From a resource to help identify “forever chemicals” in cosmetics and skin care products to objective measures to use in the chart note, there are a number of tools, tips, and tricks that dermatology care professionals can use on a daily basis. Speaking at DERM2023, dermatologists David E. Cohen, MD, MPH, Ted Rosen, MD, and Michelle Hure, MD share some of their best practical tips. Plus, Linda Stein Gold, MD, offers an update on topical eczema treatments in the pipeline and Brad Glick, DO talks about the cutaneous signs of systemic disease.
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From a resource to help identify “forever chemicals” in cosmetics and skin care products to objective measures to use in the chart note, there are a number of tools, tips, and tricks that dermatology care professionals can use on a daily basis. Speaking at DERM2023, dermatologists David E. Cohen, MD, MPH, Ted Rosen, MD, and Michelle Hure, MD share some of their best practical tips. Plus, Linda Stein Gold, MD, offers an update on topical eczema treatments in the pipeline and Brad Glick, DO talks about the cutaneous signs of systemic disease.
Like what you're hearing? Have a topic you want to hear more about? Hit us up and spread the word on Instagram!
The Dermalorian Podcast is an independent program made possible with support from UCB. Among the many highlights of Derm 2023 in Las Vegas this summer was the sharing of tips and tricks that can make the clinic day and patient experience more productive.
From better use of documentation to online resources, faculty share a variety of practical recommendations. For example, perennial attendee favorite dermatologist Dr.
Ted Rosen discussed how to make better decisions. We'll hear from him in a moment, but first dermatologist Dr. David Cohen shares strategies for making more of the chart note.
Chart notes are an interesting part of our lives, right? There are things that can slow us down quite a bit, but they are invaluable parts of the tools we use to take care of patients.
Imagine going into a busy clinic and having no chart note available for anyone, how difficult and how you struggle to get through that visit.
So I think you have to look at the chart note in a modern way. Many of us use electronic medical records and that chart note is completely available to the patient, so they may read through that and want to know how you're taking their history,
their physical exam, and trying to treat them. But I think fundamentally the chart note is for the medical professionals treating that patient.
It's for us to remember what that patient said to us at that initial visit, what did they try, what did they fail, what is the natural history of their disease state, what were our findings and what were our plans,
what were our aspirations for our treatments for that patient. So when we see them a week later, six months later or a year later, we can refresh that and update it.
So I think fundamentally there are many stakeholders for chart notes. They are principally the healthcare providers. They are the patients, but they have administrative roles as well.
There are going to be people in insurance companies that are going to read through your note that want to know what you're thinking and why you're picking the therapy, but there are medical legal issues. You may have something that goes wrong or the perception that goes wrong.
People are going to be reviewing that note to see what were you thinking and how did you come to your conclusions. And they can be very valuable for your treatment of that patient.
I think we all strive to have an ideal chart note, right? Now it's always aspirational. We never quite get there. But the ideal chart note should have,
particularly as we're thinking about inflammatory diseases, is what's the history of the present illness? When did it start? Tell me about the signs and symptoms.
And apropos to that, can we be objective when we're assessing symptoms? One thing I would say for inflammatory diseases, right in the beginning of that note, what is the numerical rating score for itch?
It's an objective, verified way of tagging how a patient is doing. So the NRS itch is zero is no itch. 10 is the worst imaginable itch.
And that patient can tell you what their itch is right sitting there with you and can give you the 24 -hour worst NRS. So I think that's very important. It gives you a sense of how much a patient may be suffering with an itchy inflammatory disease,
right? If they tell you it's eight or nine out of 10, they are screaming for help for you. They come back two and three months later and the numerical rating score for itch is a one or a two. We know we've got success before we've even examined the patient.
So it's objective and it lets anyone reading that note know how that patient is feeling. The other part of the medical history that's critical for so many reasons is what are the things that you've tried and you failed?
What topical medicines have you tried and failed? Are you using moisturizers? What systemic therapies have you tried and failed? So when you're building your case for the next therapy, it is based on the facts of prior use.
Now, we go into the physical exam and of course, let's not forget past medical history, current medications and drug allergies. Those are part of every great chart note because we don't want to give a patient something they're allergic to.
We don't want to give a drug that has an interaction. How do you know they have an interaction? Make sure the current med list is accurate and doesn't have things they were taking three years ago that they were off of. When we go to the physical exam,
there's of course a subjective component. Erythematous, scaling and lichenified plaques for the atopic patient or erythematous, scaly and indurated plaques for the psoriasis patient.
Another important component is the body surface area. That's objective. Use the rule of nines. One arm is 9%, one leg is 18%,
the front of the trunk is 18%, the back is 18%, the head is about nine, the groin is about one. Very objective data. And then we can use other metrics like easy score components,
PASI score components. How red is this patient on average? Zero, no redness. Four, very blood red. Scale and crusting. Zero is none.
Four is lots of crusting or scaling. And lichenified or induration, likewise zero is none. Four is the maximum there. These are objective ways of putting verbiage into the note,
but any person reading that note will know exactly how severe it is. So if that person has 30 % body surface area with a three out of four redness, for example, they follow up after putting them on a great systemic agent.
They're coming in with 5 % body surface area and a redness score of zero or one. It's objective and it tells the story. And in your assessment and plan, you can put severe AD,
severe psoriasis, well -controlled on X. How do you make good decisions? There are really two aspects to that. Number one is,
don't make bad decisions. So, how do you make bad decisions? Well, bad decisions are things like knee -jerk reaction, no thought.
I'm just going to make the decision on the spot. Another way to make a bad decision is to hop on the bandwagon. I'll listen to what other people decide and that's what I'm going to do too.
But you didn't give it any thought at all. Another couple of ways to make bad decisions are making a decision based upon fear.
Fear is the enemy of good decisions. Fear makes you think about what if, think about past failures, immobilizes,
almost paralyzes someone from making a good decision. And the last way to make a really bad decision is make a serious decision when you're angry. You can't think straight.
And so, those are ways to make bad decisions if you avoid those, you're likely to make a better decision. Now, how do you make really good decisions?
First of all, you have to think about how important is this decision and a lot sufficient amount of time to think about it carefully.
I actually like to write down the pros and the cons, the good and the bad of each choice so that I can consider them right in front of me.
Sometimes it's good to consult neutral people who aren't involved, who may have a more unbiased opinion for their suggestions.
And then always when you're making decisions, especially those that are important, think about two things. What's the long -term impact of your decision?
Not just what it's going to do today, tomorrow, next week, but how is this going to affect your life or your work, your personal life? life, a month from now, two months from now,
six months from now, years from now, and always consider the other people. When you make a decision, it often affects other individuals.
Could be co -workers, could be the company or the office that you work for, could be your family, your spouse, significant other, children,
and you always have to take into account what your decision will mean for them. And if you do those things and avoid the bad decisions, you're likely to make a good decision.
Making decisions is a skill, and yes, some of that's inherent, some people are just good decision makers, but for a lot of us,
it takes time and you learn. You learn from your mistakes. If you can't make a mistake, you can't make a decision,
you have to be willing to occasionally be wrong and own up to your wrong decisions and rectify them, fix them. I also think it's important to watch how other people make decisions,
especially decisions that are similar to the types you may have to make. Learn from their successes and their failures and adopt their success ways into your own decision making processes and avoid the things they did which weren't very helpful.
So in that way, you can actually learn to be a better decision maker. Here's an easy decision. Stay tuned for more tips and tricks from Durham 2023 faculty after this break for our Dermalorian clinical clip.
Dermatologist Dr. Linda Stein Gold provides a peek into the topical treatment pipeline for eczema. Well, we actually have an exciting horizon for atopic dermatitis as well.
Our two friends for our topical nonsteroidal options for psoriasis are also finished with phase three clinical trials for atopic dermatitis. So tapinarof; really nice efficacy using this once a day for eight weeks,
we saw really good efficacy, almost 50 % using it in patients with moderate to severe atopic dermatitis, well tolerated, good safety profile,
doesn't sting and burn. And then we have roflumilast, which is the topical phosphodiesterase type four inhibitor. Also studied now in mild to moderate patients over the course of four weeks.
And what we found was about a third of patients got to clear almost clear, again, a very nice safety profile. And for all of these nonsteroidal options, the important thing is they don't sting and burn.
So it's very easy to prescribe. Up next, dermatologist Dr. Michelle Hure shares a resource to help patients identify and avoid per and polyfluoroalkyl substances alcohol substances,
so -called forever chemicals in their skincare and cosmetic products. I really want to talk about the issues that you see in consumer goods. So what we're buying,
using on a daily basis, this is really important for us in the exam room, right? This is the what do we care? Well, what we care,
this is important. This is going to affect how we treat patients and how we manage them. So there's not a lot of papers talking about the role of PFAS in dermatology.
And that is because there's not a lot of data as of yet. But looking at the data out there, then I really feel that we should be looking at their role in atopic dermatitis and endocrine disruption because we do have papers talking about the risk of diabetes,
thyroid disorder, sex hormone disorder, whether it's men are key issues, menopause issues, and then we have issues out there. we know about with skin cancer,
there can be a link. And then another one is decreased vaccine efficacy, which is actually very interesting to me. Dr. Hure described a study from 2021 that looked at the presence of forever chemicals in cosmetics.
So they looked at about 230 different cosmetics out in wherever, Sephora, Target, whatever. And they looked at a proxy and they checked the fluorine levels,
which can tell us a little bit as to how much of the fluorinated compound is in it. They found that half of these had fluorine.
So they took those and they realized that they needed to be tested further, right? So they took these 52 % and they randomly took 29 of those products to check more of a targeted analysis,
like looking at individual PFAS. So whether it's PFOA, PFOS, and because it can be a little bit expensive to look at all 230 of them.
Interestingly enough, of the 52 % of the products that had increased fluorine levels, only 8 % of those had something listed on the ingredient list.
And of the 29 products that they tested, targeted, only 3 % of those had any sort of PFAS listed on the ingredient list.
This was huge in that when they tested all these guys, they range that the PFAS concentration range from 22 nanograms per gram up to 10 ,500 nanogram per gram.
The average for each one was over 1 ,000 nanograms per gram. Please keep in mind, the EPA safe level now is 0 .004 nanogram per gram.
This is huge, especially when you consider the fact that you can absolutely have issues with dermal absorption, which we've seen in the firefighters,
but this is more of a direct path, right? So if you put something on your eyes, it's going to go in your tear duct. You're going to inhale it if it's a spray or anything close to your nose,
and you're going to eat it if it is a lip product. And by the way, the lip products had the most sort of number of PFAS, and most of the products,
the lip products had PFAS. They may not have been the highest. I think the 10 ,500 was long wearing foundation, but definitely the lip products had, you know,
most of them had something in it, okay? And that makes sense, right? So let's talk about that dermal absorption. If it doesn't have a direct effect by going in the mouth or the eyes,
what about the dermal absorption? There aren't a lot of studies on this, and they found that the absorption rate, the total rate actually where a compound put on the surface of the skin made it,
either into the epidermis -dermis and stayed there, or actually would have transferred all the way through into the blood supply with 69%.
The amount of PFAS that was applied to the surface that actually just went straight through and didn't stay in the skin was 48%.
So that is a huge percentage of chemicals. So most of the time, if you see wear -resistant, water -resistant,
smudge -proof, all this glass skin, be very careful. Even if they don't list it on the ingredient list, more than likely it will have some effect. PFAS in it.
Going forward, yes, absolutely. There are potential for regulations on this, whether from the EPA trying to decrease the levels allowed in water,
even though they're only really doing that for six out of the 9 ,000, at least it's a start. The FDA is trying to do something by updating its MoCRA, Modernization of Cosmetics Regulation Act,
looking at how do we enforce these product manufacturers to either list their ingredients, let us know if there are any issues with safety,
and they're really trying to make it more of a regulated environment for these cosmetic, the Cosmaceutical companies to really list their ingredients and whether or not they're adverse health issues with their ingredients,
and that hopefully will be something that will help out. And of course, there are some issues, some bills coming out here and there, the No PFAS in Cosmetics Act that was introduced at the federal level,
I think it's a little bit died, but who knows, but many states have passed their own bills, which has been very helpful. If you want to look into this more, Silent Spring Institute is really a great look into that organization.
It's actually a joint effort between Northeastern and Michigan State, and they're fantastic scientists that are really looking at this, and they helped create this app, which you can have on your phone called Clear yet,
which you, it's really, really cool. I have it on mine. So if you want to look for waterproof mascara, say at Amazon, you put in waterproof mascara and you search,
and say you want to click on this brand. When you do that, this little guy shows up. And if you click on it, if the product has its ingredients listed,
which many don't it will actually kind of tell you all Of the issues with the ingredients in this product and it'll tell you this is a PFAS And so maybe you might not want to get it You can access the search tool at pfas-exchange .org Now we turn to the Dermalorian Derm Decoder Dermatologist Dr.
Brad Glick highlights some cutaneous manifestations of systemic diseases Cutaneous manifestations of systemic disease is really one of our babies in dermatology I like to say that the skin is a window and you can look through the window Depending on which side of the window you're on but what's important for us with every patient Is to look at a skin disease like an inflammatory skin disease as a potential sign of
systemic disease Let's pick one It may not be one of the more common ones, but let's just take dermatitis herpetiformis. That's an immunologic disorder All of us in dermatology know a lot about it.
We know that it may be associated However, with a gluten sensitive enteropathy That means that there is a systemic phenomenon that affects the GI track We have to hone in carefully and have an index of suspicion for instance for that condition No to do a biopsy No to do a lesion or perilesional immunofluorescence biopsy So that we evaluate that skin process,
but we at the same time Partner up with our gastroenterology colleagues and make sure that we treat the whole patient and that's just one simple example And that is a skin disease that globally speaking is a skin sign You know when we talk of signs,
there are some classical signs that actually I didn't even discuss in my talk Because it's a very large topic There are rheumatologic Diseases of which there are cutaneous signs ophthalmologic infectious disease signs as well too of which we have many.
One of the areas that I discussed at the end of the talk which I think is important for everyone in dermatology and I talked to the residents about this all the time in that are nail signs of systemic disease which is an area that I'm very interested in clubbing being one of them.
You know these bulbous digits the the patients will have a positive shamrock sign where you see this little rhombus here or this triangle that you see when you oppose the dorsal surfaces of your thumb.
It's obliterated because they're angle which is that angle between the proximal nail fold and your nail unit. It increases to about 180 degrees.
That's clubbing. If you see clubbing someone must have some underlying disorder. It might be a pulmonary process, idiopathic pulmonary fibrosis, hopefully not bronchogenic carcinoma,
cardiovascular disease, underlying Graves disease which you may notice outwardly, even HIV disease. So nail signs of systemic disease are very important.
There's Muehrcke's lines, these white lines that occur on the nails, white lines that are striate like knees lines and we see that in patients with nutritional disorders and hyperalbuminemia.
The point is there are many outward signs and we have to have an index of suspicion that those cutaneous signs may reflect something that has a bigger problem on the inside of our patient's bodies.
Thanks for joining us for the Dermalorian podcast from the Dermatology Education Foundation. The Dermalorian podcast is an independent program made possible with support from UCB.
Catch up on past episodes anywhere you listen to pods and be sure to tell your colleagues about the Dermalorian podcast. Thanks for listening.
*This transcript has not been verified for accuracy.