DermNewsletter of the American OsteopathicLine College of Spring 2016 Vol. 32, No. 1

Message from the President

Greetings from Houston, Texas - again!

As President of the AOCD, I welcome you to another edition of DermLine. As I think about our recent past and the dramatic changes afoot, I recall Suzanne Sirota Rozenberg, DO, FAOCD, Past President of AOCD, commenting in the Spring 2014 edition of DermLine about the coming AOA/ACGME merger. As I stated previously, “Today, at this moment, we are living in yesterday’s future.” Our future has arrived. Because the AOA, along with the Accreditation Council for Graduate and the American Association of Colleges of Osteopathic , have agreed to a single accreditation system for graduate medical education programs in the United States, our graduates of osteopathic institutions, along with graduates of allopathic medical schools will complete their residency and/or fellowship education in ACGME-accredited programs and demonstrate achievement of common milestones and competencies side-by-side. I hope you realize the power in the previous statement. Trained together, osteopathic and allopathic graduates will no longer be divided.

Perhaps the most exciting news to share is the AAD vote that just passed last month. This has been a battle we have been fighting for generations. The vote suffered defeat in 2004 and 2010. On both occasions, a majority of the membership voted in favor, but the required two-thirds majority required to approve a change to the bylaws fell short. I was told I would never see this vote go through in my lifetime. Today, however, our osteopathic certified by the American Osteopathic Board of Dermatology will be recognized as Fellows in the AAD. This exemplifies what we all have known for a long time—we are equals with our MD counterparts. This vote gives us the ability to hold offices and serve on committees. I sincerely hope we all serve the AOCD and AAD in some capacity. By harnessing the strength of both organizations, we all can make a change.

However, our work is far from being done! More than ever, the preservation of our osteopathic roots will be critical. The AOCD remains a strong organization. I am proud of our heritage and mindful of the work that lies ahead. This great organization has nurtured me throughout my career and will do the same for generations of osteopathic dermatologists to come—if we believe in and support the AOCD. The AOCD brought us to where we are. Each of us emerged as dermatologists because of this great organization.

The AOCD will remain a strong provider of service and support to dermatologists who chose osteopathy for their medical training and philosophy. Our boutique organization is special. Our members are not lost among the masses. Our professional development will remain world-class. Our publications will continue to disseminate valuable information and updates. The person-to-person connection is what makes AOCD one of the greatest assets in our daily professional lives.

As you read this edition of DermLine, reflect on how fortunate we are to be osteopathic dermatologists. Our future will remain strong as long as we join together in keeping the vision alive, provide outstanding training and seminars to our members and In this issue... never forgetting that our purpose is to serve patients. AOCD Details Path to ACCME Accreditation for Meetings 2-5 I look forward to seeing you in Santa Monica! AOCD Thanks 2016 Spring Meeting Alpesh Desai, DO, FAOCD Sponsors and Exhibitors...page 6 President, American Osteopathic College of Dermatology 2016 Spring Meeting Highlights and Notes ...pages 12-33 Line DermNewsletter of the American Osteopathic College of Dermatology Executive Director’s Report Board of Trustees by Marsha Wise, Executive Director PRESIDENT Alpesh Desai, D.O., FAOCD Hello (DOs) within the Fellow membership category PRESIDENT-ELECT Karthik Krishnamurthy, D.O., FAOCD Everyone, of the AAD. FIRST VICE-PRESIDENT Daniel Ladd, D.O., FAOCD We’ve had a We want to stress to our members that this is SECOND VICE-PRESIDENT busy start to only a status change. Both the AAD and the John P. Minni, D.O., FAOCD the year. We AOCD remain separate organizations and offer THIRD VICE-PRESIDENT just returned unique services to their respective members. Reagan Anderson, D.O., FAOCD from our IMMEDIATE PAST-PRESIDENT spring We continue to offer informational updates Rick J. Lin, D.O., FAOCD meeting in to our members via the Thursday Bulletin. TRUSTEES New York When the bulletin arrives in your inbox, be Danica Alexander, D.O., FAOCD City held sure to take a moment to review. We try to David Cleaver, D.O., FAOCD Tracy Favreau, D.O., FAOCD March include reminders and updates on pertinent Peter Saitta, D.O., FAOCD 30-April 3, 2016 at the Battery Park Ritz information as much as possible. Amy Spizuoco, D.O., FAOCD Carlton. The reviews coming in from this Michael Whitworth, D.O., FAOCD conference have been outstanding! It will We recently announced that the AOCD SECRETARY-TREASURER Steven Grekin, D.O., FAOCD be time for our fall meeting before you was is in the process of seeking initial EXECUTIVE DIRECTOR know it. Join us at the Loews Hotel in Santa accreditation with the Accreditation Council Marsha A. Wise, B.S. Monica, CA, September 14-18, 2016. Online for Continuing Medical Education (ACCME). registration and hotel information is available The staff and I are excited to get this project Editorial/Public Relations Committee on our web site. Remember to log in with completed for the membership. Click here to CHAIR your username and password to get the learn more about the ACCME. David Cleaver, D.O., FAOCD AOCD member rate. DERMLINE EDITOR What does this mean for the AOCD? Once Danica Alexander, D.O., FAOCD The 2016-2018 CME guide for physicians is obtained, the AOCD will be able to grant DERMLINE ASSOCIATE EDITOR Marsha Wise now available. AOCD members must earn AMA CME in addition to AOA CME. MEMBERS one hundred twenty (120) CME credits for Getting to the Initial Accreditation will take Danica Alexander, D.O., FAOCD membership in the American Osteopathic work. Specific criteria must be met. Jason Green, D.O., FAOCD Association within this three-year cycle, Susun Kim, D.O., FAOCD beginning Jan. 1, 2016 and ending Dec. 31, The Accreditation Criteria are divided Albert Rivera, D.O., FAOCD Lawrence Schiffman, D.O., FAOCD 2018. Of this total, 30 CME credits must be into three levels. To achieve Provisional Dustin Wilkes, D.O., FAOCD obtained in Category 1-A and the remaining Accreditation, a two year term, providers

Corporate Partners 90 CME credit may be obtained with either must comply with Criteria 1, 2, 3, and RUBY Category 1-A, 1-B, 2-A, or 2-B credits. 7–12. Providers seeking full accreditation Sun Pharma or reaccreditation for a four-year term must DIAMOND To maintain your specialty certification, you comply with Criteria 1–13. To achieve Galderma must earn a minimum of FIFTY (50) specialty Accreditation with Commendation, a six- Valeant Pharmaceuticals CME credits in each primary specialty held year term, providers must comply with all PLATINUM Lilly USA, LLC (e.g. dermatology) during the three-year CME Accreditation Criteria. GOLD cycle. For dermatology, as required by the AbbVie AOBD, at least TWENTY-FIVE (25) of the Criterion 1: The provider has a CME mission Celgene required FIFTY (50) specialty credits must statement that includes expected results Bronze Allergan be Category 1-A. AOA Category 1-A credit is articulated in terms of changes in competence, Anacor Pharmaceuticals granted for formal face-to-face programs that performance, or patient outcomes that will be Dermatopathology Laboratory of Central States meet the Category 1 quality guidelines, faculty the result of the program. Pearl DUSA Pharmaceuticals requirements and are sponsored by AOA- Novartis accredited Category 1-A CME sponsors. The Criterion 2: The provider incorporates Contribute to DermLine AOCD is a Category 1-A accredited sponsor into CME activities the educational needs for dermatology CME. (knowledge, competence, or performance) that If you have a topic you would like to read about or an article you would like to write for the next issue of underlie the professional practice gaps of their DermLine, contact Marsha Wise by email at We are happy to share the results of the recent own learners. [email protected] or John Grogan at [email protected]. American Academy of Dermatology’s recent American Osteopathic College of Dermatology P.O. Box 7525 By-Laws amendment vote. The vote which Criterion 3: The provider generates activities/ 2902 N. Baltimore St. passed with 69.42% voting in favor, will educational interventions that are designed to Kirksville, MO 63501 Office: (660) 665-2184 | (800) 449-2623 allow osteopathic physicians certified by the change competence, performance, or patient Fax: (660) 627-2623 American Osteopathic Board of Dermatology outcomes as described in its mission statement. Web: http://www.aocd.org http://www.aobd.org Criterion 4: This criterion has been Accreditation with Commendation include financial relationships of a spouse eliminated effective February 2014. Criterion 16: The provider operates in or partner. The ACCME has not set a a manner that integrates CME into the minimum dollar amount for relationships Criterion 5: The provider chooses process for improving professional practice. to be significant. Inherent in any amount is educational formats for activities/ the incentive to maintain or increase the interventions that are appropriate for the Criterion 17: The provider utilizes non- value of the relationship. setting, objectives, and desired results of education strategies to enhance change the activity. as an adjunct to its activities/educational Standards for Commercial Support: interventions (e.g., reminders, Standards to Ensure Independence in Criterion 6: The provider develops patient feedback). CME Activities activities/educational interventions in the context of desirable attributes [eg, Criterion 18: The provider identifies factors Standard 1: Independence Institute of Medicine (IOM) competencies, outside the provider’s control that impact on Accreditation Council for Graduate Medical patient outcomes. Standard 1.1: A CME provider must ensure Education (ACGME) Competencies]. that the following decisions were made free Criterion 19: The provider implements of the control of a commercial interest. Criterion 7: The provider develops educational strategies to remove, overcome (See www.accme.org for a definition activities/educational interventions or address barriers to physician change. of a “commercial interest” and some independent of commercial interests. (SCS exemptions.) (a) Identification of CME 1, 2, and 6). Criterion 20: The provider builds needs; (b) Determination of educational bridges with other stakeholders through objectives; (c) Selection and presentation Criterion 8: The provider appropriately collaboration and cooperation. of content; (d) Selection of all persons and manages commercial support (if applicable, organizations that will be in a position SCS 3 of the ACCME Standards for Criterion 21: The provider participates to control the content of the CME; (e) Commercial SupportSM). within an institutional or system framework Selection of educational methods; (f) for quality improvement. Evaluation of the activity. Criterion 9: The provider maintains a separation of promotion from education Criterion 22: The provider is positioned to Standard 1.2: A commercial interest cannot (SCS 4). influence the scope and content of activities/ take the role of non-accredited partner in a educational interventions. joint provider relationship. Criterion 10: The provider actively promotes improvements in health care and Disclosure of conflicts of interest by Standard 2: Resolution of Personal NOT proprietary interests of a commercial anyone involved with planning or Conflicts of Interest interest (SCS 5). presenting the CME program will be reviewed. Disclosure of ALL commercial Standard 2.1: The provider must be able Criterion 11: The provider analyzes support will also be required. to show that everyone who is in a position changes in learners (competence, to control the content of an education performance, or patient outcomes) Financial Relationships and Conflicts activity has disclosed all relevant financial achieved as a result of the overall program’s of Interest relationships with any commercial interest activities/educational interventions. Financial relationships are those to the provider. The ACCME defines relationships in which the individual “’relevant’ financial relationships” as Criterion 12: The provider gathers data benefits by receiving a salary, royalty, financial relationships in any amount or information and conducts a program- intellectual property rights, consulting occurring within the past 12 months that based analysis on the degree to which the fee, honoraria for promotional speakers’ create a conflict of interest. CME mission of the provider has been met bureau, ownership interest (e.g., stocks, through the conduct of CME activities/ stock options or other ownership interest, Standard 2.2: An individual who refuses educational interventions. excluding diversified mutual funds), or to disclose relevant financial relationships other financial benefit. will be disqualified from being a planning Criterion 13: The provider identifies, plans committee member, a teacher, or an and implements the needed or desired Financial benefits are usually associated with author of CME, and cannot have control changes in the overall program (eg, planners, roles such as employment, management of, or responsibility for, the development, teachers, infrastructure, methods, resources, position, independent contractor (including management, presentation or evaluation of facilities, interventions) that are required to contracted research), consulting, speaking the CME activity. improve on ability to meet the CME mission. and teaching, membership on advisory committees or review panels, board Standard 2.3: The provider must have Criterion 14: This criterion has been membership and other activities from which implemented a mechanism to identify and eliminated effective February 2014. remuneration is received or expected. resolve all conflicts of interest prior to the education activity being delivered Criterion 15: This criterion has been ACCME considers relationships of the to learners. eliminated effective February 2014. person involved in the CME activity to

Page 3 Dr. Van Acker Wins Everett C. Fox Award at AAD Residents and Fellows Symposium On March 6, 2016, Standard 3: Appropriate Use of Commercial Support Monica Van Acker, DO, (pictured third from the Standard 3.1: The provider must make all decisions left) was awarded the regarding the disposition and disbursement of Everett C. Fox Memorial commercial support. Award at the Residents and Fellows Symposium Standard 3.2: A provider cannot be required by of the American a commercial interest to accept advice or services Academy of Dermatology concerning teachers, authors, or participants or Annual Meeting. other education matters, including content, from a commercial interest as conditions of contributing funds Dr. Van Acker, a second- or services. year resident in the Saint Joseph Mercy Health System program, under the direction of Daniel Stewart, DO, FAOCD, was one of only Standard 3.3: All commercial support associated with eleven finalists chosen to present from all osteopathic and allopathic a CME activity must be given with the full knowledge entrants. The finalists presented their papers at the symposium. A and approval of the provider. panel of faculty judges, led by Robert Dellavalle, MD, PhD, selected the top three papers presented in each of the eligible categories— Standard 3.4: The terms, conditions, and purposes clinical and laboratory, to receive the award. of the commercial support must be documented in a written agreement between the commercial supporter Dr. Van Acker’s paper titled, “Transcriptional Analysis Confirms that includes the provider and its educational partner(s). Dysregulation of the Th17 Pathway in Alopecia Areata,” won second The agreement must include the provider, even if the place in the laboratory category. support is given directly to the provider’s educational partner or a joint provider. The Everett C. Fox Memorial Award was established to encourage research by dermatology residents and fellows. The award is Standard 3.5: The written agreement must specify supported by an endowment provided by its namesake. Dr. Fox was the commercial interest that is the source of an educator and dermatologist who practiced in Dallas, TX until commercial support. retiring in 1975. Standard 3.6: Both the commercial supporter and the provider must sign the written agreement between the commercial supporter and the provider.

Dr. Posnick Wins Quiz Competition at Real World For Standard 3.7: The provider must have written policies Dermatology Residents Conference and procedures governing honoraria and reimbursement David Posnick, DO, a third-year resident in the Palisades Medical of out-of-pocket expenses for planners, teachers and Center program under the direction of Adriana Ros, DO, FAOCD authors. took home top honors at the Real World Dermatology for Residents Interactive Quiz at the conference in Las Vegas. Over 200 Standard 3.8: The provider, the joint provider, or osteopathic and allopathic residents from across the country took designated educational partner must pay directly any part in the competition. Competitors were tasked with buzzing teacher or author honoraria or reimbursement of out- in and answering 15 challenging clinical dermatology questions of–pocket expenses in compliance with the provider’s before their opponents. written policies and procedures.

Sunny Chun, DO, also Standard 3.9: No other payment shall be given to the a third-year resident in director of the activity, planning committee members, the Palisades Medical teachers or authors, joint provider, or any others Center program, and involved with the supported activity. Chase Scarborough, DO, a third-year resident in Standard 3.10: If teachers or authors are listed on the the O’Bleness Memorial agenda as facilitating or conducting a presentation Hospital program under or session, but participate in the remainder of an the direction of Dawn educational event as a learner, their expenses can be Sammons, DO, FAOCD, reimbursed and honoraria can be paid for their teacher placed in the top ten. or author role only.

Dr. Posnick (pictured third from the left) was awarded a Bose Standard 3.11: Social events or meals at CME activities headset, and all three placing residents won free registration cannot compete with or take precedence over the and two-night hotel accommodations for the 2017 Winter Clinical educational events. Dermatology Conference in Hawaii.

Page 4 Standard 3.12: The provider may not an ACCME accredited provider to of self-study CME activities or arranging for use commercial support to pay for pharmaceutical and device manufacturers’ electronic access to CME activities. travel, lodging, honoraria, or personal product Web sites are permitted before or expenses for non-teacher or non-author after the educational content of a CME Standard 5: Content and Format without participants of a CME activity. The activity, but shall not be embedded in the Commercial Bias provider may use commercial support educational content of a CME activity. to pay for travel, lodging, honoraria, or Advertising of any type is prohibited Standard 5.1: The content or format of personal expenses for bona fide employees within the educational content of CME a CME activity or its related materials and volunteers of the provider, joint activities on the Internet including, but must promote improvements or quality in provider or educational partner. not limited to, banner ads, subliminal ads, healthcare and not a specific proprietary and pop-up window ads. For computer business interest of a commercial interest. Standard 3.13: The provider must be based CME activities, advertisements and able to produce accurate documentation promotional materials may not be visible Standard 5.2: Presentations must give detailing the receipt and expenditure of the on the screen at the same time as the a balanced view of therapeutic options. commercial support. CME content and not interleafed between Use of generic names will contribute to computer windows or screens of the CME this impartiality. If the CME educational Standard 4: Appropriate Management of content. For audio and video recording, material or content includes trade names, Associated Commercial Promotion advertisements and promotional materials where available trade names from several will not be included within the CME. companies should be used, not just trade Standard 4.1: Arrangements for commercial There will be no ‘commercial breaks.’ For names from a single company. exhibits or advertisements cannot influence live, face-to-face CME, advertisements planning or interfere with the presentation, and promotional materials cannot be Standard 6: Disclosures Relevant to nor can they be a condition of the provision displayed or distributed in the educational Potential Commercial Bias of commercial support for CME activities. space immediately before, during, or after a CME activity. Providers cannot allow Standard 6.1: An individual must Standard 4.2: Product-promotion representatives of Commercial Interests to disclose to learners any relevant financial material or product-specific advertisement engage in sales or promotional activities relationship(s), to include the following of any type is prohibited in or during while in the space or place of the CME information: The name of the individual; CME activities. The juxtaposition of activity. (Supplemented, February 2014; The name of the commercial interest(s); The editorial and advertising material on the information that follows previously nature of the relationship the person has the same products or subjects must appeared in ACCME policies. No with each commercial interest. be avoided. Live (staffed exhibits, changes have been made to the language.) presentations) or enduring (printed or For Journal-based CME, None of the Standard 6.2: For an individual with no electronic advertisements) promotional elements of journal-based CME can relevant financial relationship(s) the learners activities must be kept separate from contain any advertising or product group must be informed that no relevant financial CME. For print, advertisements and messages of commercial interests. The relationship(s) exist. promotional materials will not be learner must not encounter advertising interleafed within the pages of the within the pages of the article or within Standard 6.3: The source of all support CME content. Advertisements and the pages of the related questions or from commercial interests must be disclosed promotional materials may face the first evaluation materials. to learners. When commercial support is or last pages of printed CME content as “in-kind” the nature of the support must be long as these materials are not related to Standard 4.3: Educational materials that disclosed to learners. the CME content they face and are not are part of a CME activity, such as slides, paid for by the commercial supporters abstracts and handouts, cannot contain any Standard 6.4: ‘Disclosure’ must never of the CME activity. For computer advertising, corporate logo, trade name or include the use of a corporate logo, trade based, advertisements and promotional a product-group message of an ACCME- name or a product-group message of an materials will not be visible on the screen defined commercial interest. ACCME-defined commercial interest. at the same time as the CME content and not interleafed between computer Standard 4.4: Print or electronic Standard 6.5: A provider must disclose the ‘windows’ or screens of the CME information distributed about the non- above information to learners prior to the content. (Supplemented February 2014; CME elements of a CME activity that beginning of the educational activity. the information that follows previously are not directly related to the transfer of appeared in ACCME policies. No changes education to the learner, such as schedules Click here to learn more about Standards have been made to the language.) Also, and content descriptions, may include for Commercial Support. ACCME-accredited providers may not product-promotion material or product- place their CME activities on a Web site specific advertisement. Thank you for your continued support of owned or controlled by a commercial the AOCD. Please call or email the AOCD interest. With clear notification that Standard 4.5: A provider cannot use a office at [email protected] if you need the learner is leaving the educational commercial interest as the agent providing a assistance or have questions or concerns. Web site, links from the Web site of CME activity to learners, e.g., distribution

Page 5 Corporate Spotlight By Shelley Wood, MaE, Administrative Grants Coordinator Corporate Sponsors Support 2016 Spring Meeting in New York

I appreciate having had the In addition to corporate membership, Sun Pharma, has had a long opportunity to thank several of relationship with the College and continues to support us through our corporate sponsors for their generous sponsorships. Sun Pharma’s most recent sponsorship continued support of the College was for the Welcome Reception that was held Thursday, March and to welcome new exhibitors at 31, 2016 in the Manhattan Ballroom of the Ritz-Carlton Battery the 2016 AOCD Spring Meeting. I Park. The Welcome Reception gives exhibitors and physicians have received positive feedback from the opportunity to meet in an informal setting. We appreciate several exhibitors. The AOCD is everything Steve Hecklein and Sun Pharma is doing for the very fortunate to have corporate sponsors who join us as partners College and CME. with a commitment to medical excellence. Our corporate sponsors remain committed to the College and continuing medical education For the past several years, Dermatopathology Labs of Central States (CME). It goes without saying that our corporate sponsors are (DLCS) sponsored our meeting t-shirts and bags. We appreciate the critical to helping us accomplish our mission. continued support from Christine Anthony and DLCS.

New and returning corporate sponsors are as follows: ProPath Laboratories sponsored our meeting lanyards. ProPath • Sun Pharma (Ruby Level) Laboratories was a new exhibitor for the 2016 Spring Meeting. We • Galderma, Valeant Pharmaceuticals (Diamond Level) look forward to working with ProPath in the future. • Lilly USA, LLC (Platinum Level) • AbbVie, Celgene (Gold Level) Lilly USA, LLC sponsored the coffee cups for the meeting. Lilly • Allergan, Anacor Pharmaceuticals, DLCS (Bronze Level) has been a corporate sponsor and supporter of the AOCD the last • DUSA Pharmaceuticals, Novartis (Pearl Level) couple years, this year being their first year as a Platinum Level Corporate Member. We appreciate all Ginger McWilliams, Tara Burke, and Lilly does for the AOCD. Galderma has been a longtime supporter of the AOCD. This year, Galderma sponsored the product for the cosmetic lecture Dr. Suzanne Sirota Rozenberg delivered. We appreciate the support Tom Fitzgerald and Galderma has given the college over the past several years.

The AOCD also appreciates Allergan for providing an evening product theater on Friday, April 1, 2016. Dr. James Q. Del Rosso spoke on “Introducing New Aczone (dapsone) 7.5% gel for the treatment of acne vulgaris”. The lecture was well-attended and highly-discussed

Southeastern Skin Cancer & Dermatology is a thriving medical/surgical/Mohs among attendees. dermatology practice with one physician and two physician assistants. We are an established, growing practice seeking a BE/BC dermatologist to join our office family. It is a very enjoyable, friendly office environment with a highly educated, Exhibitors for the 2016 Spring Meeting were as follows: professional patient base and extremely collegial medical community. The ideal candidate will have interest in leading the cosmetic growth of the practice as well as Aclaris Therapeutics, Inc.; Allergan; Aurora Diagnostics; contributing to our excellent medical dermatology offerings; however, surgical and Mohs interests are certainly welcomed. Offerings include a competitive salary and Aqua Pharmaceuticals; Bayer Healthcare; Celgene; generous benefits above the customary findings to help your time away from the Crown Laboratories, Inc.; Dermpath Diagnostics; office be as enjoyable as your time in it. Dermpath Lab – Central States; DUSA Pharmaceuticals;

Madison (Huntsville), Alabama facts: Encore Dermatology; EzDerm; Galderma Laboratories; Located on the Tennessee River and at the tail of the Appalachian Mountains 90 miles to Birmingham, AL – 110 miles to Nashville, TN George Tiemann; Heartland Payment Systems; Hill National Blue Ribbon award winning schools US News – top 5% of American high schools Dermaceuticals, Inc.; IntraDerm Pharmaceuticals; Janssen US Census – top 30 fasting growing metros in Southeast Livability – one of best places to live Biotech; Leo Pharma; Lilly USA, LLC; Medimetriks Progressive Policy Institute - #4 America's high tech hot spots NerdWallet – top 10 US cities on the rise Pharmaceuticals; Novartis; PharmaDerm; Promius Pharma, Google – digitial capital of Alabama CNN Money – #7 great place to live and find a job in country NerdWallet – #3 best places for science, technology, engineering, math grads LLC; ProPath Services, LLP; Ra Medical Systems, Inc.; Sun Family Circle – 10 best towns for families Policom – nation's top 20 economies Pharma and Valeant Pharmaceuticals. Metro Magnets – fastest growing US cities Gallup - 4th most optimistic city in America Home of Redstone Arsenal Home of NASA Space Camp We hope that many of you had an opportunity to express your appreciation to our sponsors while you were in New Contact Albert E. “Bo” Rivera, DO with any questions or to express interest in joining our team York. The fact that they continue to support the College, 256 705-3000 office many of them doing so for many years, speaks volumes [email protected] about the value of their commitment to our organization.

Page 6 Resident Liaison Update By Lacey Elwyn, D.O. Dear Colleagues, • The due date of the 2016 AOCD Resident Research Paper Competition has been extended to June 30. Greetings from your AOCD resident • Be sure to keep your patient logs updated as this will make liaison! Spring is finally here! I hope submitting your Annual Report as efficient as possible. this column finds you well and allows • Remember that at least once in your residency you must you to welcome the new beginnings! submit an abstract to the Gross and Microscopic Symposium held by the American Academy of Dermatology (AAD). This Thank you to all residents who cannot be anything that was previously published or submitted responded to Dr. Desai’s request in for publication. gathering our questions and concerns • Second year residents are required to submit an electronic regarding ACGME accreditation poster at an AOCD meeting. This can be from a previously and the future of our in-service training exams. Dr. Suzanne Sirota published or submitted work, including the AAD symposium. Rozenberg took the time to address all resident questions regarding • Newly matched residents these pressing issues. Her responses to your submitted questions will • Congratulations on matching your dermatology residency! We be summarized in this column. Dr. Rozenberg, we sincerely thank are all so excited for you to join our family! you for all your contributions. Moreover, I have much to share after • Please be sure to respond promptly to all requests from attending the ACGME Q&A Session with Eileen Anthony, Executive the AOCD. Director of the ACGME Review Committee for Dermatology, during the 2016 AOCD Spring Meeting. Before doing so however, I would End of housekeeping… like to remind you of a few housekeeping items. ACGME Accreditation: Our New Beginning Housekeeping First, congratulations to the programs that have successfully received • First, I would like to extend a friendly reminder that individuals ACGME accreditation and to those pending accreditation who have who did not pay AOCD membership dues by April 1, 2016, are submitted the application. This is an immense task, and I commend the no longer members in good standing, which is a requirement for program directors and residents that have accomplished this already! all residents. • In-Training Examination As we all move towards ACGME accreditation, it is important to • The AOCD will NOT be giving an in-training examination remember one way we can all preserve our osteopathic distinction is for the 2016-2017 academic year. In its place, all residents by applying for Osteopathic Focus, which can be completed after will be required to take the 2017 ABD In-Training Exam. receiving ACGME accreditation. I strongly encouraged us all to Registration begins November 2016. The AOCD will do this. Our allopathic colleagues also have the option to apply for give a supplemental essay portion, which will cover the Osteopathic Focus. osteopathic component. • 2017 AOCD Spring Meeting – Atlanta, GA, March 29-April 2 For those of us currently working on our application, our ACGME • Resident attendance is required for all future Spring ADS support contact is Kevin Bannon. [email protected]. 312- Meetings. For our upcoming Spring Meeting in Atlanta, 755-7111. GA, resident lectures will take place on Wednesday, March 29. The presentation of resident awards will take place at If your residency program does not plan to apply for ACGME this meeting as well. I wish all programs the best in putting accreditation, you can put your mind at ease because the AOCD together future presentations! will work with all residents to ensure they complete their training • 2016 AOCD Fall Meeting – Santa Monica, CA, September 15-18 program. The new AOA Standards set deadlines for programs to • This meeting is not required for residents; however, attendance either apply for ACGME accreditation, or stop accepting trainees is encouraged. if the trainees cannot complete the program by June 30, 2020. • Attention third year residents For dermatology, the last day a resident can begin training in a • Regarding AOBD certifying examination, please remember program without ACGME accreditation is July 1, 2017. that all application materials are due by July 1, 2016 for the upcoming exam held on Saturday, September 17, 2016, at the Editorial note: Per 10.6 of the newly updated AOA Basic Documents Loews Santa Monica Beach Hotel. Once you register for login for Postdoctoral Training: AOA programs that do not have ACGME credentials on the AOBD website, you will find the course initial or continued accreditation as of July 1, 2019 must work for the 2016 primary exam as well as any other necessary with their OPTI and sponsoring institution to develop and submit materials required for applying at aobd.instructure.com. a plan by September 1, 2019 for the potential transfer all trainees • Remember to submit your annual publication prior to leaving to an ACGME accredited program. The plan will be reviewed by your program, as well as your AOCD Annual Report within the Specialty College Evaluating Committee (SPEC) and PTRC for 30 days of leaving your program. approval. This does not negate continued application for ACGME • Congratulations for reaching your dreams of becoming a initial accreditation. dermatologist! We are all sending you good luck vibes!!! Your sincere efforts and dedication are deserving of all the success The AOCD encourages program directors and prospective residency sure to come your way! candidates to monitor the AOA’s website for policy and procedure • First and second year residents updates regarding the AOA Match as the Single GME Accreditation • Please do not forget to submit your annual publication. System deadline approaches.

Page 7 Fellowships CME/Recertification Once your program submits the complete, 2-part ACGME Requirements are determined by which board certification you application, your program will be in Pre-accreditation status. At have (AOBD or ABD) and the state in which you practice. this time, all residents in your program will be eligible to apply Please refer to either aobd.org or abderm.org. Current AOCD for ACGME accredited fellowships. All osteopathic dermatology members boarded by AOBD must complete AOA requirements fellowships will have to apply for ACGME accreditation. for CME. Of note, the AOCD has been approved to seek initial accreditation from ACCME to be able to grant AMA credit. It is AOBD Board Examination important to mention that the AOCD is a separate organization Residents graduating from solely AOA-accredited dermatology and still will provide opportunity for CME to our currently board- residency programs will only be allowed to sit for the AOBD certified members. The AAD is a membership organization only board examination. and we are all very excited that AOBD-certified physicians are now allowed AAD fellow membership! Congratulations ABD Board Examination DO dermatologists! Graduating residents will NOT be eligible to sit for the ABD board examination unless the program is fully accredited by the ACGME In conclusion, I hope this column finds you well and allows you by the time of graduation. For those of us who receive ACGME to welcome the new beginnings! I am very excited for our future as accreditation before graduation, please refer to the ABD website for osteopathic dermatologists. I thank you for allowing me to advocate the requirements on taking the ABD exam. Once initially accredited for all of our osteopathic dermatology residents this year. If you ever via ACGME and the AOA accreditation is closed, your program is have any questions or concerns, please email me at responsible only to the ACGME. [email protected].

Join Us for the 2016 AOCD Fall Meeting Loews Santa Monica Beach Hotel | Santa Monica, CA | September 15-18 Thursday, September 15, 2016 Embryology for the Rest of Us Interesting Cases in CLIA Proficiency Test Derrick Adams, DO, FAOCD Lisa Swanson, MD Gregory Papadeas, DO, FAOCD How Classical Homeopathic Medicine Can Dermatology in Nursing Homes What is an Osteopathic Dermatologist? Be Helpful for Children with Skin Diseases Peter Saitta, DO, FAOCD Reagan Anderson, DO, FAOCD Robert Signore, DO, FAOCD Common Dermatology Mistakes from a Rules, Regulations, Compliance and Veterinary Dermatology Dermatopathologist’s Point of View Medico-Legal Considerations for Jacquelyn Campbell, DVM Whitney High, MD Cosmetic Medicine Dysplastic Nevi Male and Female Pattern Hair Loss Will Kirby, DO, FAOCD Whitney High, MD Craig Ziering, DO, FAOCD Radiation and : Traditional and Urticaria and New Treatments from an Osteopathic Continuous Certification Update New Approaches of the Nuts and Bolts Allergist’s Perspective Lloyd Cleaver, DO, FAOCD Tim Brant, MD Nathanael Brady, DO EMR Lunch Lecture Sunday, September 18, 2016 Dermoscopy Update Medical and Legal Implications of Being a Melanoma Ashfaq A. Marghoob, MD Dermatologist in 2016 Rene Gonzalez, MD Saturday, September 17, 2016 Whitney High, MD Updates in Dermatology Laser Fundamentals and New Technology Top 10 Dermpath Diagnosis and Karthik Krishnamurthy, DO, FAOCD E. Victor Ross, MD Treatment Implications Pearls in -Dermatology Laser Lessons Learned Amy Spizuoco, DO, FAOCD Karthik Krishnamurthy, DO, FAOCD E. Victor Ross, MD Business of Dermatology Eric Adelman, DO, FAOCD Friday, September 16, 2016 General Pediatric Dermatology Dermatology and Marijuana Lisa Swanson, MD Acne: The Old and the New Marc Epstein, DO, FAOCD James Q. Del Rosso, DO, FAOCD Baseline1,* Hour 41,* Instant gratification.2,† Introducing Neotensil™—the only noninvasive solution that reduces the appearance of under-eye bags, within an hour.3,‡

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*Photos have not been retouched. Results may vary. †Study results for one application of Neotensil in a 16-hour durability study; 4% of patients saw results within 10 minutes and 70% of patients saw results within 1 hour; N=28. ‡Study results for once-daily application of Neotensil in a 2-week pilot study; N=25. References: 1. Data on file, Living Proof, Inc.2. Draelos ZD, Investigator. Strateris 16-hour durability study, DCS-105-13. Data on file, Living Proof, Inc. 3. Kauvar A, Kilmer S, Ross EV, et al. A pilot study of a novel non-invasive topical under-eye contouring technology. Poster presented at: 71st Annual Meeting of the American Academy of Dermatology; March 1-5, 2013; Miami, FL. Neotensil and Living Proof are trademarks of Living Proof, Inc. used under license. Except as otherwise indicated, all other product names, slogans and other marks are trademarks of the Valeant family of companies. Distributed by OMP, Inc. ©2014 Obagi Medical Products, Inc., a division of Valeant Pharmaceuticals North America LLC. DM/NEO/14/0008c 03/14 Residents Update By John Grogan, Resident Coordinator Hello everyone, James Bernard Leadership Award With a July 1 deadline, it’s a great time to begin thinking about It was great to see all of you who nominations for the James Bernard, D.O., FAOCD, AOCD were able to attend the recent Spring Residency Leadership Award. Meeting, and I hope to see many of you this fall in Santa Monica. With The award offers third-year residents a future position on an AOCD summer just around the corner, it’s committee. Among those committees with availability are the a great time for a few important following: Ethics, Awards, In-Training Examination, Journal, CME, reminders regarding residency and Editorial/Public Relations. requirements, annual reports and resident awards. Third-year residents must be nominated by their program directors. Nomination criteria are as follows: Annual Reports • Integrity—Maintains the highest personal standards of honesty, It will soon be time for annual reports to be turned in. All forms can fairness, consistency, and trust. be downloaded from our website. • Respect—Displays a professional persona and is open-minded and courteous to others. It is important for everyone to remember that handwritten reports • Empowerment—Provides knowledge, skills, authority, and and older versions of the report forms will no longer be accepted. If encouragement to fellow physicians and staff. old versions of the reports or handwritten reports are received, they • Initiative—Takes prompt action to avoid or resolve problems will be returned to the resident to resubmit in the approved format. and conflicts.

The resident’s annual report due to the AOCD office within 30 days In addition, the resident must be a member in good standing of after the end of each training year. Residents are encouraged to keep both the AOCD and AOA. a copy of the report for their records. Applications will be reviewed by the Awards Committee, which will One original copy of the report should be sent. The signature page forward its recommendations to the national office. Winners will be must be signed by the resident, program director and director of notified by mail. All correspondence concerning the program and/or medical education. It is an affirmation of complete and accurate awarded grants should be directed to the Awards Committee. reports. Once the reports are received by the AOCD, we will upload them to FileWorks, which is our online storage system. The Education Winners of the award will be recognized at the 2017 Spring Meeting. Evaluating Committee (EEC) members will then be able to view each report as they are uploaded at their convenience, allowing them more AOCD Resident Research Paper Competition time for review. Incomplete reports will not be uploaded. Please do I also want to remind everyone that the entry deadline for AOCD not fax your reports, as these will not be accepted. Resident Research Paper Competition has been extended to June 30. Annual awards are presented to recognize the osteopathic All reports submitted late are subject to a late fee penalty and dermatology residents’ papers which are judged as the best in this will not be reviewed by the EEC until the fee is paid. The late fee competition. All papers submitted will be reviewed by the AOCD schedule is as follows: Resident Research Paper Competition Committee. Papers will • $100 for all reports submitted 30 to 365 days past deadline be judged for originality, degree of scientific contribution and • $250 for all reports submitted 365 to 730 days past deadline thoughtfulness of presentation. Cash awards have been provided by • $500 for all reports submitted 731 days past deadline Lilly USA, LLC for 2016.

Late documents will delay the approval of each year of training by Requirements for competition: the EEC and the AOA’s Postdoctoral Training Review Committee. • The resident must be in an approved AOA/AOCD dermatology Board eligibility is granted only upon approval by both committees. training program. Please do not staple the forms, bind them or use color paper. Please • Complete the enclosed cover sheet. print single-sided only. Review your report before submitting it to • Submit six (6) copies of the paper to be judged. ensure that it is complete. Finally, report packets should be sent to • Only one paper per year may be submitted. the locations specified below. • The paper must have been written and submitted while the resident is in training. If using the US Post Office, please continue to send your reports to: • The paper must be typed and suitable for publication. American Osteopathic College of Dermatology • Authors’ names are not to be included on the paper itself, only P.O. Box 7525 include the title on the paper. Names of the authors are to be Kirksville, MO 63501 placed on the cover sheet only. • Papers submitted for the competition do not automatically If using any other parcel service, such as FedEx or UPS, please use become part of your annual training reports. If it is to be used the following address: as your annual paper, it must also be submitted to the AOCD American Osteopathic College of Dermatology National Office with your annual reports. 2902 N. Baltimore Street • Do not ship or mail the papers in a manner that requires a Kirksville, MO 63501 signature for delivery.

Page 10 • Failure to follow the competition Lehigh Valley Health Network South Texas Osteopathic Dermatology requirements will result • Carl Barrick, D.O. • Ryan Scheuring, D.O. in disqualification. • Claire Otteni, D.O. St. Barnabas Hospital Submissions should be addressed LewisGale Hospital-Montgomery/VCOM • Monica Huynh, D.O. as follows: • Nathan Miller, D.O. Dr. Gene Conte • Robert Murgia, D.O. St. John’s Episcopal Hospital, South Shore 271 Thoroughbred Drive • Vladyslava Doktor, D.O. Prescott, AZ 86301 MSUCOM/Lakeland Regional • Shoni Rozenberg, D.O. Medical Center • Adrian Tinajero, D.O. Once again, the deadline for submission is • Ryan Jones, D.O. June 30. Winners will be announced at the St. Joseph Mercy Health System 2017 AOCD Spring Meeting. Still-OPTI/Northeast Regional • Felicia Ekpo, D.O. Medical Center • Luke Killpack, D.O. Koprince Winners Announced for the • Ryan Jackson, D.O. • Adam Richardson, D.O. 2015 Fall Meeting • Leslie Marshall, D.O. • Shahrzad Akbary, D.O. Congratulations to the following programs who were selected as Koprince Award NSUCOM/Broward Health Medical Center University Hospitals recipients for their lectures presented at the • Trevor Batty, D.O. • Gregory Delost, D.O. 2015 Fall Meeting in Orlando: • June Kunapareddy, D.O. • Emily Shelley, D.O. • NSUCOM/Largo Medical Center for • Miguel Villacorta D.O. their presentation Pediatric Epidermal West Palm Hospital and Appendageal Tumors: An Update NSUCOM/Largo Medical Center • Jessica Kim, D.O. • St. Barnabas Hospital for their • Maheera Farsi, D.O. • Matthew Uhde, D.O. presentation Pediatric Pigmented Lesions • Kelley Segars, D.O. • Texas OPTI/UNTHSC for their • Jason Solway, D.O. OPTI-West/Silver Falls Dermatology presentation Pregnancy Dermatoses • Collin Blattner, D.O. • University Hospitals Regional Hospital NSUCOM/Larkin Community Hospital • Karsten Johnson, D.O. for their presentation Photodermatoses • Andrei Gherghina, D.O. • John Howard, D.O. Documentation needed for new residents Incoming Residents for 2016-2017 • Andrew Jensen, D.O. New residents beginning training in July I would like to introduce the new residents • Liz Levacy, D.O. 2016 should submit all of their application joining our programs for the 2016-2017 materials to the national office. Dues should year. The AOCD will welcome 55 new O’Bleness Memorial Hospital be paid at this time, if payment has not been residents on July 1. The incoming residents • Gabriela Maloney, D.O. made this year. Those who have already paid (listed with their programs) are as follows: student dues for the current year will owe Oakwood Southshore Medical Center a balance of $25 when they begin training Advanced Desert Dermatology • Rachel Cetta, D.O. in their residency program. If you are • Jonathan Bellew, D.O. • Sonam Rama, D.O. uncertain if you have paid this year, please feel free to contact me. Affiliated Dermatology OMNEE/Sampson Regional Medical • Dylon Howard, D.O. Center All residents are asked to provide the • Dustin Mullens, D.O. • Dana Baigrie, D.O. following documents: • Joseph Prohaska, D.O. • A copy of your diploma Botsford Hospital (and exact date of graduation) • Derek Hirschman, D.O. OPTI-West/Aspen Dermatology • A copy of your internship diploma • Roxanne Rajaii, D.O. • Devin Burr, D.O. (exact dates of attendance and name and • Seth Goodman, D.O. address of school) CEME/Park Avenue Dermatology • Anne Nguyen, D.O. • A copy of your state license • Alyssa Miceli, D.O. • 2 passport size photos OPTI-West/Chino Valley Medical Center • A current CV LECOM/Dermatology Residency of • Conrad Benedetto, D.O. Finally, I would like to wish our graduating • Orlando Palisades Medical Center residents all the best as you begin your • Jeffrey Collins, D.O. • Charles Elias, D.O. careers as attending dermatologists. It • Elyse Julian, D.O. • Shannon McVey Wedersum, D.O. has been a pleasure working with you • Michael Noparstak, D.O. all. To the incoming first-year residents, PCOM MedNet/North Fulton Hospital congratulations on earning your positions. LECOM/Tri-County Dermatology Medical Campus I look forward to working with each of you • Olga Demidova, D.O. • Caitlin Porubsky, D.O. over the next three years. • Laura Jordan, D.O. Page 11 2016 AOCD Spring Meeting Highlights By Laura Jordan, D.O.; Brandon Basehore, OMS-IV & Shane Swink, OMS-II

• Gold • 30% positive patches with only about half which hold relevance • Dermal contact dermatitis • Can have rash on eyelids or face because of handling • Chrysiasis: blue grey pigmentation (when gold seeps out of metal and dyes skin blue) • Dermatitis to metal implants • Local or generalized rash • Metal diagnosed before implant did not increase the risk of implant failure. After implant is in patients could develop delayed hypersensitivity reactions at the implant area. • Most common with knee arthroplasty American Contact Dermatitis Society Core Allergen Series • Pain is most common symptom Peter Saitta, DO • Anesthetics • 20% of all rashes in children are due to contact dermatitis • Ester-sensitive individuals can safely use amide-derivatives and • Patch testing vice versa • The patch test reader influences the reproducibility rate • Cross-sensitivity inconsistent in same group • Baseline series based on populations and geographic areas • Benzocaine 5% cross-reactions • Not recommended in children 8 years and younger; • Procaine hydrochloride follicular reactions can occur; chance of scarring; chance • PPD of anaphylaxis • Sulfonamides • Thimerosal • PABA in sunscreens • Found in vaccines, ophthalmic, and nasal products • If patient is allergic to PPD and Benzocaine then they are • Controversy over if it causes autism; nothing to support this at allergic to all of the above this time • Caine Mix II 10% • 4.53% with positive patch test reactions; none of these cases • Lidocaine 15% pet were relevant • Shoe dermatitis • Metals • Rubber adhesives is most common cause; followed by • 10-15% of the world population has metal hypersensitivity mercaptobenzathiazole, thiuram mix, and P-tert-buty-phenol • Patients often allergic to >1 metal • Clinical picture • Nickel • Dorsal foot and toe involvement, sweat, thin stratnum • Most common cause of ACD corneum; can be just one toe (great toe); toe webs spared; • Sources include stainless steel, cookware, metal jewelry, metotarsalphalangeal joint involvement perspiration, food (soil, water) • Sole involvement: spares instep, flexural toe creases, toe webs • Not all buttons and belts have sufficient nickel to • Mercaptobenzothiazole 1%: rubber adhesive cause ACD • Mercapto mix: rubber bands, adhesives • Clinical presentations • Carba mix: rubber accelerators • ID reaction (acute and symmetrical, pruritic, red papules • Thiuram mix: rubber accelerators; including antabuse on LATERAL arms, legs, trunk, and neck) • P-tert butylphenol formaldehyde: glue, neoprene adhesives, • Dyshidrosis rubber shoe-lining • Systemic contact dermatitis (Baboon syndrome); macular and brighter rash; inner thigh, flexural folds • Potassium dichromate • Sources include: metal alloys, cement (most common cause of sensitization in men), leather • Palladium chloride • Component of white gold • Patients allergic to palladium are also allergic to nickel • Cobalt • Found in dental metal alloys, blue and green pigments, vitamin B12 • Poral effect: pinpoint follicular purpuric papules • Large percent of people allergic to cobalt are also allergic to nickel; very expensive to separate the two metals

Page 12 • Colophony 20%: used to glue • Associated with lower rates of pregnancy for psoriasis that suppress the rubbers together and low birth weight immune system? • Patch testing available • Psoriatic arthritis • Correct the MRSA; MRSA • Recommendations: change shoes • 80% of the time will occur after eradication regimen frequently; double pair of cotton cutaneous disease • Antimicrobial body wash socks; hypoallergenic shoes (Trippen, • Asymmetric • Mouthwash Loint’s, Think, Miss Clair, Brako) • Enthesitis (tendon attaches to bone) • Hand disinfectant • Nail changes • Disposable combs Psoriasis Comorbidities • Pits, grooves, nail thickening • Disposable disinfectant wipes Jerry Bagel, MD • QoL impacted greatly, too for surfaces • Psoriasis is a psychological condition • Risk of lymphoma increased • Mupirocin ointment to affected area • Plaque psoriasis • As individual DLQI worsens, family • Change linens daily • Accounts for >80% of cases DLQI worsens, too; Impacts • Examine children, partners • Common sites: elbows, knees, family dynamics • 5 day regimen; 10 day regimen if lower back it doesn’t work, coupled with oral • Cardiovascular disease Problem Psoriasis antibiotics • Associated with multiple Mark Lebwohl, MD • Is it important to treat psoriatic comorbidities that increase risk • My patient is doing well. Should I arthritis early? of cardiovascular disease: HTN, give him a rest from his biologic? • Answer: YES; those treated earlier diabetes, dyslipidemia, and obesity. (drug holiday) did better There is a 50% increased risk of • Retreatment of patients in an • Note: Methotrexate doesn’t prevent mortality and 5 years of life lost in episodic treatment fashion can lead joint damage on x-ray. Also, no severe psoriasis. to development of antibodies. Studies evidence supports methotrexate • Psoriasis is independently associated have shown that loss of responders improving synovitis. with MI; people with severe psoriasis, due to antibody formation is worse in • What tests should I follow to monitor especially in younger age group, have infliximab and adalimumab than in my patients on biologics? What vaccines greater association etanercept and ustekinumab. should I administer? • 3 times as many people with psoriasis • Many of these drugs improve psoriatic • Tests have DM compared to those arthritis; however, these data are • PPD (before treatment without psoriasis based on continuous (and not and annually) • Age of psoriasis onset associated with taking drug holidays) • Hepatitis profile (before treatment, earlier comorbidity and mortality • Answer: NO repeat if increased LFTs) (<25yo) • My patient is having major surgery; does • CBC (before treatment and every • Patients’ perception of disease severity he have to stop his biologic? 2-6 months) doesn’t directly correlate with skin area • Consider suspending TNF blockers • Chem (before treatment, every 2-6 involved (patients’ self-reported disease before surgery for four half-lives months; if treated with IFX, then severity can be greater than their self- • My patient has recurrent MRSA check Chem at beginning of each reported BSA) infections. Is she no longer a candidate 1-2 infusions) • Increase in anxiety, suicide, depression, and 2016 Spring Meeting State and Regional Attendance Breakdown use of SSRIs in people with psoriasis • DLQI (Dermatology Life Quality Index) • 60% of people with psoriasis believe it has an impact on their quality of life • Greater PASI reduction correlates to greater improvement in DLQI • Employment • Full-time employment decreases with psoriasis severity • Job negatively affected by psoriasis • Severe psoriasis correlated to lower income

Page 13 • ANA (most don’t check but some • Paisley tie DDX: syringoma, • Benign; seen on face perform before treatment) microcystic adnexal carcinoma, • Histo: FBF: cords of epithelial • Vaccines BCC (morpheaform) strands; TDC: fascicles • Give primary immunizations • Trichoblastoma • Neurofollicular hamartoma before treatment • Benign; head and scalp • Commonly seen on the nose • Vaccinate household contacts • Histo: irregular nest of basaloid cells • Histo: Hyperplastic • Avoid live vaccines with pilar differentiation pilosebaceous unit • Increase of VZV in patients treated • Cutaneous lymphadenoma • Sebaceous tumors with TNFs; however, there is a • Benign, rare, prominent • Ectopic sebaceous glands possible association of lower rate lymphocytic infiltrate in tumor • Fordyce’s spots and related ectopias; of postherpetic neuralgia in these nests; face and legs in adults not associated with pilosebaceous unit patients. This finding reduces some • Tumor of the follicular infundibulum • Histo: sebaceous glands without of the urgency to give the live • Isthmic origin; benign; head, neck, attached follicles shingles vaccine. upper chest • Folliculosebaceous cystic hamartoma • How does biologic therapy affect my • Histo: can resemble BCC, SM; pale • Composed of patient’s risk of malignancy? staining, peripheral palisade of folliculosebaceous structures • 50% increase in non-melanoma skin basal cells • Histo: infundibular structures, cancer in patients on TNF blockers • Dilated pore of Winer cystic; mesenchymal stroma tends • In patients on biologics, for which • Benign; head and neck, upper to be fibrous malignancies is there evidence of trunk; commonly seen in • Sebaceous hyperplasia an increase? elderly patients • Histo: mature sebaceous lobules • NMSC • Histo: dilated follicular grouped around one cystic duct • MM pore extending into dermis; • Steatocystoma • Lung cancer in COPD keratohyaline granules; acanthosis; • Benign; cystic structure lined by • Lymphoma no pilar unit epithelium resembling sebaceous • NOT in most solid tumors • Pilar sheath acanthoma duct; seen in pachonychia • For which patients should you raise • Benign, upper lip congenita; keratin 17 mutation the possibility of malignancy if they • Histo: central dilated follicular • Muir-Torre syndrome [AD, subtype are started on a biologic? cavity with keratin of HNPCC, associated with • History of lymphoma, deep • IFK keratoacanthomas; MSH2 (90%) melanoma, multiple SCC’s, • Benign, derived from infundibulum microsatellite instability] smoking/COPD, ANY non-cured • Histo: endophytic, finger • Apocrine tumors malignancy, ALL patients like projections • Apocrine hidrocystoma: cysts lined by • No mitotic figures; no atypical cells two cell layers Diagnosis and Treatment of Adnexal Tumors (versus SCC) • Syringocystadenoma papilliferum: Amy Spizuoco, DO • Trichelemmoma benign; on histo will see duct-like • Hair follicle tumors • Outer root sheath differentiation; structures, diffuse amount of • Trichofolliculoma clear cell change/glycogen; solitary plasma cells • Benign, solitary; head and neck • Cowden’s syndrome (multiple • Benign apocrine tumors • Histo: dilated central hair follicles; form): PTEN hamartoma syndrome • Hidradenoma papilliferum: usually contains keratinous material • Histo: sharply circumscribed; one partly cystic, partly glandular; • Trochoadenoma or more lobules; squamoid cells/ ‘decapitation’ secretion • Benign, nodular; face and buttocks glycogen vacuolization • Tubular adenoma: benign; cheek, • Histo: dermal; epithelial islands; • Desmoplastic form axilla, breast; circumscribed lobules; central cystic cavity with • Pilomatricoma ‘decapitation’ secretion keratinous material • Calcifying epithelioma of • Hidradenoma: stroma-hyalinized • Trichoepithelioma Malherbe, benign; from hair collagen, well-circumscribed • Benign; solitary, multiple, and follicle matrix, B-catenin gene • Apocrine mixed: benign, solitary, desmoplastic variants; central face mutation, teeter-totter sign; head, middle-aged to elderly males; • BCC v. TE: CD34 negative within neck, and upper extremities epithelial component in a myxoid, the tumor in BCC; positive in the • Variant is multiple seen in muscular chondroid, fibrous stroma stroma for TE dystrophy, Turner’s syndrome, • Cylindroma: benign, solitary; • Papillary-mesenchymal bodies: cup- trisomy 9, Sotos syndrome, multiple are seen in Brooke- like proliferations of basaloid cells Gardner’s syndrome Spiegler; poorly circumscribed, • Brooke-Spiegler syndrome: germline • Histo: sharply demarcated, lower irregularly shaped mutations in the CYLD gene dermis, calcification; basophilic and • Spiradenoma: benign, solitary, • Desmoplastic TE: benign; histo eosinophilic cells present painful; found in head, neck, shows cords of small nests of basaloid • Fibrofolliculoma/trichodiscoma trunk, extremities; collection of cells, scanty cytoplasm, horn cysts, • Seen in Birt-Hogg-Dube Syndrome: basaloid cells in epidermis; many comma-shaped epithelial projections AD, FLCN gene lymphocytes; trabecular arrangement

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• Eccrine tumors • Most common preservative in cosmetics; moisturizers (79%) • Syringoma: benign, multiple, small papules; comma-like tail • Diazolidinyl Urea on histo; clear cell variant • DMDM hydantoin • Poroma group: derived from acrosyringium; pink or red; • Imidiazolidinyl Urea exophytic nodule; plantar or palmar skin; histo shows tumor • Bronopol of cords and stroma is richly vascular and telangiectatic • Paraben Mix 12% • Complex adnexal tumors • Most common preservative to cause contact dermatitis • Organoid nevus: pilosebaceous follicle; hairless, yellow, • Found in foods and topical drugs used to treat leg ulcers or waxy nodule; SCALP syndrome; histo shows enlargement of stasis dermatitis sebaceous glands during puberty • Avoid cross-reactions with: butyl, ethyl, methyl, propyl, and associated trade names Allergic Contact Dermatitis: North American Standard Series, Part II • Weakly positive reactions may actually be irritant reactions Peter Saitta, DO • Methylchloroisothiazolinone/Methylisothiazolone 0.1% • P-Phenylenediamine 1% (PPD) (MCI/MI) • Hair dye prevalent; PPD is a prohapten; found in almost all • Combination found in rinse off products (shampoos, permanent hair dyes soaps, etc) • Three basic clinical presentations • Recently a decrease has been noted in this allergic reaction to • Angioedema-like reaction MCI/MI combination • Eczematous reaction (14%, scalp margin, superior helix) • Allergic response to MI increased because companies used MI • Long lasting reactions (50% remain at 3 weeks) alone in higher concentrations; thus, we missed noting allergic • There are about 100 ingredients in hair dyes; Cross reactions reactions as companies split MCI/MI and dispensed separately with PPD and P-toluenediamine and disperse orange at higher concentrations • Do reading on day 4 for patch testing if you can only do one • If allergic to MI, avoid all isothiazolinones reading. Perform reading on day 3 and day 5-7 if you can do • If allergic to MCI, may not be allergic to all isothiazolinones two readings. • MI: found in paints; wet wipes (recurrent dermatitis on child’s • 12/7% cross-sensitization with textile dyes; common with buttock and face, hand in caretaker, Cottonelle and panty-hose Huggies wipes • Black henna tattoo • Clinical presentations • Studies on hair dressers with hand eczema: initially ICD but • Post-auricular seborrheic dermatitis presentation later ACD; PPD is most common allergen • Caretaker hand dermatitis • Glyceryl Thioglycolate 1% pet. • Impetigo-like presentation in a child (very • Used as perming solutions; persistent chemic and can lasts for vigorous presentation) months to years after contact • Methyldibromo glutaronitrile/Phenoxyethanol 2% pet • Used in depilatory agents (Nair, Veet products) • Lubriderm products • Formaldehyde 1% • Demonstrates hyper-reactivity upon allergen re-exposure • Ubiquitous; in everything; wrinkle-free clothing (rarely (found in this allergen and nickel); T-lymphocytes remain in now); paper products and smoke (in extremely at location of reaction; upregulation of CCL27 sensitive individuals) • Fragrance allergy • 51% of patients with formaldehyde ACD have reactions • Fragrance compound is used to neutralize odor (this can be for years called “fragrance-free”); when a fragrance is used to create a • If someone is allergic to formaldehyde they are not necessarily pleasant scent, then it is not “fragrance-free” allergic to formaldehyde releasers and vice versa; but they • Patch testing should avoid formaldehyde releasers • Fragrance mix I and mix II (75% will test positive) • Formaldehyde-releasing agents • Fragrance mix I, mix II, and balsam of Peru (90% will • Quaternium 15 (releases the most amount of formaldehyde); test positive) most common cause of contact dermatitis in cosmetics • Most common cause of ACD in cosmetics; most common cause is cinnamic alcohol (found in balsam of Peru) • Hand dermatitis is most common reaction, followed by face and neck dermatitis • Pigmented contact dermatitis • Non-eczematous; lacks sign of dermatitis (no itching, erythema, or scaling) • Presents as hyperpigmentation on the face Our Goal Is Clear • Histo displays PIH, accumulation of hemosiderin, and incontinentia pigmenti histologica (no epidermal spongiosis; basal layer destruction; accumulation of melanin pigment) • Requires frequent and repeated contact with allergens Visit booth 261 (clothes, fragrances) AU95810 03/2015 PRINTED IN USA ©2015 LILLY USA, LLC. ALL RIGHTS RESERVED • Pigmented contact cheilitis: diffuse hyperpigmentation of lower lip; commonly caused by lipsticks, mustache hair dye,

Page 16 green tea (high amounts of nickel) determined by their composite score and details about personal life • Not treatable with corticosteroids; will see their payments cut by up • Text and email reminders; send must avoid allergen for months to 9% birthday cards to patients to years • Clinical practice improvement • Expanded practice access, Use of PA’s in Successful Dermatology Practice Pitfalls and Pearls of Dermatology Practice 2016 population management, care John Minni, DO; Jeff Johnson, PA coordination, patient safety and • History of the PA Profession practice assessment, participation • PAs in APMs • Trained under medical model • Decreasing reimbursement • Must work under a • Independent payment advisory supervising physician board: 15 members appointed by • Not now, or will ever be in direct the President; aim is to reduce per competition with physicians capita growth rate in Medicare • Defined: medical providers who spending; physicians will be are licensed to diagnose, treat, and primary targets prescribe medications to patients • Non-profit patient-centered • Brief History outcomes institute: examines • Take advantage of military-trained clinical effectiveness of medical combat medics treatment, procedures, drugs, and • Training modeled the fast track for medical devices Physicians in WWII Steven Grekin, DO • Physician quality reporting system: • Design was for PAs to “think like • Affordable Care Act (ACA) AAD trying to develop meaningful a doctor” • General points quality measures • Work closely with physicians • Studies demonstrate only modest • What’s the solution? Change • Duke University 1965 – first class benefit in patient outcomes • Consolidate—consider joining groups of PAs • No actual decrease in to spread out overhead and strengthen • PA Education healthcare spending reimbursement, negotiations. This • Modeled on physician education: • Actual IN Network, Out of Pocket protects dermatology from primary One year basic medical sciences; maximum costs have increased care. Become the “big dog” in the clinical phase training (specialties) • Deductibles, copays, and room so that insurance companies • 2000 hours of supervised coinsurance have increased must listen to you. clinical practice • 70 changes to ACA so far • Stay informed—become familiar • Scope of practice within physician- • The newly insured are with practice realities; learn about led team unemployed, paying $60 a month, different payment models • A PAs scope of practice is with a $5000 deductible • See more patients—add one more determined by: • Marketplace exchange: provides a patient per day to fill gap. It’s your • Individual training set of government-regulated and obligation to see more patients and • State law standardized health care plans from to offer care. • Facility policy which individuals may purchase • Establish a dashboard—measure • Agreement of responsibilities with health insurance eligible for everything (open slots in schedule, supervising physician federal subsidies no show rate, invest in resources • Current status of the PA profession • The ACA will force more that compare yourself to similar • Approx. 70,000 practicing PAs communication between physician practices, assess practice patterns • 2800 currently in the field and patient about costs of that may trigger an audit) of dermatology; 3.6% of all procedures; patients may opt out of • Calculate—what is the procedure practicing PAs services because of costs; costs are value per hour; utilize non- • Since the inception of the driving care physician clinicians and other profession, the PA commitment • Increasing rules and regulations ancillary personnel to full extent; has been to a physician-led team of have limited practices free up physician to see more healthcare professionals • Merit-Based Payment Incentive patients and generate more revenue; • What’s the liability in hiring a PA? System (MIPS) cut wasteful spending; analyze • Theory: PA school is shorter duration, • Based on MU, PQRS, VBM, and expenditures quarterly which may lead to more errors of clinical practice involvement • Collect—collect co-pays upfront cognition and judgment • MIPS amplifies and consolidates • Improve patient satisfaction—the • However, PAs may carry less litigation the application of incentives and customer is always right; prior risk than physicians penalties while relying on the experience is the most important • PAs often treat patients with less performance measurement rules of antecedent of satisfaction; give them acute conditions the three individual programs realistic expectations of treatment • More complicated patients are left • The poorest performing physicians outcomes; use your patient’s name to the physician

Page 17 chronic sun damage in the trunk; worse overall survival • Two heads are better than one (Pilot/co-pilot theory) • BRAFi: Vemurafenib, Dabrafenib • While two people can make mistakes, they are not likely • MEKi: Trametinib (adverse effects include extremely the same mistakes pustular acne when given by itself, lacy erythematous rash, • Journal of Medical Licensure & Discipline 2009 and erythema surrounding tattoos) • 17 years of data in the US National Practitioner Database • Combination of targets on BRAF and MEK increase • All studies show liability of PAs was less than doctors in terms efficacy duration of malpractice payments and number of citations • Possible adverse effects of BRAFi: arthralgias, myalgias, • One paid claim per 85 physicians rash, hepatotoxicity, hand foot syndrome, pyrexia • One paid claim per 520 PAs (after about 4 weeks of therapy with dabrafenib), • Why you should hire a PA photosensitivity, new cutaneous skin cancers (when • PAs in the daily clinic patients were on solo BRAFi versus combined therapy • Allow the physician to focus on the items you want with MEKi); diffuse macular rash • Patients offered appointment with physician first • Checkpoint inhibitors • Told they are seeing a PA when apt made, at confirmation, • Anti-CTLA4 monoclonal antibodies for melanoma and when the patient is roomed • Stimulate T cells to recognize cancer antigens and develop • Mohs: More patients seen = more cancers treated mechanisms for cell death • Added Benefits • Break tolerance of T cells to self antigens in order to permit • Patient waiting times are decreased anti-tumor response • Readily available for follow-ups/wound checks • Potential side effects are autoimmune diseases • Tremendous asset for educating the staff • Ipilimumab • Educations programs for your community • Augments T cell activation and proliferation by binding • Minimize the time you are on call tightly to the CTLA-4 receptor and blocking CTLA • Salaries and contract negotiations • Toxicities include: thyroiditis (1.5-2.5%; begin as • Salary hyperthyroid), panhypopituitary hypophysitis (4%; • Average (dermatology): $105,000 annual salary present with central headache), adrenal failure (1.5- • Cost to employ a PA: 30 cents on the dollar collected; Ex: 3%), ALT/AST rise (30%), hepatitis (4%), colitis $600,000 x 0.30 = $180,000 diarrhea (30%), dermatitis (43.5%; usually very • Benefits package pruritic) • “Competitive” salary, 401K, CME allowance ($1500- • Endocrinopathies usually occur after treatment $2000 annually), state license, professional fees, insurance, • Pseudo-progression: may occur when T cell infiltration uniform, profession organizations, maternity leave/holidays, causes tumors to flare or new lesions to appear upon vacation/personal days imaging. If your scan looks bad, but your patient looks • Hiring a crucial member of your team good---indication of pseudo-progression. • If you are considering hiring a PA, the success of the hire • Anti-PD1 Antibodies for melanoma likely rests on a few simple questions: • Targets PDL-1 and 2 receptors on tumor cells • What do you want the person to do? • As a single agent approximately 30% of patients with MM • What are you willing to let them do? respond • What amount of support will they receive? • Less side effects compared to Ipilimumab • Set the parameters of the job • Given by vein every 2-3 weeks depending on PD1 compound • Formalize a job description, additional duties, call schedule, • Side effects include rash, itching, diarrhea and pneumonitis seeing new patients, level of supervision • Anti-PD-1: Nivolumab, Pembrolizumab • Dual checkpoint blockade with anti-CTLA4 and Advances in Metastatic Melanoma Therapy anti-PD1 Anna Pavlick, DO • Conjugated monoclonal antibodies • Overview of cutaneous MM • Glembatumumab • If caught early, it is 95% curable • MOA: CR011=vcMMAE binds to GPNMB on the • 1 in 50 Americans will be diagnosed surface of cancer cells. After internalization, the valine- • One or more blistering sunburns as a child doubles citruline linker is cleaved by endosomal enzymes. Free melanoma risk MMAE inhibits tubulin polymerization, leading to • Use of tanning beds dramatically increases melanoma risk cell death. • Less than 5% of all patients survived for 5 years with • Skin rash only occurs in warm and moist places; in folds metastatic disease prior to 2011 • 50% with metastatic disease develop brain metastases Manifestations and Treatment of Cutaneous Venous Hypertension • Targeted therapies Ronald Bush, MD • Mutations in MM: BRAF (50%), NRAS (25%), MEK, KIT, • Spider Veins GNAQ (ocular melanoma), GNA11 (ocular melanoma) • Most spider veins are related to an area of venous HTN. • BRAF • Reticular veins are the final pathway for transmission of • Mutated in approximately 50% of melanoma; most venous HTN in the majority of patients but not all. common mutation is V600E; younger age, fewer markers of • Reticular veins are usually connected to a deeper source

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of of patients with contact dermatitis? • The branches of the reticular • Venous Ulcers • Are their workplace exposures to complex in the majority of clinical • Occur in 1% of the population potential irritants or allergens? situations are the final pathway • Increase in leg ulceration is • Is the anatomic distribution of the leading to cutaneous telangiectasia directly related to post exercise dermatitis consistent with cutaneous • The GSV, SSV, AAGSV, and thigh venous pressure exposure in relation to the job task? extension branch can transmit • Leukocytes accumulate in the leg • Is the temporal relationship between abnormal pressure to the skin under conditions of high venous exposure and onset consistent with if incompetent pressure; this activates a cascade of contact dermatitis? • Ultrasound: use the ultrasound events at the micro-circulatory level • Does dermatitis improve away from at 2cm depth to trace reticulars that may lead to ulceration work exposure to the suspected to origin of HTN; all pathologic • Treatment irritant or allergen? pathways will reflux • Standard of care: compression • Are non-occupational exposures • Pathogenesis of spider veins (archaic); even with compression excluded as probably causes? • Secondary to high venous pressure alone, there is still a high • Do patch tests or provocation tests which causes dilatation of the recurrence rate identify a probably causal agent? smooth vessel wall of the venules in • TIRS (Terminal Interruption of • Follow up the criteria the reticular dermis; one constant Reflux Source): the percutaneous • 4 of the 7 must be positive to finding in spider vein telangiectasia technique allows for the treatment conclude occupational dermatitis is vessel wall hypertrophy of venous ulcers with or without the • Contact dermatitis • Histological studies find that there availability of an ultrasound • Most obvious and commonly affected is always an abnormal valve • 3mL of foam is injected using area is the hands • Reticular veins are conduits of flow 1% sclerosant; if the patient is • “Common allergens cause contact and pressure anticoagulated use 3%. Rapid dermatitis, commonly” • Length of spider vein is directly healing of ulcer in most patients • Prevalence is 5-10% proportional to the amount of within 4-6 weeks. • Twice as common in women pressure beneath the surface • Those exposed to frequent hand • Treatment of spider telangiectasia Occupational and Environmental Dermatology washing or solvents is one of the (4 steps) David Cohen, MD most common causes • Unload cutaneous venous HTN: • Occupational skin disease is basically • Atopic dermatitis is recognized as a a punch biopsy disconnects the everything that general dermatologists top risk factor for hand eczema cutaneous telangiectasia; also the deal with in the office every day • Chronic hand dermatitis can lead to branch feeding the cutaneous • Skin disease is the number one organ effacement of dermatoglyphics over pathology may also be removed at affected by the workplace, and has been the fingertips the same time that way since the 1930s • Predictive factors of hand eczema • Treat spider vein • Nowadays, skin disease is roughly • Contact sensitization is an • Assess collateral flow 12% of work related disease, second to independent risk factor for • Minimize sequalae repetitive stress injury (carpal tunnel, hand eczema • Evaluation of clinical and histo findings i.e.). Because we got much better • Fragrances and isothiazolines using varying sclerosant concentrations at recognizing and treating cases of • Other risks: atopy, xerosis, hay fever, for the treatment of spider telangiectasia contact dermatitis largely. filaggrin null mutations • Sclerosing agents: destroy endothelial • Epidemiologic data across large • Hand dermatitis is the most cells and expose subintimal layers to populations is a major source of the common skin complaint reported the sclerosant with eventual fibrotic strides made in this field in workers’ compensation cases; occlusion of the vein • In the late 80s, there was an Adds up the greater than 1.5 billion • Undesirable effects: vessel wall epidemic of rubber allergens from dollars in lost work necrosis with extravasation of red glove use. This coincides with • Most common in: healthcare, cells, leading to inflammatory the introduction of universal custodial, and machinists changes and/or angiogenesis precautions. Then this epidemic • Most common allergens: • Agents included were Sotradecol and decreased because glove rubber, epoxy Asclera (Polidocanol) production changed. • Health care works evaluated for • Evidence of muscle wall damage is • In 1992 the German government contact dermatitis visible on microscopic analysis of outlawed hair permanents because of • Most commonly allergic to fibrin replacement of smooth the increasing number of work related preservatives and rubber muscle cells injuries due to the use of • Shoe induced dermatitis • Ideal concentrations were found to this chemical • Similar allergens than the hands, be Sotradecol 0.15% and Polidocanol • Evaluating occupational causality: but not the same 0.31%. questions to consider/ask when talking • Most commonly: glue used to • Clinical findings: mild staining post with patients make shoes, belts, and watches, treatment occurred in 50% • Is the clinical appearance consistent chromium, rubber

Page 20 Page 20 Interesting and Educational Dermatological Cases • Choosing the best patients to patch test Stephen Purcell, DO, FAOCD • 1st: Vesicular palmoplantar dermatoses >>> hand and foot dermatitis >> fissured > hyperkeratotic • Psoriasis has not been shown to increase or decrease the prevalence of occupational dermatitis • Thiourea • Common component of rubber products that causes contact dermatitis • Found in: sneakers, computer wrist rests, globes, rubber based automobile products, splints and foot supports, neoprene grip on gym equipment • Para-phenylenediamine (PPD) • A common allergen found in hair dye and fur dye • 75% of women admit to dying their hair and close to 20% of men • This includes highlights! • This exposure occurs at a median age of 16 • Osteopathic Continuous Certification (OCC) • This is a common cause of occupational dermatitis in • Those with time limited certificates must do the OCC hairdressers. This is a critical component of their job, with the • AOBD.org has been revamped and instructions/registration highest margins of profit for their work. can be found there • This product is also found in temporary henna tattoos, which • The upcoming AAD vote to give DOs full fellow membership is a rising concern ends on April 4th • It has more PPD than hair dye • Cases from “A Day in the Life of a Dermatologist” • Methylisothiazoline (MCI) • 59 yo female with joint swelling of fingers that retreated with • Studies show up to 25% of patients have an allergy to raw diet this preservative • Erythema of the nose and left cheek was observed • All ages, including infants are affected • Biopsy showed granulomatous dermatitis à sarcoidosis • Risks: hair and beauty, healthcare, painting, welding, machine • Presents as lupus pernio, red lesions, notes, cheeks, operators, wipes, cleansers and fingers • It can penetrate latex gloves • 75 yo male, thick generalized scale since childhood, with • Tell patients to wear two sets of gloves (one on top of each other) strong familial presentations and to change them frequently. This will help to reduce the cases • Histoplathology shows epidermolytic hyperkeratosis of contact dermatitis. • Epidermolytic Ichtyosis • When patch testing patients with suspected contact dermatitis, • Bullous congential icthyosiform the results help to increase prognosis in 2/3 of patients • Autosomal dominant disease • Polychlorinated biphenyls (PCBs) are chloracne forming agents • Treatment is really limited to emollients • Colorless to dark brown thick liquids with low • 35 yo male with reticulated poikoloderma of neck, chest water solubility and shoulders, hypodontia, nail dystrophy, chronic skin and • Great insulators often seen in transformers and heat mucosal irritation exchangers often seen in hot water tanks (like in hotels) • Atypical dentition is present • These were banned in 1977 • Biopsy showed chronic ulceration • Over 1 billion pounds were manufactured, but half of that has • Dyskeratosis congenital leaked into the environment • Bone marrow failure syndrome. These patients • Chloracne lasts for about 4 years after exposure, but pitted are at high risk for squamous cell carcinoma and scarring remains lymphoproliferative disease • 39 yo male with ulcers on skin over three years, progressively worsening • Erosions have orange-brown coloration • Patient was a heroin addict, but on methadone chronically • This patient had a fixed drug eruption from omeprazole use • Follow up patient taking imiquimod • Red eyes, edematous and erythematous lips and tongue, mucosal erosion, vesicular palmar eruption, and generalized diffuse erythematous popular eruption, and some central eruption • Diagnosis is erythema multiforme induced by imiquimod • Treated with supportive care • 69 yo female presents with history of skin dysesthesia and “substances” extruding through skin

Page 22 • Patient sends samples to be tested • 70 yo female presents with brown • Field Cancerization (bags and bags full of samples) spots on the cheeks • Clusters and contiguous patches • Lots of notes documenting the • Subtle black/brown pinpoint papules of altered cells in photodamaged “substance” extrusion on the cheeks, both are involved skin; Multiple clonally related • Upon entering the room, the • Biopsy shows deposition in upper neoplastic tumors can develop. patient has subtle grayish-blue dermis of brownish discoloration • He was sent to radiation oncologist pigmentation of the face, nailbeds and waxy ocher like deposition for xray therapy; He presented after • Biopsy shows brown/black stipling of material treatment with even more lesions of eccrine gland • Urine negative for • Intralesional 5-FU was used and the • Diagnosis is argyria homogentistic acid lesions eventually resolved • Products marketed as dietary • Diagnosis is exogeneous ochronosis • Female presents with brown patch on supplements can still contain silver • Hydroquinone is a common her ankle despite FDA ban in 1999 cause, rarely phenolic compounds • Biopsy was consistent with tinea • 68 yo female, hospitalized for sepsis, (phenol, piric acid) versicolor, with dark hyphae developed ARF during the stay • vesphene IIse (2 phenylphenol) • Diagnosis was actually tinea requiring renal artery embolization was the cause in this patient nigra (an uncommon superficial with gadolinium contrast. She had • 25 yo male presents with facial rash dermatomycosis) caused by hardening and thickening of skin with other involvement, spares Hortaea weneckii or 11 years later. nose, ear, and perioral area with Stenella araguata • Soft brown plaques over the sharp cutoffs • Often seen in tropical regions, legs; Biopsy shows infiltrates of • Rash is a scaling white dermatitis relatively uncommon in the US fibroblasts in the dermis and that responded to topical steroids • Three cases occurred in northeast a scant amount of mucin, and but would reappear with cessation PA in a short amount of time “lollipop bodies” • No alopecia noted • Possible climate change or travel • Diagnosis was nephrogenic systemic • Biopsy shows perifollicular related exposures? fibrosis (NSF) lichenoid infiltrate with exocytosis • Male presents with 18 year history of • Gadolinium is chelated by of lymphocytes squamous cell carcinoma on the scalp, the kidney, but not in cases in • Diagnosis is follicuolotropic and was referred to chronic kidney failure; In these cases, it can spread to the other • <10% of MF cases, with or Atopic Dermatitis Update tissues of the body without mucin, predilection Brad Glick, DO • This particular patient had acute for head and neck, renal failure, and had returned follicular prominence to normal, however, she still had • Treatment is poor to respond, continuing developing lesions PUVA is an option, 15 year survival • No evidence for efficacy of is 40% chelation therapy • 60 something yo female has targetoid • 20 yo female presents with scaling asymptomatic rash on her right thigh erythematous linear plaques on her • Histopathology did not show legs since two months old features of erythema migrans • Biopsy shows psoriasiform dermatitis • It did show diffuse • Diagnosis: ILVEN erythrocyte extravasation • Treatment: ablation therapy (not • Some cases have been reported efficacious in this patient) of unconventional patterns of • Excimer laser was much more erythema migrans effective for these plaques • Diagnosis “Casino • 59 yo old male transferred to burn Carpet Dermatitis” • Clinical features unit from outside hospital with • Cleared up with doxycycline • Chronic pruritic eruption, relapsing history of b cell lymphoma presents • 78 yo male presents with keratotic • Factors contributing to pathogenesis: with desquamation of the skin and papule on the arms environmental, genetics, , blistering • Squamous cell carcinoma, epidermal barrier dysfunction • Extensive desquamation of the skin cleared margins • Most common chronic skin disease • Frozen jelly roll shows in tact • On follow up, a new squamous of children epidermis, some necrotic appeared next to scar with • Persists into adulthood in 10-30% keratinocytes, but not full thickness clear margins of cases • Biopsy shows subepidermal clefting, • He presents with another keratotic • Increased prevalence noted in acantholysis, dyskeratotic cells papule, excised with clear margins, industrialized countries • Diagnosis paraneoplastic and the progression continues up to • Threefold risk in atopics to have pemphigus, but looks like TEN four excisions asthma, rhinitis, food allergy

Page 23 • Non-allergic comorbidities: mental • Goals of therapy: control flares, of systemic inflammatory immune health, HTN, obesity, infections, minimize pruritus, intervene with mediated diseases; open label study sleep disturbances topical steroids; restoring barrier; underway for AD adults • Commonly affected areas good skin care routines (soak and • Ustekinumab • Infants: face and extensor areas seal; short bathing time, emollients); • Nemolizumab (CIM331) increased • Children: flexural areas wet wrap therapy (soaking three sleep efficiency and decreased use of • Adults: variable times per day for 15 minutes) hydrocortisone butyrate; improvement • Signs and symptoms: pruritus, • Impaired barrier function limits in skin was modest but significant eczematous dermatitis, xerosis, treatment results reduction in pruritus urticarial eruptions; lichenification at • Therapy in general is stepwise sites of chronic rubbing and scratching • OCT/Rx topical corticosteroids are Adherence to Treatment • Immunopathophysiology mainstay; beware of side effects such Steven Feldman, MD • Excessive T cell response; Langerhans’ as striae, acne, rosacea, atrophy • Getting patients to use their medicine is cells thought to play major role; • Abx when indicated an easy way to clear up many conditions, superantigens; imbalance of Th1/Th2 • Phototherapy: successful for chronic such as atopic dermatitis; Think of it as • Outside in hypothesis: FLG mutation disease, requires multiple office visits “low hanging fruit” associated with early onset AD and • Topical calcineurin inhibitors: second • Do we need new drugs… or do we just often more persistent and debilitating; line; not in children younger than need patients to use their ? fewer filaggrin repeats correlate with 2yo; should be used for short periods • Big reasons for poor treatment outcomes: dry skin; reduction of skin integrity of time; not in immunocompromised • Poor compliance is most likely and greater TEWL; reduction and patients; patients don’t suffer from • 40% of patients admit to dysfunction of both skin surface the side effects that can occur in noncompliance proteins and ceramides topical corticosteroids • Many patients don’t even fill • Inside out hypothesis: associated with • New topical therapies prescriptions, and psoriasis patients T helper cell dysregulation, mast cell • PDE inhibitors (Crisaborole): are some of the worst hyperactivity, and IgE production; naturally occurring product; most • Studies monitoring patients use of IL-31 associated with pruritus in AD; common side effect is application site medication versus their reported usage activity of cytokines persist irritation; favorable safety profile shows that patients lie about their • Role of Phosphodiesterase: • JAK inhibitors (topical tofacitinib 2% actual usage increased in AD; inhibitors of PDE ointment in phase II RCT) • However, adherence rates decrease as increase IC cAMP and reduce • Calcineurin inhibitors time increases inflammatory cytokines • Systemic therapies • Tachyphylaxis à the less you use the • Antimicrobial peptides in AD: • Indicated in severe AD medicine, the less it works correlation with predisposition for • Systemic steroids: generally advisable • In addition, increased visits increases cutaneous infection in staph carriage to avoid yet still frequently used in patients usage of drugs and improves • Common triggers children because there aren’t any their overall condition • Anxiety, climatic factors, irritants, other options • You might suspect that patients with microbial organisms, contact or • Cyclosporin: use short duration more severe diseases will use their inhaled antigens • MTX: safe, underutilized therapy medication more, but this is not the case • Colonization with S. aureus; • Azathiaprine: variable responses; better • Studies of adherence to biologics show scratching results in bacterial on cost; use in children; check TPMT that patients sometimes go months adhesion; microbiome shifts occur level before starting therapy between doses • Clinical assessment • Mycophenolate mofetil: trials • What you can do is to ask patients • Pruritis, erythema, edema, not abundant, efficacy variable; if they’re keeping their extras excoriation, lichenification disadvantages with long term use refrigerated like they’re supposed to. • Cutaneous hyperreactivity; variable (congenital malformations, 17 cases If they say yes, you know they’re not and difficult to predict of PML taking them appropriately. • Variations: palmar/plantar, eyelid, • Biologic therapy in AD • Moving a follow up visit closer to an hand, nipple, cheilitis • IFN gamma: negative findings initial visit will increase compliance • In African Americans AD is more • Mepolizumab, Omalizumab • A major reason that patients stop using papular, follicular, PIH (neg findings) medicine so quickly is because their • HSV and AD: eczema herpeticum • TNF inhibitors condition starts to clear up right away • Management • Rituximab • Encourage better compliance by • Monitoring IgE is not recommended • Targeted therapy (dupilumab) • Good relationship as there is no correlation with • Targets against IL-4 and IL-13 • Involve patients in planning disease severity • Significant improvement in SCORAD • Don’t scare them with side effects • Patient education is key and IGA with dupilumab versus placebo • Choose fast acting agents • Diagnosis and assessment: allergic • New therapies • Return visits are key contact dermatitis, CTCL in adults, • Apremilalst: PDE4 inhibitor; • Clear, written instructions are helpful scabies, seborrheic dermatitis, etc investigations underway in variety

Page 24 • Keeping patients waiting and spending little time with them • The rate of hyperkalemia in healthy young women taking will decrease patient satisfaction, but only by a little amount. If spironolactone (0.72%) for acne is equivalent to the patients think you don’t care about them, this more significantly baseline rate in the general population (0.75%) decreases their satisfaction. • Conclusion: routine monitoring of K+ levels in healthy • A key to dermatologic therapeutics is to make patients feel like young women taking spironolactone is UNNECCESSARY you care about them • Laboratory Monitoring During Isotretinoin Therapy for Acne • Interventions to appear caring • Evidence from this study does not support monthly lab testing • Sit down, examine patients carefully (palpate the rash, for use of standard doses of isotretinoin waive a magnifier over lesions), asking a few questions • Acne in Adult Women about the disease (“Your previous treatments have • Conventional discussion on U-shaped pattern of probably been frustrating…), address psychosocial issues inflammatory acne on lower face and submandibular- (use support groups), while washing your hands inform lateral neck the patient they know you’re doing that to protect them • Therapeutic focus has been on use or oral contraceptives from disease and spironolactone • Don’t look at your watch! Put clocks on the wall • Absence of studies on pathophysiology, presentations, and behind patients. treatment in adult women with acne • Other pearls • Comparative efficacy and tolerability of Dapsone 5% in Adult • Choose vehicles that patients will use; Patients prefer solution, v. Adolescent Females with Acne: Greater effects and better foams, but the best choice is the one they’ll use results seen in ADULTS • Simplify treatment as much as possible; Adherence is better • Challenges related to evaluation of baseline and follow- with less products Up Severity • Visits are you most powerful tool! • Patients at either end of severity spectrum (high or low) are • Kids with atopic dermatitis did much better with 1 week often left out of the studies follow ups compared to 4 weeks • Visible difference in acne severity not captured by lesion • Makes people get the medicine and use it counts or IGA • Giving patients your cell phone number is a powerful • Use of Antibiotics for Treatment of Acne statement of how much you care (whether you answer the • How to Use Antibiotics More Responsibly When phone or not) Treating Acne • Do NOT pre-print your cell phone number on your • Recognize that abx are like knives, they are excellent tools business card! when used properly • Electronic reminders to use medication does not seem to • Accept that if you can avoid abx use and resistance, this is a increase adherence good thing • Teen psychology: watch out for oppositional defiant behavior. • Accept that abx resistance is an unavoidable consequence of DO NOT tell them that many others are non-adherent (they use of abx and some antimicrobial agents (triclosan) want to be like others!) • Ask yourself, “Is abx therapy needed for this patient?” If so, • Side effects: “Sting means it’s working!” “Spironolactone is a anticipate and discuss your “exit plan” from the outset diuretic…so you may notice some weight loss” • New oral abx? • Prescribe “all natural” treatments • Small, film-coated doxycycline 150 mg oval-shaped • Do not use the word “steroid” with a mom. They are “all tablets and 75 mg round tablets purposefully designed to natural topical anti-inflammatory” be easy to swallow; Film-coated tablets have decreased GI adverse effects Therapeutic Update • Isotretinoin fasting v. fed absorption values James Del Rosso, DO • Taking isotretinoin in a fed state (fatty meal) increases the bioavailability • Absorbica is pre-solubilized in fat; Difference in bioavailabilty of fed v. fasting state is small

My Approach to Cosmetic Dermatology Laura Benedetto, DO • Procedures • Neuromodulators: Botox, Dysport, and Xeomin • Fillers: HA’s, calcium hydroxyl apetite, poly lactic acid, silicone • Aging changes • Intrinsic aging • Photodamage (sun exposure): wrinkles, surface changes, pigmentary changes • Potential Changes in Approaches to Laboratory Monitoring • Patient evaluation • The usefulness of potassium monitoring among healthy young • Patients don’t know what they want really; don’t understand women taking spironolactone for acne how their face ages

Page 25 • Most point to nasolabial fold and • Treatment: will need an assistant when • Electronic brachytherapy marionette lines but just filling in administering Sculptra as you will • Small, inexpensive, minimal shielding these lines leads to poor cosmetic need to work quickly • Scarce data result (pudgy face) • Post-treatment: massage, ice, instruct • Need to know physics and radiobiology • HA’s patient to ice that day, have patient to best manage patients with this • Are forgiving, go away, are immediate, start massaging the next day (3 treatment. No therapy is without risks. can dissolve with hyaluronidase times per day/5 minutes/ for 1 • Most popular fillers; best to start in week); concealer may be applied Medicare Fraud and the False Claims • Calcium hydroxyapatite (Radiesse) immediately after if bruising noted Act (FCA) • Thicker product; watch for vascular (Glo, Dermablend) Ted Schiff, MD & Daniel R. Miller, Esq. occlusion; face and hands • Tips: never overcorrect; be • Available with and without lidocaine; conservative in younger patients; With lidocaine creates a thinner you have more leeway in older product that is easier to massage in patients; harder to correct in older the hands patients; younger people heal faster • Poly lactic acid and they will have a more robust • Synthetic polymer; results take collagen response months (2-3 treatments minimum); • Avoid clogging: mix at least 24-72 lasts years; highly technique hours beforehand; refrigerate after dependent product 72 hours • Indicated for restoration and or • Silicone correction of the signs of facial fat loss • Permanent product; good for lips, in HIV patients scars and “fixed” scar like wrinkles; • Polylactic acid aesthetic (Sculptra) never goes away but patients age and is intended for use in people need more because of more with healthy immune systems collagen loss • History of the FCA for correction of shallow to deep • Tuberculin syringe with micro-droplet • During the civil war, there were many nasolabial food contour deficiencies technique; usually requires 2-3 problems the Union army faced that and other facial wrinkles treatment sessions, 6-8 weeks apart lead to many losses • Response to injection: involves • Deoxycholic acid (Kybella) • One of President Lincoln’s solutions several progressive phases; there is an • Recently approved for treatment in was to establish the FCA in order to immediate mode of operation related submental fat in the neck investigate these problems such as to injected volume and injection- • Requires several treatments poor uniforms, sawdust mixed with related edema resolves in a few hours • Youthful face gunpowder, and lame horses to days; tissue response includes • Cheek bones heart shaped for women; • This is the same law that impacts foreign body reaction and gradual male face is angular (keep it that way) physicians today production of collagen as polymer • Face loses volume with structural • FCA allows those to file suits against degrades (collagenesis) changes, lifestyle changes those claiming certain goods or • Used for volume and lifting, • Consult services but not providing them fully duration (persist for up to 2 years), • Hand patient mirror and ask them • During WWII in 1943 the FCA was and biocompatibility what bothers them greatly weakened by congress against • Sculptra evaluation: examine and • Assess degree of damage, amount of multiple filed suits study face, mark off face, explain improvement expected, timeline for • 1986 Reagan strengthened the FCA results will be gradual, multiple improvement and budget in response to overcharging by treatments will be needed, and ask • Come up with a plan defense contractors patient to bring in photos from 10-20 • Financial crisis of 2009 significantly years ago Superficial Radiotherapy Updates strengthened the FCA with a focus on • Adverse events: avoid lip vermillion, David Herold, MD financial institutions 1cm above lip, keloid formers; inject • How radiation works: normal cells can • The Affordable Care Act significantly subcutaneous supraperiosteal; allow repair DNA damage more effectively strengthened once more the FCA, enough time in between injections, than cancer cells if only low doses are especially in relation to medical fraud use adequate dilution delivered with time in between fractions • Since the late 1990s, healthcare fraud is • Pretreatment care: discontinue • As the lesion grows in size, fractionate the major focus of the use of FCA (80%) aspirin, motrin, fish oil, vitamin and give a smaller dose • It returns $20 for every $1 invested E. Use arnica Montana two days • Brachytherapy: in health care related cases before, day of and day after may • Can treat large and small lesions, • Process of filing a claim reduce bruising. Eat pineapple two mobile truck, emerging data • Recognizing a problem, specifically weeks before procedure. Make sure • But higher cost, source contracts, need fraud against the US government patient understands they may bruise. vault/shielding, need physicist and (Specifically in health care à Medicare/ Application of topical anesthetic. doctor direct supervision Medicaid fraud)

Page 26 From hard-to-reach spots to large body areas... We’ve Got

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Topical Aerosol, USP (0.147mg/g) 1 The Only Triamcinolone in an Aerosol Spray Formulation cools skin; decreases itch Minimal ingredients -- vehicle contains isopropyl palmitate (a moisturizer); low dehydrated alcohol content No touch, precise application at any angle Available in Delivers 0.2% triamcinolone* 63 g and 100 g sizes Relief Never Felt So Good Indication: Kenalog® Spray (triamcinolone acetonide topical aerosol, USP) is indicated for relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses. Important Safety Information: Systemic absorption of topical corticosteroids has produced reversible hypothalamic-pituitary-adrenal (HPA) axis suppression, manifestations of Cushing’s syndrome, hyperglycemia, and glucosuria in some patients. Conditions which augment systemic absorption include the application of the more potent steroids, use over large surface areas, prolonged use, and the addition of occlusive dressings. Children may absorb proportionally larger amounts of topical corticosteroids and thus be more susceptible to systemic toxicity (see PRECAUTIONS, Pediatric Use). You are encouraged to report negative side effects of prescription drugs to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch For topical use only. Please see adjacent page for full prescribing information. For more information, visit www.kenalogspray.com Reference: 1. Data on file. Ranbaxy Laboratories, Inc. Princeton, NJ. * After spraying, the nonvolatile vehicle remaining on the skin contains approximately 0.2% triamcinolone acetonide. Each gram of spray provides 0.147 mg triamcinolone acetonide in a vehicle of isopropyl palmitate, dehydrated alcohol (10.3%), and isobutane propellant. KENALOG® is a licensed trademark of Bristol-Myers Squibb Company. KS 1212

Kenalog Derm Times 5-9-13 indd.indd 1 5/9/13 7:25 AM • Do an investigation • Immunofluorescence staining pattern • Heart block seen in up to 50% • Contact an attorney (homogenous, peripheral, speckled, of patients; permanent defect. Risk • Collect evidence nucleolar, centromeric) for mothers with • Round up witnesses and exhibits • False positives: pregnancy; subsequent pregnancies. • Claims are filed under seal elderly persons • Plaquenil clinical pearls • After filing a claim • Internal organ involvement was most • High affinity for melanin- • The DOJ would evaluate the claim. commonly observed in containing tissue; <1% risk of eye They may request an interview. • Ro/SS-A antibody + patients with damage; don’t need eye exam unless • 90% of cases are declined by the LE presenting with LE-nonspecific patient has been on medication for government (many are just disgruntled cutaneous manifestations over a year employees who want to give their • Ro/SS-A antibody + patients • Increased chance for skin cancer with employer a headache) presenting with acute cutaneous lupus patients who smoke • If they intervene, the DOJ will LE and mucosal LE high risk • Treatment: alitretinoin for CLE (not investigate the case with (highest frequency of lupus approved in US yet); apremilast multiple agencies nephritis and serositis) (PDE4 enzyme inhibitory) • The US government is the plaintiff • Approximately 50% of patients with • Sarcoidosis and they have large resources to subacute lupus erythematous • “Great imitator”—should always be investigate the case and they are quite • Patients with SLE (versus SCLE) have on your differential with funky things the formidable opponent oral ulcers, + anti-dsDNA, + ANA, • Higher female preponderance; more • How do you get caught? low complement likely to be chronic and fatal in • Disgruntled employees, other providers • Cutaneous lupus black Americans in your practice or community, or even • Tumid lupus • Cutaneous disease in 30% the public accessing public insurance • Patients do not get systemic disease • Can occur in tattooed areas payment records • Diagnosis: clinical (nonscarring • Lofgren’s syndrome • Many physicians that are found to plaques with a smooth surface in (erythema nodosum) violate the FCA go to the federal sun-exposed area) • Heerfordt’s syndrome corrections facility in Danbury, CT • Treatment: antimalarials, topical • Darier-Roussy Disease (keep in your • Conclusion steroids/intralesional kenalog, ddx with RA nodule and Subq RA) • Practice good medicine and treat dapsone, sun protection • Diagnosis of exclusion; no one test patients honestly! • DLE that can be used to make diagnosis • Don’t become involved in schemes to • Increased prevalence/severity in • Treatment: corticosteroids, tetracycline defraud your patients and black/Hispanic peds abx, antimalarials (Plaquenil), MTX, their insurance • Can be seen without serologic or TNF alpha antagonists • If you become aware of such systemic manifestations of SLE (Inflixumab, Thalidomide) activities in your community take the • Follicular plugging • Morphea appropriate action • Chronic lesions may show hyper/ • Imaging studies can be useful as there • If you do pathology in your office, hypopigmentation with atrophy may be bone defects (especially with collaborate with a pathologist • Most common in head and face linear morphea) • If you offer , make • Management: • Female predominance; TH2 mediated sure it is done by the book • Spontaneous involution with disease which causes fibrosis (TGF- • A good way to stay out of trouble is scarring is common; rarely BCCs beta enhances collagen I, II, and III to have an attorney to consult with or SCCs may occur in scars production) on opportunities/”arrangements”/etc. • Treatment of localized disease with • Linear morphea so you have the “Advice of Counsel” topical steroids or intralesional • Most common subtype in children defense should an FCA case be steroids (don’t go deep) • Involves underlying fascia, muscle, brought against you • Photoprotection and Vit D and tendons • FCA has a statute of limitations supplementation • Primary type to cause disability for 6 years for submission, but the • Generalized DLE requires • + anti-ssDNA abs government can intervene and go back systemic therapy with • Melorheostosis (candle up to 10 years Plaquenil and if not effective wax dripping) add quinacrine • Clinical: muscle weakness, shortens Dermatology Rheumatology: Lupus, • Neonatal lupus erythematosus muscles, immobilizes joint, growth Sarcoidosis, and Morphea • Dermatologic disease (transient retardation in children; may Adam Friedman, MD effects; 50% of patients with NLE) effect trigeminal nerve and cause • Autoantibodies • Cardiac disease (permanent effects, hemifacial atrophy • Positive ANA titer does not equal responsible for mortality in 15%) • En coup de sabre (unilateral on diagnosis; don’t give out • Papulosquamous variant (most forehead; can involve underlying diagnoses lightly common); annular variant; raccoon CNS conditions and cause seizures) • ANA screening tool; good sensitivity eyes appearance but low specificity

Page 28 AOCD Call For Papers We are now accepting manuscripts for publication in the upcoming issue of the JAOCD. J‘Information for Authors’ is available on our website at www.aocd.org/jaocd. Any questions may be addressed to the editor at [email protected]. Member and resident member contributions are welcome. Keep in mind, the key to having a successful journal to represent our College is in the hands of each and every member and resident member of our College. Let’s make it great!

- Karthik Krishnamurthy, D.O., FAOCD, Editor • Treatment: topical tacrolimus, low • Occupational allergen • Group D subdivisions dose UVA1, medium dose UVA1, • Medication exposures: cross reacts • D1 C16 methyl substitution and NB-UVB, MTX, calcipatriol with hydroxyzine; sensitized from halogenation and betamethasone Mycolog cream; only found in creams; • D2 lack prodrug • Pirfenidone gel (new bronchodilators) • D2 metabolites significantly cross antifibrotic therapy) • Epoxy Resin 1% react with group A and group B • Sensitization only occurs in uncured • Sodium Metabisulfite 1% Allergic Contact Dermatitis: North American epoxy resin • Antioxidant in pharmaceutical creams, Standard Series, Part III • Patients do NOT have to avoid printing, and photography Peter Saitta, DO plastics and rubbers (unless they use • Marker for sulfite allergy • Sesiquiterpene Lactone Mix 0.1% pet these in an industrial way) • Sorbitan sesquioleate 20% • Plants from composite or • Tosylamide/Formaldehyde Resin • Sorbitol based emulsifier; high to asteraceae family • Durability to nail polish and lacquer super potent topical steroids; baby • Patients allergic to sesiquiterpene may (not particular to any color) products (Desitin)—recurrent diaper react to plants or pollen • Clinique and Almay nail polishes do rash that won’t go away • May produce contact dermatitis not have these resins • Must avoid ALL types of sorbitol (type 4); can have recurring contact • Ethyl Acrylate 0.1% pet • Latex Allergy dermatitis from fall to frost • Glues; cross reactions among acrylates • Type 4 reaction • Compositae family are common • Type 1 reactions: contact urticaria • Arnica can also cross react with the • Ethyleneglycol Dimethacrylate 2% • Coaimdopropyl Betaine 1% ragweed group • Propylene glycol 5% • Surfactant; irritant reactions • Chamomilla romana 1% • Enhances absorption (water channels • Amidoamine 0.1% • Yellow dye extracted from dried in epidermis connect and form • Used in synthesis of flower heads of the compositae family, channels in epidermal layer) cocaimidopropyl betaine shampoos, vegetable hair dye, mirror • Humectant (takes water from dermal • Contaminant manufacturing, drinking chamomile BV and moves it to the epidermis) • Benzophenone can flare original area of dermatitis • Preservative • Oxybenxone in sunscreens; immediate • Alpha-tocopherol 100% • Can cause irritant contact dermatitis urticarial reactions; most common • Oral vitamin E doesn’t cause systemic • Intoxication in a premature infant photoallergen in sunscreen allergic reactions; topical can cause when wounds were being dressed with • Textile dermatitis ACD and contact urticarial propylene glycol • Disperse dyes used to color synthetic • Lavender absolute 2.0% • Found in food: Duncan Hines cake textiles; azo dyes (disperse blue 106/124) • Obtained from steaming lavender mix, Durkee, Jello, Kraft, Pepperidge • Color of the dye has no bearing on plants; needs to be autooxidized in Farms, Pillsbury, Sara Lee color of the garment order to be allergenic • Corticosteroids • Dyes are metabolized by skin bacteria • When you do a patch test with • 3 clinical scenarios: chronic dermatitis, • Cross-sensitivity with para-amino lavender and you get a strong reaction, fails to respond to steroids, rarely compounds (P-toluenediamine; it is likely your patient is likely allergic dermatitis that worsens with steroid disperse orange) to all the components in the mix • Co and cross reactions present • Rare; anterior/posterior axillary folds • Airborn dermatitis seen • Inhaled, oral, and intramuscular (sparing the vault); seldom itchy with aromatherapy steroid exposure: systemic contact • Dimethylol dihydroxyethylene urea 4.5% • Linalool 10% dermatitis, widespread purpura, • Permanent press clothing, low- • Factor of lavender Absolute 2.0% widespread urticarial formaldehyde releaser, 500-750ppm • Tea tree oil 5.0% • Need delayed readings for to induce ACD • Main allergenic component is corticosteroid allergen testing (day • Lanolin alcohol 30% and amerchol L D-liminome 10), vasoconstriction, vasodilation 101 00% • Propolis 10% (impalpable erythema at first reading), • Mixture of esters and polysters from • Derived from tree resin; contains paradoxical edge effect (positive sheep wool cinnamic acid and vanillin test; negative test for anything other • Composition can vary • May cross react with Balsam of Peru than steroids), edge effect (usually • Uncommon to have reactions • Can have honey (non-reactive) considered an irritant reaction on normal skin; high non- • Neomycin sulfate 20% • No animal studies on steroids; only reproducibility rate • Most common allergen for antibiotics clinical and molecular studies • Eucerin products (aquaphor) • Causes follicular contact dermatitis • Group A, B, and D are highly co- • Allergens in cleaning products (can’t transcend the epidermis to reactive (ex. Buesonide) • Methylisothiazolinone; formaldehyde form a normal rash because it is a • Group C does not cross react • Fabric softeners: isothiazolinone large molecule; also seen in metals with other corticosteroid groups • Pine smell: citronella oil like cobalt) (Topicort/Desoximetasone, Cloderm/ • Laundry detergent is a very rare cause • Triclosan 2% Clocortolone) of contact dermatitis • Ethylenediamine dihydrochloride 1%

Page 30 • Aero-allergen triggered atopic dermatitis • Treatment of staph aureus colonization Approach to the aging face • Atopic patch test: allergens that in AD decreases disease severity. Bleach • Knowing your facial anatomy is key! elicit an IgE-mediated reaction; no baths can help or swimming in the • It’s critical to know the function of antihistamines for one week prior to pool three times per week. the muscles you’ll be working with patch testing; remission of • Molluscum contagiosum • All first time patients get numbing, atopic dermatitis • Dome shaped papules with central and then it’s as needed per patient • Aero-allergens exacerbate AD umbilication; very common • “Botoxnatomy” is a great resource • High reproducibility rate • Basic treatment regimen to correlate structure and function • Black dermographism • No treatment necessary usual course • Arterially: the main area of concern • Depends on hardness of the 1-2 years is the superior labial and transverse metal; role of cosmetics; all metals • Topical immiquimod facial arteries near the alar sulcus. As can theoretically produce black • Cantharidin well as in the glabella region. These dermographism; chlorides in sweat • LN2 are worrisome for developing necrosis. • Curettage • Neuromodulators and fillers should be Pediatric Dermatology • Oral cimetidine a normal part of your everyday practice Sourab Choudhury, DO • Candida antigen immunotherapy • Assessment (1st treatment 0.1cc in 1 • Be realistic with your patients and molluscum; 2nd treatment 0.2 cc in don’t set too lofty of goals 2 molluscum; 3rd treatment 0.3cc • Know your patients pain tolerance in 3 molluscum) • Assess the bruising risk, • Immiquimod injection: unpublished hypersensitivity to anesthetics, study found that it was not beneficial medical history (i.e. Bell’s Palsy) in treatment of MC; consider stop • Keep patients at a 75-80-degree using angle, and then sit them up and • Gianotti Crosti Like reaction: forward. Gravity has a significant inflammatory papules even where the effect on the areas of concern. MC exists • Take pictures and point out • Pigmentary disorders asymmetry. The smile is • Tinea versicolor very important! • Hemangioma • Topical selenium sulfide; oral • Products will not last nearly as long • Majority are not present at birth but diflucan for severe cases in smokers appear in first few weeks of life • CARP • Neuromodulator treatment • Some can be associated with • Minocycline treatment • Soften facial creases and lines that respiratory problems; however, most • Associated with obesity and insulin form over time do not require treatment resistance • Each smile, frown, or squint will • Propranolol can be used for treatment • Progressive macular hypomelanosis contribute to wrinkles of severe hemangiomas of infancy • Topical antibacterials could be used • Lines become constantly visible • Important to get cardiac clearance for treatment as P. acnes is thought • You still want to maintain a natural look before starting to be involved • Fillers • Side effects: hypoglycemia, • Hypopigmented MF in differential • Add volume to tissue to push out bronchospasm (don’t use in • Bites wrinkles and folds asthmatic patients) • Bed bugs: “Breakfast, lunch, • Immediate results that last up to 4 • Topical timolol gel can be used prior and dinner” months to more than a year to propranolol for treatment • The best approach is a combination • Atopic dermatitis Cosmetic Dermatology of products • Basic treatment regimen Suzanne Sirota Rozenberg, DO • “Deals” tend to work better than • Daily bath 10-15 minutes incentivizing programs • Mild soap: dove, cetaphil • Don’t make promises. • Topical steroid • Financial costs, less results with • Moisturizer: aquaphor, eucerin cream constraints, and combine treatments • Oral antihistamine: benadryl, atarax • You can do wonders with just • Topical immunomodulator: one syringe! protopic, elidel • Body dysmorphic disorder • Barrier treatment and bleach baths are • Recognize and refer!!! new to therapy • Don’t use a 10-20x mirror – it is • Atopic march not realistic! • Be proactive with patients; find the • The car mirror is also not realistic minimum amount of treatment • No one truly sees you this way necessary to keep them from flaring • Everyone has pores- nothing will make these go away, they can only

Page 31 be minimized; But in these mirrors • Borst-Jadassohn phenomenon: the • 75% of sebaceous carcinomas. <1% they are much more obvious epidermis has clones of cells in clusters of eyelid tumors. • Don’t be afraid to tell a patient no • Malignant spiradenoma • Upper eyelid, elderly, F>M • This is normally a deep dermal nodule • Most common arises from Malignant Adnexal Tumors without epidermal components meibomiam glands Michael Nowak, MD • Seen in young adults, M=F • High rate of metastases • Lesions should be classified so it’s easier • Associated with Brooke- • Easily mistaken for chronic chalazion to remember and to also understand their Spiegler syndrome • Pagetoid spread behavior based on appearance (Follicular, • Surgical excision is recommended due • Atypical cells show foamy sebaceous, apocrine, and eccrine) to recurrence and metastasis risk cytoplasm (lipid) • Most of the adnexal tumors are • Malignant nodular hidradenoma • Oil Red O positive, CEA/EMA + highly malignant • Clear cell morphology (mimics renal • Extraocular type • Benign versus malignant cell Ca) • Head and neck; May have regional • Size, symmetry, circumscription • Older adults, M=F metastases, but don’t have a • Invasion of adjacent structures • ER/PR, recurrence and poor prognosis • Cytological atypia, mitotic metastasis common • Muir Torre Syndrome figures, architecture • Malignant chondroid syringoma • Variant of Lynch Syndrome • Metastases • Wide age range, F>M, extremities • Associated with malignancies (GI • Rapid enlargement can also be a • Glandular and stromal component and GU) feature of malignancy • Very high rate of recurrence • Mutations in DNA mismatch repair • Immunohistochemistry does not and metastasis genes and microsatellite instability define malignancy • Carcinomas with follicular • Carcinomas with apocrine differentiation • Adnexal versus epidermal differentiation • Apocrine carcinoma • Epidermal continuity • Malignant proliferating • Very rare, but has all of the features • Differentiation trichilemmal tumor of metastatic breast cancer • Immunohistochemistry • Sudden scalp nodule, resembles • Axilla most frequently • When you don’t see epidermal SCC, no surface changes clinically • Extramammary Paget’s Disease connections on pathology, you should • Trichilemmel carcinoma (not that • Vulva most common, male genital suspect adnexal tumors rare, better prognosis) area, perianal area, and axilla • Adnexal versus metastatic • Elderly, face/ears, indurated plaque • Sharply demarcated erythematous • Also think about metastatic lesions with surface changes patch, pruritus is common – they are very easily mistaken with • Recurrence and metastasis • Can be primary or secondary one another are uncommon • Cytokeratin 7 positive • Some may be ER/PR, so understand • Periodic Acid-Schiff positive clear cells • Pagetoid Pattern DDx patient history and maybe refer • Associated Pagetoid • Paget’s disease/Extramammary to OBGYN pattern occasionally Paget’s disease • Pitfalls to diagnosis • Unusual in Cowden’s disease • Melanoma/MIS • Poor sampling • Pilomatrix carcinoma • SCC in situ • Lack of differentiation • Elderly, M>F • Sebaceous carcinoma • Benign and malignant components • Cellular basaloid tumor • Pagetoid reticulosis • Unable to recognize the • Asymmetric and infiltrative • Carcinomas with eccrine differentiation benign component • Shadow cells and cystic necrosis • Classic type eccrine Ca • Metastatic lesion (clinical history, • Frequent recurrence and metastases • Extremely rare; Head and neck P63, etc.) • Trichoblastic carcinoma region; High rates of metastases • Malignant cylindroma • Middle age to elderly, M=F • Syringoid eccrine Ca • Occur in elderly patients • Face and scalp > trunk • Head and neck, low metastatic rate, predominately; Slight and extremities perineural invasion and common female predominance • Really resembles BCC recurrence; Deeply infiltrative • Frequent recurrence and metastasis, • Best way to recognize is to notice • “comma and tadpole forms” can present with multiple cylindromas no refraction artifact • Micocystic adnexal Ca • Some of these lesions are classified in • Frequent recurrence and metastases • Middle aged, F>M, upper lip, various lines of differentiation • Clear cell tumors common recurrence but • Follicular, eccrine, and apocrine • Adnexal tumors rare metastasis • Deep invasion, atypia, mitoses • Metastatic carcinomas • Deeply infiltrative • Malignant poroma (porocarcinoma) • Ballo ncell nevus and melanoma • Horn cysts in the upper dermis with • Occurs on the legs and feet, eroded • Clear cell BCC and SCC perineural involvement red nodule • Clear cell DF and AFX • Mucinous eccrine Ca • De novo or malignant transformation • Salivary gland tumors • Elderly, F>M, head and neck with • Eroded, erythematous nodules; Deep • Sebaceous carcinoma eyelid being most common infiltration at the base • Ocular type

Page 32 • Recurrence common, and metastasis 3. Assess for etiology • Definitions is rare 4. Therapeutic ladder • Urticaria (hives): reaction in the • Strands of fibrous tissue, islands of • Cutaneous vasculitis superficial dermis; lesions last atypical cells in a sea of mucin • Key features <24 hours • Mucoepidermoid Ca • Cutaneous signs of vasculitis are a • Urticarial reaction: similar, but • Similar to the salivary gland reflection of the size of the lesions last >24 hours counterpart of the same name vessels involved • Angioedema: reaction in the • Adenoid Cystic Ca • Vasculitis can be limited to the submucosa, deep dermis, and • Metastasis uncommon, perineural small vessels of the skin or it can be subcutaneous tissue involvement, relatively uncommon a sign of life-threatening internal • Acute urticaria: <6 weeks • Adenoid and cribiform patterns, organ involvement • Chronic urticarial: >6 weeks resembles a BCC • The clinical diagnosis of cutaneous • A personal classification of urticarial • Aggressive digital papillary Ca vasculitis requires histopathologic reactions • Hands and feet, fingers and toes confirmation and multiple biopsies • IgE-dependent urticarial • Young adults, M>F may be required and angioedema • High rate of metastasis • Vasculitis has many • Specific antigen identified • Cellular dermal nodule, can be classification problems • Physical urticarias deceptively bland • Example of the ACR criteria • Non-IgE dependent • Any glandular lesion of the digits • Age at disease onset >16 urticarial angioedema should be considered a carcinoma • Medication at disease onset • Direct mast cell effects • Palpable purpura • Arachidonic acid pathway effects Outpatient Consultations in Complex Medical • Biopsy including arteriole and • Angioedema related to complement Dermatology Selected Aspects: 2016 venule with histologic change • Hereditary v. acquired Joseph Jorizzo, MD showing granulocytes in perivascular • Urticarial reactions probably related or extravascular location to immune complexes • Cutaneous small vessel vasculitis • Urticarial vasculitis • Key features • Serum sickness-like reactions • Palpable purpura, urticarial lesions, • Idiopathic hemorrhagic macules or vesicles • My evaluation of patients with • Lesions favor the lower extremities, chronic idiopathic urticaria dependent areas or pressure points • Complete H&P by PCP • Only involves small vessels • Screening laboratory tests and (primarily postcapillary venules) follow up positives by PCP • Evaluation for systemic involvement • Review medications and avoid all • Utilize the primary care internist non-steroidal drugs • Possibilities for a patient who presents or pediatrician • Circle lesions with a complex medical dermatosis and • Where are immune reactants most • Biopsy if circles lesion lasts more systemic signs and symptoms: likely to deposit? than 24 hours (not urticarial • Clinicopathologic diagnosis of • Kidneys, pleura/pericardium, GI by definition therefore, exclude dermatosis integrates all findings tract, CNS or PNS, joint synovia, urticarial vasculitis) • Eg. sarcoidosis – skin, eye, retina, adrenal glands • Consider (3) day rice and water lungs, etc. • Therapeutic ladder: non-ulcerative elimination diet • Clinicopathologic diagnosis reveals a cutaneous lesions • Review prognosis and limited reactive dermatoiss – communication • No therapy chance for total cure with internist or pediatrician will • Topical therapies (access to site • Consider activated charcoal therapy outline underlying medical conditions of pathology) • Avoid (and/or taper to zero if • Eg. vasculitis • Gradients support hose already receiving) • No direct relationship • Antibiotics systemic corticosteroids • Eg. scabies/fibromyalgia • Pentoxifylline • Recognize impact of disease on • A patient wishes to know from the • Colchicine quality of life internet whether they need x or y • Dapsone/sulfapyridine • Review that antihistamine will therapy for their presumptive diagnosis • Combination colchicine/dapsone only flatten lesions and reduce • Instead it is important to not let the • Urticaria pruritus not “eliminate the red” as patient “drive” for their own benefit • Key features corticosteroids do • Steps to follow • An inflammatory dermatosis • Combine several antihistamines 1. Clinicopathologic diagnosis: Caution resulting from vasodilatation, from different classes with different influence of therapy on biopsy and increased vascular permeability, and sedating potential and H1 and H2 clinical appearance extravasation of protein and fluids blocking effects taking half-life 2. Assess the extent (internal • Individual lesions, by definition, last into effect manifestations of disease) less than 24 hours

Page 33 OCC Processes for Time Dated Certificates

It’s the new CME cycle so it’s time to register for OCC again with For those that are new to this system, this is the new testing system the American Osteopathic Board of Dermatology. and the system where you can keep track of your OCC registrations. For those that are newly board certified, you need to make sure that OCC registration is now due for the CME cycle 2016-2018. All you registered for OCC as well. Some of you did it by December 31. time-dated certificate holders must register for OCC every CME cycle no matter when your recertification date is.

If you have already used Canvas in the (www.aobd.instructure.com) past few years you will already have a login. Please use your login to register for OCC. If you have not used Canvas for testing in the past 2 years you will need to register for a login. To do so please go to www.aobd.org and register for the login. On the home page please see below as shown on that page and click on the blue link to register for application process for OCC.

Payment may be made by two ways. 1. Mailing in a check to AOBD, PO Box 493, Kirksville, MO 63501 2. Paying by credit card by going to the aobd.org web page and going to the OCC page (http://aobd.org/aobd/occ/) on the site. At the bottom of the page there is a link under the registration fees that says pay by OCC fee by credit card. If you click on that link you can enter the credit card To complete the OCC registration process you will need to go information. to the aobd.instructure.com web page and login. Your login will be your email address and your AOA number is your password (unless you have logged in before and changed it). You will received the login after you have completed the above step within seven days.

Once you login go to the course OCC and then click on the assignments page. As you can see there are three assignments for If you have any questions at all regarding this process please email 2016-2018. Two of the three are forms to download, print, sign, Renee at [email protected] or Beth at [email protected]. scan in and upload back into the assignment page. The payment The AOCD cannot answer questions about OCC. OCC is a part of page is for me to indicate once I have received the payment. certification and all question should be addressed to the AOBD. HELP WANTED Seeking Experienced Dermatologist To Join Florida Practice • Initiate and maintain all necessary documentation in the medical record • We currently have immediate full-time employment opportunities for an Other measures may be initiated depending on the patient’s condition experienced dermatologist to work in our Riverview and Tampa offices. and judgments of the dermatologist • Office hours are Monday – Friday 9 a.m. – 5 p.m. This position offers a Performing biopsies and cryo-therapy • competitive compensation package including bonus, benefits that include Uncomplicated dermatological procedures • Health insurance, PTO, a 401K, Malpractice Insurance compensation and Other procedures which the dermatologist has been trained and/or a setting that is conducive to further professional growth. Academic ap- educated to perform • pointments and research available. Prescribe medications Candidates must have FL License, MD or DO License, DEA License and1 The job description of the position is as follows: or more years of experience working in a dermatology practice For more • Initial and subsequent dermatology medical history, physical exam, information and to apply, contact Kathy Jimenez at diagnosis and treatment, and planning [email protected] or (813) 880-7546.