cells. – Systemics 3) Decrease sebaceous (oil) gland production. • Isotretinoin (Accutane®, Amnesteen®, Claravis®, etc.) • Acitretin (Soriatane®)

Retinoids Retinoids

• Basic Mechanism of Action • Basic Mechanism of Action

Retinoids affect skin cell growth and differentiation. Retinoids affect skin cell growth and differentiation. – In Acne, skin cells inside the pores can become – In sun-damaged and aging skin, skin cell production is “stagnant”, clump together, and clog the pores. also slowed down. • Retinoids keep skin cell production “moving along”, • Cosmetically abnormal skin cells (dull, irregular decreasing the time they have to clump together and pigmentation, etc.) become more visible. clog the pore. • Microscopically abnormal (“pre-cancerous”) skin cells have extra time to develop and potentially make transition to skin cancer.

1 Retinoids Retinoids

• Basic Mechanism of Action • Basic Mechanism of Action

Retinoids affect skin cell growth and differentiation. Retinoids alter the adhesiveness of skin cells. – In sun-damaged and aging skin, skin cell production is – In Acne, Retinoids help the mixture of skin cells and also slowed down. oil within the pores to “breaks up” more easily, • Retinoids keep skin cell production “moving along”, helping to unclog the pores. decreasing the time the cells have to start looking – In sun-damaged and aging skin, Retinoids help the (cosmetic) or acting (“pre-cancerous”) abnormal. “abnormal” skin cells to exfoliate more easily, making way for newer, younger skin cells within the epidermis.

Retinoids Retinoids

• Basic Mechanism of Action • Basic Mechanism of Action

Retinoids alter the adhesiveness of skin cells. Retinoids decrease sebaceous (oil) gland production. ― In Psoriasis, Retinoids help to break the bond between – In Acne, sebum “feeds” bacteria within the oil glands. the built-up skin cells, thereby helping to decrease the Drying out the sebum production essentially starves thickness and scaling of Psoriasis plaques. the bacteria. – Systemic versions are much more effective at decreasing oil gland production. • Topicals provide relatively little decrease in oil gland production.

Retinoids Retinoids

• How Used • Side Effects – Topical Retinoids – Topical Retinoids • Applied in the form of cream or gel. • Application site irritation! – Redness and peeling are common. • Usually QD for most conditions. • Increased sun-sensitivity. – Sometimes BID for Psoriasis. • Interesting Fact: – Systemic Retinoids – Many believe that retinoids are prescribed for • Taken in pill form. evening use because of the potential for sun- sensitivity. • Most often taken QD, but may be split into BID dosing. » The true reason for this perception is that the “original” retinoid, Tretinoin, is degraded in the presence of ultraviolet light.

2 Retinoids Retinoids

• Side Effects • Side Effects – Systemic Retinoids – Systemic Retinoids • Potential side effects generally fall into one of • Common (but relatively harmless/annoying). four categories….. – Dryness of the skin, lips, eyes, and hair. – Common (but relatively harmless/annoying). – Photosensitivity. – Less common (but potentially serious). – Peeling of the skin. – Unseen/Unfelt (laboratory changes). – “Sticky” sensation of hands or feet (Soriatane®). – Questionable/Debatable (their connection to – Decreased night vision. systemic retinoid use remains uncertain/unproven). – Headache, bone, joint and/or muscle pain.

Retinoids Retinoids

• Side Effects • Side Effects – Systemic Retinoids – Systemic Retinoids • Less common (but potentially serious). • Unseen/Unfelt (laboratory changes). – Teratogenicity (can cause birth defects). – Elevated “Lipids”. » Patients should NOT get pregnant while taking! » Quite common. – Pseudotumor cerebri. » Exact reason is unclear. » Very rare. » Elevation is temporary. » Brain swells, causing headache and double vision. – Elevated liver enzymes. • Highest risk in patients taking a “tetracycline” – Changes in blood cell/platelet count. antibiotic at the same time. • Reversible upon discontinuation of medication.

Retinoids Retinoids

• Side Effects • Side Effects – Systemic Retinoids – Systemic Retinoids • Questionable/Debatable (uncertain connection). • Questionable/Debatable (uncertain connection). – Depression and suicidal ideation. – Isotretinoin may be a “trigger” for inflammatory » No “definitive” evidence linking Isotretinoin and depression, suicidal ideation, or psychosis. bowel disease (Crohn’s or Ulcerative Colitis). » Teenagers and young adults (15-24 y/o) represent » Again, the connection is unproven. the most at-risk group for suicide deaths. • It is thought to possibly serve as a “trigger” for • These are the ages that Isotretinoin is most unmasking IBD in otherwise genetically pre- often used. disposed individuals. » The “potential” psychological side effects, along with the known risk of birth defects, were the driving force behind the “iPledge” registry.

3 Retinoids Retinoids

• Side Effects • What Patients Should Know – Systemic Retinoids – Topical Retinoids • Questionable/Debatable (uncertain connection). • Patients must be told about the potential for irritation! – Patients should consider using only 2-3x/week initially, – Premature closure of the “growth plates”. increasing frequency only as tolerated. » A few cases have been reported in literature. – Highly sensitive areas such as the eyelids, lips, and nasal » In clinical practice, the incidence seems to be quite creases should be avoided. rare. • Avoid excessive sun exposure and take appropriate precautions, such as using sunblock. • Should not use while pregnant. • Consider giving patients an instructional handout, such as this one, describing how to properly use.

Retinoids Retinoids

• What Patients Should Know • What Patients Should Know – Systemic Retinoids – Systemic Retinoids • Isotretinoin • Acitretin (Soriatane®) – iPledge Registry does not apply. – iPledge Registry MUST BE FOLLOWED! » Potential side effects must still be explained! » We must follow the iPledge rules to a “T” or else – Females must remember…. Isotretinoin cannot be prescribed. » Drinking alcohol while taking Acitretin will convert it » However, the iPledge consent forms and registration to a form which remains in the body for years. process leave no room for patients to claim that they » Do NOT get pregnant (or donate blood) while weren’t informed of the potential side effects. taking or for 3 years after discontinuation! » An entire “iPledge” learning module is available – All patients must remember… elsewhere in our CDT® program. » Bloodwork (as determined by your supervising physician) should be performed in a timely manner.

That concludes the module on Retinoids. Please proceed to the next topic.

4 Topical Antipruritics

Definition Topical Topical medications which relieve Antipruritics itching but have little (if any) effect on inflammation.

Topical Antipruritics Topical Antipruritics

Doxepin HCl • Basic Mechanism of Action – Zonalon® Cream as well as generics. –Doxepin HCl (Zonalon®) Pramoxine HCl • Has strong antihistamine properties. – Found in numerous OTC and Rx products. –Exact mechanism of action, however, is Menthol, Camphor, & Other “Irritants” uncertain. –May have “numbing” properties which help – Sarna® and numerous other OTC antipruritics. alleviate the itching.

Topical Antipruritics Topical Antipruritics

• Basic Mechanism of Action • How Used –Pramoxine HCl (Pramasone®, etc.) – Applied topically in the form of lotion, • Provides anesthetic (“numbing”) effects. cream, or gel. – –Menthol, Camphor, & Other “Irritants” If formulation contains no cortisone, may be applied more frequently and for longer • Override the itching sensation with either duration than their cortisone-containing a “warming” or “cooling” sensation. counterparts.

1 Topical Antipruritics Topical Antipruritics

• Side Effects • Side Effects –Pramoxine HCl , Menthol, Camphor, & –Doxepin HCl (Zonalon®) Other “Irritants” • Redness, Irritation, Burning, Stinging, • Redness etc., but also…. • Irritation • May cause drowsiness! • Burning –Rare, but may occur especially if applied to a large surface area. • Stinging

Topical Antipruritics

• What Patients Should Know – If the patient experiences any That concludes the module on uncomfortable side effects, they should d/c Topical Antipruritics. the product and notify the office. Please proceed to the next topic. – Those applying Doxepin HCl to a large surface area should be aware that it may cause sedation.

2 Topical Chemotherapies

5-fluorouracil (5-FU) Topical – Efudex®, Carac®, Fluoroplex®, and generics. Imiquimod Chemotherapies – Aldara®, Zyclara®, and generics.

Topical Chemotherapies Topical Chemotherapies

• Basic Mechanism of Action • Basic Mechanism of Action – 5-fluorouracil – Imiquimod • Interferes with the production of rapidly • Helps the body to “heal itself”. growing cells by mimicking “thymine”. – Our own immune systems produce substances like – Thymine is needed for normal DNA production. Interferon, Tumor Necrosis Factor (TNF), and – 5-fluorouracil takes the place of thymine on DNA Interleukin, which can destroy abnormal cells. strand, and the affected cells die. » Imiquimod raises the body’s own levels of – “Pre-cancerous” and skin cancer cells are quicker to Interferon, TNF, and Interleukin where applied. use this “fake thymine”, so they’re more easily destroyed than “normally” growing skin cells.

Topical Chemotherapies Topical Chemotherapies

• How Used • How Used – 5-FU and Imiquimod –A few examples… • Both are applied topically. • Actinic Keratosis – • Otherwise, exact frequency and duration of Efudex® is applied BID x 2-4 weeks. – Carac® is applied QD x 3 weeks. treatment depends on… • Condyloma – Condition being treated. – Imiquimod applied 3x/week for up to 16 weeks. – Location of the treatment site. • Superficial BCC – Patient tolerance to treatment. – Efudex® is applied BID x 6 weeks. – Preferences of your supervising physician. – Imiquimod applied 5x/week x 6 weeks.

1 Topical Chemotherapies Topical Chemotherapies

• Side Effects (both 5-FU & Imiquimod) • What Patients Should Know – Redness – Patients should ALWAYS be warned about – Irritation the likelihood of redness/irritation. • Work and social commitments must be taken into – Soreness consideration before beginning treatment. – Crusting/Erosion – Direct, prolonged sun exposure of the application • Side effects are often proportionate to the sites during treatment should be avoided. amount and degree of atypia found within • Some doctors will recommend waiting until the fall or winter to treat. the treatment sites.

Topical Chemotherapies Topical Chemotherapies

• What Patients Should Know • What Patients Should Know – Consider providing education handouts such – Both 5-FU and Imiquimod are expensive! as these… – Pregnancy • 5-FU is Category X = AVOID!! • Imiquimod is Category C. Efudex®/Carac® Imiquimod Handout – To be used only in rare circumstances and with Handout obstetrician’s approval!

That concludes the module on Topical Chemotherapies. Please proceed to the next topic.

2