Managing Actinic Keratoses, Confirming a Diagnosis of Scabies, and More
Tip 1: Long-term Management of Actinic Keratoses
For patients with many actinic keratoses (AKs) and skin cancers, I use a 3-week course of fluorouracil (5-FU; Adrucil). Then when the reaction subsides, I proceed to maintenance: the patient uses 5-FU alternating with retinoic acid (ie, 5-FU 2 days a week and retinoic acid the other days). The goal is to walk a line between no reaction and a mild erythema. If erythema develops, then I instruct the patient to skip a day or two.
When someone has had numerous AKs or cancers or both, treating the visible lesions only is not enough. It is a chronic disease that requires lifetime management. For inexpensive topical 5-FU, Dr Ely Haines recommends 10 cc of injectable 5-FU in 10 cc of cetaphil cleanser. I often mix 3 to 6 cc in 30 cc in a 1-oz sample bottle of moisturizer. This gives a good reaction in almost everyone and our cost is very low; to enhance the reaction, we also add retinoic acid. We purchase our retinoic acid and sell it for much less than a pharmacy.
Barry Ginsburg, MD
Tip 2: Getting Rid of Dog Ears
While we have been taught how to avoid or manage dog ears surgically, another useful technique that I have found is to simply use my hyfrecator to burn off the extra skin tissue when the dog ear is visible. It seems to work like a charm with nice cosmesis, and without having to extend or revise the existing scar.
Lyn Giroux, MD
Sudbury, Ontario, Canada
Tip 3: Confirming Scabies Diagnosis
There is a global epidemic of scabies. The only way to be sure of the diagnosis is to visualize the parasite, its eggs, or even feces, on direct microscopic examination. It is not always easy to do as many lesions are due to scratching. A place that has never failed to help me confirm the diagnosis is the presence of pruritic papules on the male genitals (scrotum or penis). Mites are often found there.
Mauricio Goihman-Yahr, MD
Tip 4: Moisturizing To Prevent Atopic Dermatitis
A recent study in JAMA Pediatrics1 examined the cost-effectiveness of prophylactic moisturization for newborns at high risk for atopic dermatitis. While all moisturizers in the study were efficacious, the least expensive product also demonstrated the best overall cost-benefit ratio.
Brian T. Maurer, PA-C
1. Xu S, Immaneni S, Hazen GB, Silverberg JI, Paller AS, Lio PA. Cost-effectiveness of prophylactic moisturization for atopic dermatitis. JAMA Pediatr. 2017;171(2): e163909. doi:10.1001/jamapediatrics.2016.3909
Tip 5: How to Get Patients to Accept Shots
When I have a patient who is naive to biologics and skittish about shots, I use the following technique to help them accept them more willingly:
“One of the best treatments for psoriasis is to take an injection once a day. Wait, did I say once a day? I’m having a senior moment. You only have to take the shot [pick one] once a week, once every other week, once a month, or once every 3 months.”
Humans view things subjectively. Going from no shots to shots is terrifying. But if we reset their expectations by “accidentally” saying its once a day and then move to something much less frequent, the shots do not seem nearly so bad.
Steve Feldman, MD
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Dr. Barankin is a dermatologist in Toronto, Ontario, Canada. He is author-editor of 7 books in dermatology and is widely published in the dermatology and humanities literature.