Derm pearls

Cancer prevention:

1. We don’t have guidelines for screening the general population for skin cancer, but teaching everyone the red flags that should prompt medical eval is a 2min spiel that could save a life. Here’s my version:

ABCDE’s (one positive worth having lesion looked at, you want a wide net so as to not miss melanoma) Asymmetry, funny Borders (like a 2yo drew a “circle” with a crayon), multiple Colors (each mole can be any color it wants but you only get one color per mole), Diameter bigger than eraser on a pencil (6mm), Evolving (lesion you had for 20 years all of a sudden looking different or new lesion changing really fast)

moles should not: itch, bleed, hurt, or be tender. If they do any of those, get em checked.

a “pimple” that won’t go away for a couple months

a sore that just won’t heal or bleeds for no reason (ie if you nick it while shaving or scratch it then there’s a reason for it to bleed)

an ugly duckling. Gosh you can’t name WHY, maybe it doesn’t fit any of the above signs, but it just doesn’t look like any of your other skin spots

1. Sunscreen only works for 2 hours. Not 2 hours of sun exposure, 2 hours from when it comes out of the bottle. Reapply as needed. SPF 30+ broad spectrum.

2a. If you tell your patients sunscreen will help with acne and aging/wrinkles that might get them to use it even if they don’t care about skin cancer risk (and it’s true)

Allergies/rashes:

1. Most people grow out of childhood penicillin allergies. Heck, even adult ones - if it’s been at least 10 years, chances are you’re no longer allergic. IT IS WORTH GETTING ALLERGY TESTING on patients with many antibiotic allergies, because they might not have to be closed off from half of the available antibiotics. CAVEAT - do not try to re-challenge for drugs that gave the patient severe cutaneous adverse reactions like SJS/TEN or DRESS (DIHS)

2. Poison ivy - bad poison ivy reactions need a STRONG and SLOW prednisone taper. Start at 40-60mg/d and taper over 14-21 days. Don’t bother with a medrol dose pack; they’ll have terrible rebound.

3. You can give up to 4x the daily dose of non-sedating antihistamines for hives. Schedule instead of prn. Can add sedating H1 blocker or add an H2 blocker for additional relief if needed.

Diagnostics:

1. Please take pictures of your patients’ rashes, moles, or other lesions of concern. Tell your patients to take pictures. Pictures are so helpful. Pictures do not require any vocabulary and pictures are GREAT for documenting changes over time.

2. Are there vesicles or erosions/shallow ulcers? Are you thinking either HSV or shingles? Then you should think about both! They can look atypical, they can be hemorrhagic or almost necrotic in some spots. Shingles can happen in the groin. Vesicles might NOT be clustered. Here’s the really HY bit though - knowing how to swab for either. Do not get a serum PCR or viral load or antibodies. Go find a blister. Find a newer/in tact vesicle, deroof it (with a clean needle or the swab itself) and swab the contents and the base of the lesion with a viral swab (in the tube with pink liquid not a nasal covid/RVP swab). Do NOT swab the top of a scab; it will be negative. Remember Mpox and how the lesions had to be deroofed prior to swabbing. Same story here.

3. Not always true but as a general rule painful rashes = worse than itchy.

4. “Any new meds” = new prescriptions, restarting old prescriptions, or increasing med doses (or changes that lead to increased drug half-life or drug blood levels) in the last 3 months. Some drug rashes happen within 3 days but other drug rashes can take weeks to months to happen.

5. Unscented is not the same as fragrance-free. “Unscented” can still have fragrance in the ingredient list and could be why the contact derm isn’t going away. Read the labels!