PracticalDermatology

One of the traps in any profession is that we assume people understand what we are talking about. The more knowledge our profession requires, the deeper we get into our own sub-language and the harder it is to talk to patients in a way that they will understand and remember. This is why analogies and familiar ideas are key to effective patient education. Here are my most effective patient education techniques, those which will prompt understanding in our patients as well as improve results.

Actinic Keratosis: Whack-a-Mole

I use this familiar concept with my patients who have actinic keratosis (AK) when we reach the point at which freezing is not enough and we need to discuss field therapies. The term “whack-a-mole” is familiar to almost everyone. This beloved and enduring carnival/arcade game image is used to depict a situation characterized by a series of repetitious and futile tasks, in which the “moles” are coming up faster than you can kill them. It always gets a chuckle out of patients.

Patients with AK identify with this analogy right away. Most patients are bothered by the progression of AKs, may pick them, tire of the constant freezing (and potential scarring), and may wonder at some point where this treatment is going. This analogy is the perfect way to enter into a discussion of field therapy, which most patients are very receptive to at this point. Even if they ultimately want to just continue freezing, you can at least get them to come in more frequently, and they will appreciate that you are taking the initiative in their AK treatment.

I typically explain that AKs are growing underneath the skin for months before you can see or feel them. I further explain that field therapies kill off many of these AKs in this “seed state,” decreasing the need for freezing, biopsies, and skin cancer surgeries in the future. This last part is crucial. You should tell patients the exact benefit that they are gaining from the field therapy. This also lets patients know that you are practicing preventive medicine and do not want to see them go through endless procedures. This field therapy message is especially well received after surgery.

Think of It as a Scrape, Not a Rash

Over the years, I have found all types of occlusion therapy from wet wraps to silicone-lined gloves to plastic wrap, to be safe and indispensable in treating patients with severe or chronic rashes. Patients typically understand rashes as something you put a cream on and scrapes or other wounds as something you put ointment on and cover.

I tell the patient, “Think of your rash more like a scrape. If you had a scrape, what would you do? Put ointment on and cover it, right? This rash has a lot in common with a scrape. The skin is compromised and is drying out. This prevents the rash from healing and causes pain, itching, and stinging. I am giving you an anti-inflammatory ointment. Without a covering it will do what it is designed to do, spread on the skin. We don’t want it to do that. We want the ointment to stay in place so it doesn’t lose its potency and will seal off the skin. You will get better much faster if you do this (if you are asking patients to do extra work you always have to tell them the benefits), even if it is only for a few hours a day.” I then discuss whatever form of occlusion therapy is needed.

Seborrheic Dermatitis and the Normal Flora

Seborrheic dermatitis responds rapidly to topical steroids, and the improvements can be well maintained with the combination of antifungal agents and corticosteroids. Patients have to understand two things. When used properly, seborrheic dermatitis treatment is highly effective. The patients must understand how these two agents work together to control seborrheic dermatitis so they can understand treatment and maintenance.

All patients are familiar with the concept of a normal flora, so this is where I start. I tell them, “You have seborrheic dermatitis or dandruff, which we have very effective treatment for (this gets their attention), but to understand how to use these treatments you have to understand what causes dandruff. Like your gut, your skin has a normal flora. Part of the normal flora in the oily areas of the face and scalp is yeast. You don’t have an infection or overgrowth of yeast, but your body has an overreaction to this yeast. Although the scalp may feel dry, seborrheic dermatitis is not caused by dry skin, as these areas are among the oiliest of the body. It is caused by inflammation, by your body attacking the yeast too vigorously. We can’t make your body stop doing this. It will do it on and off and at some point, stop on its own, but we can control it very well. We do that using anti-yeast medication. This is not strong enough to stop a flare but can help to control it and slow it from coming back. Topical steroids can stop a flare and are used when your dandruff is bad. So you use both when it is flaring and just the antifungal when it is controlled.” This may be more time than you are used to talking about dandruff, but it definitely pays off.

Acne: Plan A and Plan B

Acne creates a heavy psychosocial burden for patients. The main question they want answered is “Will I get better?” The more severe disease the patients have, the more desperate they become. We have a very clear treatment protocol: first-line treatments (everything but isotretinoin) and isotretinoin. In my 2015 interview article, published in Practical Dermatology in 2015, “Isotretinoin Insights: Patient Counseling,” Joseph Bikowsky, MD, one of the nation’s top acne experts, said, “I tell them that I have treated about four to five thousand patients with this medication over the last 30 years, and I have never seen a patient who did not respond to it and who did not clear on the drug.”

When a patient is a candidate for isotretinoin after failing first-line treatments, I feel comfortable telling my patients, “The good news with acne treatment is that we have excellent medications, so you will definitely get better. Our plan A is a combination of topical medications and low-dose antibiotics. Many people respond well to these medications, and it takes about 2 to 3 months to see if you are a responder. If you aren’t a responder, the plan B medication completely clears acne in nearly every patient who takes it. So if plan A doesn’t work, plan B will. Any questions?” When I started using this technique, I was surprised that most patients did not have any questions. This is because the message is easy to understand, and everyone understands plan A and plan B. In addition, this approach answers the main question that patients have: “Am I going to get better?”

Warts: The Turtle

Warts are difficult to treat because they have excellent defenses. One of them is the compact corneum. I tell patients that what they are seeing when they look at the wart is all the dead skin above the wart. The wart is underneath. It has a shell similar to a turtle. We have to get through that shell and totally destroy the wart underneath or it will grow back. When patients understand more about the wart they will understand the rationale for home or in-office debridement.

Analogies help us bridge the gap between our detailed and scientific understanding and the patient’s level of understanding. You also must give the patient a reason to listen to you, emphasizing the benefits they get from the treatment. This is best done early in the conversion to get their attention. When the patient understands the benefit they expect to receive, and a strong understanding is formed with a great analogy, your patient is more likely to be compliant and have great results. If you can make it a little entertaining and make them laugh in the process, the message will be even more effective.