By Dr. Shafiq Qaadri, MD
What referrals do family physicians make to dermatologists?
They see a vast number of problems: psoriasis, acne, warts, alopecia and so on…For example, a lady who had been itching for six months. She was unable to sleep, and was excoriating her skin…She came in with her bag of topical steroids, about $600 worth, and it turned out she had scabies, which had been missed, even though she had seen 5 or 6 doctors.
We also do a lot of smaller cosmetic procedures, using botox, collagen, and other injectables.
Can family doctors also do these cosmetic procedures?
Certainly some of them can be done by family doctors. A lot of the ones that I do are injectable. For example, I will use Perlane and Restylane—these are mucopolysaccharides, hyaluronic derivatives, that can be injected in nasolabial folds, particularly in acne scars. We also inject a lot of Artecoll, which is a type of collagen.
Do these agents benefit the skin, or are they only for beautification?
These can be used to remedy different kinds of scars—old acne and chicken pox scars, for example. These are of benefit to the patients, who are frequently quite concerned about these scars.
Do dermatologists continue to see skin cancers, or is the incidence declining?
They are still seeing more and more skin cancers. Melanoma is still seen commonly. Certainly basal cell and squamous cell cancers, as well as actinic keratoses.
What are tips for the family MD to distinguish between these conditions, because they often seem quite similar?
For melanomas, it’s the ABCDs: the Asymmetry, the irregular Border, the dark Colour, or the many Colours within the nevus, and its Diameter usually being more than 6 mm. Basically, a funny-looking mole that’s atypical and growing. This is usually one that most people can recognize…Like the old surgical adage, “When in doubt, cut it out.”
Basal cells and squamous cells are often large or small spots. Patients notice that the lesions won’t heal—they bleed easily. Typically, they’ve been present for six months to a year and won’t go away…Often people don’t realize they have skin cancer until they see their family doctor or their dermatologist.
Has the skin-care message gotten out to Canadians regarding UV protection, sun-avoidance, sunblock, or is there still a gap?
I think there’s still a gap. Today I saw a young lady who had just returned from Mexico, and she actually had a reaction to the sun. She said that she hardly got any sun, though she was fully bronzed.
Some people are still in denial—this can’t happen to me--much like people who only smoke a little bit and believe they’re immune.
While performing cosmetic procedures, what sort of anesthesia do you offer patients?
A lot of smaller procedures can be done with a topical anesthetic. For example, we do a lot of hair lasering and other types of lasering in our office...and for taking off small nevi or small skin tags. Previously, we had to use Emla. You had to put this on an hour before the procedure was done and occlude the dressing, which was relatively messy. But there are newer agents available.
Are these topical anesthetics suitable for biopsies--when you’re trying to determine the presence of cancer?
For superficial biopsies, you could potentially use a topical agent by itself.
If I were going to do a deeper biopsy, with a deep suture—particularly in children--I’d use Betacaine, a newer topical agent, before they came to the office. Then I’d give a further needle of xylocaine once in the office, to make sure we had adequate anesthesia.
For taking off molluscum, for example, you probably don’t need any needle anesthesia, the topical would do...also suitable for children getting venipuncture—even some adults--who are afraid of needles.
If other physicians were more familiar with these topical anesthetics, would they do more in-office procedures?
Probably. For taking off skin tags, for example, you wouldn’t have to anesthetize 10 to 15 different spots. You could apply a little Betacaine, clip them, or lightly cauterize them.
Would these anesthetics work for removal of plantar warts, even calluses, or would that require deeper anesthesia?
A plantar wart usually requires a deeper procedure, for which you’d want deeper anesthesia.
If there were a superficial wart, say, on the arm, which you wanted to just scrape off, the topical would be fine…also to prepare children on whom you were going to use liquid nitrogen.
With this kind of anesthesia, is there any hemostasis, any control of blood loss?
No, not particularly. Betacaine is plain xylocaine, for example, so you don’t get much vascular constriction.
But that’s actually what we want in various situations. For example, if you’re going to do hair lasering, or lasering of small blood vessels on the face, you don’t want blood vessels to constrict, as you won’t be able to see the targeted spots.
Is there are increased need for better topical anesthetics in preventing pain and providing relief?
Certainly, the one that we’ve been using for a number of years was Emla. This has an onset of action about an hour.
You keep the patient there for an hour?
That’s the problem, or we’d have them use it before they came in.
At home, they’d put it on, and occlude it. So they’d drive here with this odd-looking occlusion on their face…then they come into your office as you rip the dressing off and do the procedure. Certainly it wasn’t especially elegant or cosmetically appealing.
Betacaine is an advance, because of the rapid onset, within 20-30 minutes…It’s a clear gel so it provides its own occlusion. We’re using this topical a great deal: for a lot of minor procedures, for injections of different collagen fillers, such as Artecoll, minor laser surgery for hair removal or even electrolysis.
Realizing how common skin disorders are in family practice, it seems Dermatology was vastly under-taught in medical school. Has this improved over the years?
Unfortunately, I think it’s getting even worse. The teaching has decreased: Medical school seems to focus on cardiology, endocrinology, and on number of other specialties.
But as family doctors realize, perhaps 20-25% of what you’re seeing on a day to day basis, in some way has to do with skin…These conditions, while not life-threatening, do impact on the quality of life.
Dermatologists have a lot of terminology: it can’t just be a spot, or a red, itchy rash. It’s got to be “maculopapular, vesicular eruption.” Is that just intellectualization, or is there a valid reason for all those terms?
No, the terminology is valid. Like everything, you need to pinpoint and describe the disease process...We teach medical students, when they’re dealing with an unusual rash, they should be able to describe it intelligently to another physician…Once you get the right diagnosis, you can refer to the right chapter in some textbook.
Are mycotic (fungal) rashes often referred to dermatologists, perhaps even missed by other MDs?
Family doctors will deal with much of this, jock itch, fungus on the feet…Sometimes I think they often misdiagnose nummular dermatitis, which is a round, circular ringworm-looking lesion on the torso and the limbs. They often overdiagnose it as a fungus, whereas it’s just an eczema.
What are some of the new developments in psoriasis, a very common condition?
Several different things. Firstly, 3% of the Canadian population has psoriasis of varying severities.
There’s a new drug for moderate psoriasis, particularly for the plaques on elbows and knees. It’s called Dovobid, which combines the benefits of Dovonex with a moderately potent topical steroid…After 3 to 4 weeks of use, many patients are completely clear.
For severe psoriasis, we use drugs like methotrexate or cyclosporine, which of course have significant potential side effects. There are new biologicals [proteins] being developed. There’s one called Amiveve, an injectable which has just received approval in the United States. These are monoclonal antibodies.
For severe, refractory psoriasis, dermatologists seem to use the PUVA light therapy. What exactly does that do?
PUVA combines Psoralen with ultraviolet B light. The combination affects the epidermal turnover, and stops the cells from replicating…this is anti-mitotic.
However, we’re getting away from using PUVA, because there’s a higher risk of squamous cell carcinomas and premature aging of the skin.
There’s an old saying in dermatology: “If it’s dry, wet it; if it’s wet, dry it; and just keep cycling through stronger steroids.” How would you respond?
Things have changed quite a bit, though topical steroids have been the mainstay of treatment for 50 years. For example, there are two new calcineurin inhibitors for atopic dermatitis, non-steroid based, Elidel and Protopic…The new biologics for psoriasis will also make a significant difference.
Should physicians who frequently prescribe topical steroids be concerned about systemic effects?
You should be aware of possible systemic effects, as well as local effects. For example, topical steroids can cause atrophy, striae, hypopigmentation—especially on darker skin.
If you’re treating a small child or an elderly person with a potent topical steroid, you might get systemic effects.
What is your final message?
See lots of lesions and diagnose them correctly, which will then lead to the best management.
Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca
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