The Osteopathic Dermatologist: Dr. Peter Ilowite Shares His Craft

Peter Ilowite, DO, Assistant Professor of Dermatology at Mt. Sinai Hospital and Dermatology Residency and an Assistant Professor of Medicine at Touro College of Osteopathic Medicine, both of New York City, spoke at the Atlantic Regional Osteopathic Convention (AROC) at Bally’s in Atlantic City on April 15 of his 20-year perspective as an Osteopathic dermatologist.

Dr. Ilowite opened his lecture with a history of Osteopathic medicine and the contributions made by its founder, Dr. Andrew Taylor Still, modernizing and improving 19th Century medicine. Dr. Still believed that encouraging homeostasis of the human body aided in treatment and cure of disease; that a functioning circulation was essential, as he said, “the rule of the artery is supreme;” and that the physician had to “fix the patient, not just the disease,” a contemporary controversy, yet remains the essence of any good doctor’s treatment of dermatological disease.

Dr. Ilowite spoke of his seven years of teaching in the Mount Sinai dermatology residency program as very influential in his role as a practitioner; it also inspired in him to take notice of his differences as an Osteopathic dermatologist. For instance, he spoke of teaching residents about the acid mantle of the skin—the combination of sebum, the waxy substance produced from the sebaceous gland that holds in moisture, made of fatty and free fatty acids, mixed with the stratum corneum, giving all of us a “healthy shine.” The acid mantle provides protection against exogenous invasion, trauma, and infection.

An Osteopathic dermatologist recognizes that any trauma or pathology to the skin would alter the acid mantle in that area, thus increasing the skin’s pH. Recognizing this, the Osteopathic dermatologist would use acetic soaks (a teaspoon of acetic acid in two cups cool water) directly on the pathological skin, providing succor, homeostasis, and a happy skin patient.

Dr. Ilowite presented a slide show of skin diseases that highlighted “history” and “distribution” as two important factors for the clinician to aid in an accurate dermatological diagnosis.

When examining a nevus, there are the hallmarks for dysplasia—A, B, C, D, and E. The addition of dermoscopy greatly aided the dermatologist evaluating a melanocytic nevus.

History (how long, growth change, recent or slow, family member’s perspective) can and often is the final factor whether to biopsy or not.

He also emphasized that recognizing distribution of a rash can be essential. Slides of skin diseases were shown to the audience but without the diagnosis. “Look at the distribution” and make the diagnosis:

a) Burning sensation that is unilateral with vesicles.

b) An annular macular papular rash of the trunk with mild pruritus and the largest lesion occurring around one week earlier than all the others.

c) A generalized macular papular rash also involving the palms and soles.

d) A chronic scaling dermatitis involving the scalp, elbows and knees.

e) Intense pruritus with excoriations of the trunk and buttocks also involving the scalp.

Dr. Ilowite, a lifelong musician, stated that his artistic side has always helped him home in on being a better physician. He warned the audience that this statement may not be evidence-based medicine, but he referred to a hit song from the rock opera Tommy, by the 1960s rock band, The Who, with the lyrics, “See me, feel me, touch me, heal me,” as an excellent mnemonic for the Osteopathic and all dermatologists. He further explained each sense.

See me: Refers to exposure, which is essential. If a dermatology resident is not taught to use a strong lamp during the dermatology examination, “how can this resident determine whether the rash is vesicular, burrows, plugs, scaling, crusting, atrophied, etc.?” Morphology is essential for any dermatologist in making a diagnosis. You have to have exposure.

Feel me: The Osteopathic physician has been well trained in using his or her palpating skills. Dr. Ilowite showed the audience his “Thumb Test” which he uses on patients when searching for actinic keratoses, which he stated, “feel like rocks stuck in the sand.” He uses the side of his thumb to swipe (or palpate) common areas, such as the nose, ear rims, scalp if little hair is present, cheeks, and posterior hands up to the elbows. He stated it takes only about 30 seconds to do. He also recommended using the thumb for instant diascopy. On dark-skinned patients, does the pigmented area blanch? Is the rash warm to touch?

Touch me: Dr. Ilowite showed his favorite dermatological instrument to the audience—the simple wooden cotton-tipped applicator stick. He stated he probes everything with it.

“Probe the rash…does it scale, crust, or bleed? Is it a tumor or nodule? Does it fall off without or with bleeding? Is it a tumor stuck deep into the skin?” Dr. Ilowite also uses the stick for examining the scalp. The stick, he said, helps push hair away so the scalp skin can be observed. He uses it for testing dermatographism as well.

Heal me: Dr. Ilowite said that would be best taken up by President Obama.

Dr. Ilowite ended his lecture emphasizing that the Osteo-pathic dermatologist uses more than just the visual sense. He showed his audience how he will use all his senses for diagnosis.

Audio: When medical students assist Dr. Ilowite with electrodessication and curettage of a basal cell carcinoma, he teaches them to listen to the skin as it’s being curetted. A mushy, broken, soft sound means more epithelioma must be removed, while a sandpaper, scratchy, tougher sound means healthy skin and the procedure should be close to being done.

He finished his lecture expressing his concern that Osteopathic dermatology is losing its uniqueness. Osteopathic dermatology residents primarily go into cosmetic dermatology. Recent anti-doctor “gross government intrusion” has been part of the reason. More important is whether the American College of Osteopathic Dermatology will still encourage the DO teachings in their dermatology residencies or will the Osteopathic side be diluted out as the ACGME and the AOA combine, which is in their five-year plan. Losing these traditions could be a loss to all medical specialties and dermatology, too. n