Clinical Tips

Section Editor: Benjamin Barankin, M.D., FRCPC


TIP 1: Creating Quality PowerPoint Presentations

A presentation is a reflection of you and your work. You want to make the best possible impression in the short amount of time given to you.
• Make it simple.
• Make it clear.
• Don’t let the technology dominate the presentation. You want the audience to remember the quality of your research, not your PowerPoint wizardry.

Format for Scientific Presentations:
• Keep it short, especially titles.
• Stick to plain backgrounds.
• Rule of six! No more than six words per line and six lines per slide.
• Stick to a maximum of two readable typefaces.
• Limit the use of color.
• Pick a style and stick with it.
• You need to get your audience’s attention. Many people respond better to visual cues than to straight text or lists of numbers.

Fight Clutter!
• Don’t include every word you will say.
• Limit yourself to one idea per slide.

Khalid Al Aboud, M.D.
Dermatology Department
King Faisal Hospital
Makkah, Saudi Arabia.


TIP 2: Rotating Acne Therapies

When treating patients’ acne, there are clear benefits from using topical retinoids, topical antibiotics and benzoyl peroxide. At the same, irritation and resulting loss of compliance is a huge problem in acne therapy. I have used combination benzoyl peroxide and topical clindamycin (e.g., Duac) one night, followed the next night with a topical retinoid, and then a third night of no therapy to allow the skin to recover. I then have the patient repeat the cycle.

This cyclic therapy method has afforded patients excellent improvement in their acne, and much better compliance and fewer phone calls.

Benjamin Barankin, M.D.
Toronto, Canada


TIP 3: Scheduling: Quick Surgical Removal Visits

In order to accommodate a patient who must have something surgically removed during a busy day, I commonly ask the patient to come back just 10 minutes before my lunch hour is over. This allows me to start my afternoon fresh and not have any concern about whether the patient would return at a later date for a surgical visit. Commonly, patients are surprised that the surgery can even be done the same day, and they are pleased to hear that we can accommodate them.

Ronald B. Vender, M.D., FRCPC
Associate Clinical Professor of Medicine
Dermatology Centre
Hamilton, Ontario


TIP 4: “Grasping” a BCC Diagnosis

For small lesions that are scaly, crusted, and erythematous for which I suspect a basal cell carcinoma (BCC), I grasp either side of the lesion with the index finger of each hand. Then I pull the skin away in a “Nikolsky-like” maneuver, separating the fingers. If the lesion bleeds a bit, it is likely a BCC. The other outcome is that the skin surrounding the lesion is more whitish than the normal skin when stretched like this. This also indicates a likely BCC.

Paul Adam, M.D., FRCPC
Toronto, Canada


TIP 5: Three Quick Tips

1. This is one I learned from Joe Jorizzo: What you tell the patient on the first visit is patient education. What you tell the patient afterwards is an excuse.
2. If you have a patient who has a complicated inflammatory disease, take more than one biopsy. If the patient has lesions of different ages or stages of development, take a biopsy of each lesion and tell your dermatopatholgist which is which.
3. If you are suspecting panniculitis, then perform an excisional or deep biopsy. One can also perform a telescoping biopsy: Take a punch biopsy of the subcutaneous fat, and then take a smaller punch biopsy through the initial biopsy site to get more subcutaneous fat.

Gary Goldenberg, M.D.
Assistant Professor of Dermatology
Director, Dermatopathology Laboratory
University of Maryland School of Medicine
Baltimore, MD


TIP 6: Which of These Items Contains Formaldehyde?

A regular challenge in contact dermatitis post patch test is relaying the chemical interrelation of seemingly unrelated items to patients in a meaningful and memorable way.

One particularly difficult concept to grasp is that a product could, even on the first time use, cause a problem (if it contained the same chemical ingredient as another previously used product). Another difficult concept is that even if a product has been in use for years, it can now be the culprit (as the threshold for clinically expressing the reaction has now been reached).

To “drive this concept home” in clinic, we regularly ask patients what a paperclip, spinach, and our doorknob have in common. Invariably, once we receive the blank look, we explain to them that all the items contain the common ingredient: nickel. This helps to make it clear that each and every exposure from a wide range of sources counts. We explain that avoidance is the key to practicing the art of moderation.

Below is a pictorial puzzle on formaldehyde, which was created for our clinic to simplify post-patch education. We give this to patients to help them remember their allergen and reinforce the idea that seemingly unrelated items may all contain one common chemical.

Can you identify all 10 sources of formaldehyde?


1. Wrinkle-Free Clothing — Formal-dehyde is used to add permanent-press qualities to clothing and draperies. (See this month’s “Allergen Focus” for more information on this.)
2. Sunless tanning spray may contain formaldehyde-releasing preservatives, such as diazolidinyl urea.
3./4. Breath strips and gum may contain aspartame. When aspartame is metabolized, it breaks down to form formaldehyde or formic acid.
5. Embalming fluid/fixatives contains formalin, a saturated solution of formaldehyde, water, and methanol.
6. Wood Cleaners contain formaldehyde or formaldehyde-releasing substances, as a hardener and preservative.
7. Make-up removing towelettes and baby wipes may contain formaldehyde-releasing preservatives, such as DMDM Hydantoin.
8. Money bills — formaldehyde is used in the manufacture of paper.
9. Leather — formaldehyde is used in the tanning process of leather products.
10. Nail polish — formaldehyde is used as a adhesive and hardening substance in nail color.

Sharon E. Jacob, M.D.
Department of Dermatology
University of California, San Diego

Nidhi Avashia
Medical Student
University of Miami School of Medicine


TIP 7: A Tactic for Increasing Patient Compliance

For the first 12 years I directed our psoriasis clinic at Wake Forest, I was singularly unsuccessful at managing patients’ scalp psoriasis. I tried all sorts of treatments and went to meetings to seek out a treatment that would work. Then I realized the main (and perhaps only) reason patients’ scalp psoriasis wasn’t getting better. It was because they weren’t using the medication. Who would comply when told to do something as difficult as putting the medication on the scalp and to come back in 6 to 8 weeks?

Now I tell patients I’m going to ask them to do something very difficult — to apply the medication to the scalp twice a day — for just 3 or 4 days, then I will see them back in the office (or have them call or e-mail me to report how they are doing). Because they only perceive the treatment as being for 3 days, they are much, much more willing and able to do it. Imagine how much better patients would floss if the dentist said, “I’m worried about your gums. I want you to floss twice a day. Come back here in 3 days.

And the results are dramatic. Just 3 or 4 days of topical clobetasol results in very rapid improvement in the disease. Once patients see how effective it is, I don’t have to see them again to encourage them to use the medicine. Now I find scalp psoriasis to be one of the easiest forms of psoriasis to treat! Having a patient come back in a few days or a week for a return visit is now something I do regularly — not just for scalp psoriasis, but whenever I want to make sure patients use their medication.

Steve Feldman, M.D., Ph.D.
Winston-Salem, NC



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