PracticalDermatology

Everyone has a favorite tool or technique. Something that once discovered, you would not want to practice medicine without. In the digital age, not only do we have physical tools but also websites and apps. Below are five dermatology tools that will enhance your practice and increase patient satisfaction.

1. Cryo Tweezers

The ability to precisely direct cryotherapy is extremely useful. The cryogun with its various tips is great for actinic keratoses (AKs), which can be poorly defined lesions. It is not ideal for skin tags, filiform warts, and molluscum. Most acrochordons are in sensitive areas like the face, eyelids, axilla, and groin. Cryo Tweezers (Brymill) are an inexpensive and extremely effective tool for the removal of acrochordons. For children who can tolerate a small amount of pain, they are fantastic for treating molluscum contagiosum and look much less threatening than a cryogun. Smaller Cryo Tweezers are more appropriate for molluscum, as the skin may have to be pinched to elevate the lesion so the Cryo Tweezers can grasp it. I have found that Cryo Tweezers are more successful at destroying the molluscum lesions with much less collateral damage than cantharidin.

I have cured warts on the eyelids of children who wouldn’t let me get near them with a cryogun or a needle.

Consider a neck with dozens of small skin tags—quite common and difficult to treat. With or without numbing cream a hyfrecator is too painful for most people to tolerate for long. Snipping small skin tags off is favored by some but can be painful, is bloody, and often leaves behind some of the skin tag, which can grow back over time. I had one patient who was dreading getting her small skin tags on her neck cauterized and literally had tears of joy after the treatment with Cryo Tweezers was done because the pain was so much less than she was expecting.

Where they really shine is for the treatment of numerous small to medium acrochordons. Keep in mind that the acrochordon will swell afterwards, and then slowly shrivel and fall off. During that time there will be some pain. This is why I do not recommend freezing larger acrochords, especially in the axilla. With the friction and the constant movement in the axilla and also the upper inner thighs, the healing process can be painful.

This treatment is very popular with patients.

2. RxPhoto

Years ago I had a typical acne follow up. I walked into the room and asked the mom and her son, “How did the last few months go? Is your acne getting better?” This is a pretty standard question. The mom responded by saying, “You’re the expert, you tell me!” It was then I realized that I am depending on patients and their perception of their condition to guide my treatment decisions on follow up. This is hardly scientific. This shook me up. The patient’s mother was right. Even if I did have a photographic memory and really could tell subtle differences of improvement on follow up, having the patient see it with his/her own eyes would definitely change the conversation. Knowing whether the patient is getting better or worse is central to the practice of medicine. If the results are not dramatic and obvious and we don’t have high quality comparable pictures, we have to admit that our judgment on their improvement may be more subjective than objective.

Recognizing the folly of depending on patients’ perceptions as a measure of actual results, I started taking photographs. I soon realized that taking two pictures, on different days, maybe in different rooms with the patient in different positions, with different medical assistants, created pictures that were of little comparative value. Not to mention the time accessing those pictures and the inability to compare them on the same screen. Plastic surgeons solve this problem by having a dedicated photography room, controlled lighting, background, position, and camera angle. Their medical assistants are also trained to assist in taking the photos. This is not an option for most dermatology practices.

RXPhoto is an app that allows for the capture of consistent photos to be uploaded to a HIPAA-secure cloud server (Yes. Taking pictures of patients on your phone is a potential HIPAA violation and doesn’t look professional). While the features are too numerous to list, and the app is challenging to describe without seeing it in action, here are some features that allow the app to assist you in taking consistent comparable photos:

a. You select the body part to photograph, with most body parts having a template so every person taking the photograph takes a similar picture. A two plane leveling tool ensures that your picture is level on both axes.

b. RxPhoto solves the problem of ensuring consistency across visits by having a ghost image (adjustable translucent image) of the first picture appear on the screen so you can match the ghost picture with the patient in front of you for consistent pictures. After the photos are taken you can compare them side by side with the ability to zoom in on either picture. One of the most useful features is the comparison of two photos with the slider feature to quickly transition between before and after images. Patients love this feature, which is a tremendous aide for clinical decision making.

c. I recently had a patient with a rare candida nail infection that I knew would take four to six months to resolve. I took pictures with RxPhoto every month. Around month four the patient was upset and didn’t think he was getting better. I considered changing the treatment but after comparing the photos on the RxPhoto App side by side and with the slider it was clear that much progress had been made. (See image) An upset patient was instantly happy and a treatment plan that was working was continued instead of being changed. When I have a patient with a similar condition in the future, I can search previous cases by the notes or tags that can be attached to them. Anonymity tools allow you to protect the patient’s identity. Besides the clinical benefits and higher patient satisfaction, over the long term you can compile what few if any of your competitors have. Hundreds of high quality before and after pictures—proof of the quality of your work and a gold mine for your website or social media.

3. Intralesional Kenalog Injections

Conditions like psoriasis, severe seborrheic dermatitis, and Lichen Simplex Chronicus are highly inflamed and need high concentrations of steroids to resolve or be controlled. Even with class 1 steroids under occlusion (which on the scalp is impossible) these conditions will often not fully resolve. Plus, topical medications are known to have diminishing compliance over the long term. My most frequent application of intralesional Kenalog is for psoriasis on the elbows and knees, which rarely fully resolves with topicals. With two rounds of Kenalog 5 provided one month apart followed by three month follow ups, patients are able to achieve complete to near complete clearance with little use of topical medications. I have had several patients with persistent psoriasis on the posterior hands who had failed topicals and I was considering putting on systemic treatment. Injections work just as well in these cases as they do on the elbows and knees (the patient must have a higher pain tolerance for injections on the hands), LSC anywhere, and severe Seborrheic Dermatitis on the scalp respond equally as well. Patients want these conditions treated quickly, with complete clearance, not with partial results and endless use of topicals. The intralesional kenalog injection is one of my most popular procedures and leaves the patient asking why the last dermatology provider didn’t do this!

4. VisualDx

Textbooks are great. They provide detailed information, and if you have enough of them on a bookshelf people think you are really smart. However a textbook will not provide you with a differential diagnosis list with limited data. A textbook will also not give you access to dozens of pictures and the ability to email patient-friendly versions of diagnosis summaries directly to your patients.

The benefits of using VisualDx is two-fold. One, it allows you to quickly search concise summaries of a comprehensive library of dermatologic conditions. Second, you can enter the lesion type, symptoms, and other clinical factors and search the relevant diagnosis. Your results are displayed by: Consider first, consider second, emergencies, and drug induced. ICD 10 codes are included as well. Most practices have EMR, which means having a monitor or tablet in the room. Using VisualDx to show patients pictures of others with their skin conditions and point out key sections in the text greatly enhances patient education and increases patients confidence in your diagnosis. Instead of telling them what the diagnosis is you are showing them what the diagnosis is. To top it all off there is an option to email a diagnosis summary (and in many cases a patient friendly version) that you just reviewed with your patient. Say goodbye to your pamphlet rack if you still have one.

5. The Needleless Injector

The irony of numbing medication is that it burns so much. In many cases, the burning caused by the acidity of the anesthetic can be worse than the pain caused by the needlestick. With a traditional injection, the numbing effect kicks in after you feel the stinging due to the relatively slow diffusion into the tissues. A needleless injector (Jet Injector) shoots a thin stream of anesthetic into the tissue at 1000ppsi in a diameter the fraction of the diameter of a 30-gauge needle. The anesthetic diffuses so quickly that there is no burning, and the pinprick sensation of a needle is replaced by something more like a mosquito bite.

Needle-free drug delivery using a high-speed stream of fluid to impact the skin and deliver a drug has been used for 75 years and continues to be improved upon. It is widely used for vaccinations, especially in the military, as well as by podiatrists and urologists for the “needleless vascectomy.”

I believe the reason needleless injection use isn’t more widespread is due to concern about the spread of blood borne contaminants, since it is not disposable.

The jet injector most commonly used in the US, the Madajet, is fully autoclavable with third-party studies to prove its sterility. It also has two one-way valves and other safety features.

I believe the real reason it has not caught on is that the relatively low cost (less than $1,000), no-consumable product has never been heavily marketed. In a 1995 study, 2006 minor dermatologic procedures were performed (cyst and lipoma excisions, shave removals, biopsies, and papiloma removals) using the Madajet for anesthesia. The vast majority (95 percent) of patients reported total absence of pain, and a good level of anesthesia was achieved in all patients. My experience with the Madajet was similar to that reported in this study. Nearly every patient prefers it to a conventional injection. This device produces much less pain in the digits and makes intralesional steroid injections into the nail fold for psoriasis easy for patients to tolerate. If you use it to do biopsy, it is advisable to let the pathologist know about the possibility of a “madajet artifact” as the high pressure injections can disrupt the tissue. This device delivers anesthesia in 0.1cc increments, which provides a precise level of control. The device holds 4cc of liquid and deposits fluids 5mm below the surface in a 1cm diameter wheel. Due to the force of the injections, ecchymosis is common, so it would not be ideal for injections on the face, for example.

The cone shaped distribution may put your injected steroid outside of where you want it, for example an injection to an acne cyst. Periungual injections are tolerable in both children (warts) and adults (nail psoriasis, lichen planus of the nail). It is also useful for widespread kenalog injections for psoriasis, LSC and Alopecia Areata. Patients hate needles, pediatric patients hate them even more. This is a very useful tool.

6. Teledermatology

Teledermatology, once a slowly growing subspecialty, has been thrust upon us seemingly overnight. As practices around the country have fully or partially shut down, we have all been practitioners of teledermatology overnight. We are learning both how useful and how time consuming it can be, depending on how we are practicing it.

You need the right tool for the job. This means telemedicine software. As with all medical software, you will always be more efficient with a dermatology specific program. This has been true of my experience with SkinCheck Online, a fully HIPPA-compliant telemedicine platform that specializes in dermatology and is the only platform that will soon have another specialization they call teleaesthetics for cosmetic patients. The dermatology version I have experience with is based around store and forward functionality. Video conferencing may be desirable for certain situations and necessary for some insurance reimbursements, however you must have good pictures to diagnose a patient. Often the low resolution of video is insufficient for diagnostic purposes.

The system is user friendly for both patient and provider The patient logs in and inputs their basic demographics, insurance information, pharmacy information, and dermatology-focused chief complaint and HPI. They are visually instructed on how to take three different pictures.

The provider gets a notification that they have a case pending. Upon opening the case, all the patient’s information, including their pictures, is on one convenient screen. There are settings for patients who need prescriptions, as well as a list of hundreds of OTC products that can be recommended. E-prescribing is done from this same main screen via the DoseSpot pop-up windows.

When these steps are completed, the provider advances to a preformatted letter to the patient that includes the diagnosis, and a link to patient education information. Of course this letter is fully customizable.