Clinical Tips

Benjamin Barankin, M.D., FRCPC

TIP 1: Practical Advice on “Magic Potion” Therapies

Patients frequently come to see us with goat’s milk, ginseng, herbs, and other lotions and potions from “skin specialists” outside the realm of dermatology. They always ask, “Does it work?” I tell them that I can’t say that what they have been given doesn’t work because I have no clue what they are using — or even if the treatment they’ve been given has the ingredients it is supposed to have.

However, what I can and do tell patients in these situations:

“If I had a treatment that works as well as what you have been told, I would have it in clinical trials and prove that it works. That way, people like me, your dermatologist, would be prescribing it and profits would be rolling in. Now, if your herbalist has not done this yet, it’s likely the treatment you have been given doesn’t really work!”

The first person I heard this from was Dr. Jerry Shapiro, and I use it almost every day.

Shane Silver, M.D., FRCPC
Winnipeg, Manitoba, Canada

TIP 2: Three Clinical Pearls

1. In distinguishing between lichen nitidus and follicular eczema in a child, the presence of linear arrays of papules, which are the result of koebnerization, can determine a diagnosis of lichen nitidus.

2. Wood’s lamp can be used to determine the depth of melanin in the skin. The variations in epidermal pigmentation become more apparent under Wood’s light. For dermal pigmentation, this contrast is less pronounced. However, this applies only for the fair skin types and not for type V or VI skin. Epidermal pigmentation will respond to treatment, while dermal pigmentation will not respond to treatment.

3. In the groin, anal and intertriginous areas, symmetrical verrucous papules, which appear condyloma-like, can be due to infiltrative processes such as nodular amyloid, Crohn’s disease, and histocytic processes, to name a few.

Noah Scheinfeld, M.D.
New York City, NY

TIP 3: Not Sure What To Tell Your Patient? Try This.

A good friend taught me that if you’re not interested in or able to answer a question regarding preferred brands of mascara, foundation or something else that doesn’t seem relevant to the condition (or your medical expertise), the best way to handle it can go something like this:

Patient: What foundation/mascara/eye shadow do you recommend?
Doctor: What is it that you’re using?
Patient: Brand X Doctor: That’s perfect, you should stick with that [or] I generally recommend that to my patients.

Benjamin Barankin, M.D., FRCPC
Toronto, Ontario, Canada

TIP 4: When Patients Ask if Cortisone Thins the Skin

Patients prescribed topical steroids for psoriasis or other proliferative conditions sometimes ask, “Doesn’t cortisone thin the skin?” My response is, “The thing about psoriasis is that your skin is very thick in this condition, and so you want to thin it back to normal. However, once the skin looks normal or almost normal, then it’s time to stop the medicine since at that point you wouldn’t want to thin the skin any further.”

Norman Wasel, M.D., FRCPC
Edmonton, Alberta, Canada

TIP 5: The Utility of a 10-MM Punch in “Shoe Dermatitis”

Shoe dermatitis presents a unique diagnostic challenge to the dermatologist, specifically in investigating potential shoe-based allergen sources. The most common shoe allergens include rubber, dyes, adhesive materials, and the chemicals used in tanning leather. Culprit allergens are identified by performing a patch test on the patient in conjunction with testing the shoe components themselves.

To test the shoe and obtain component pieces, we use a 10-millimeter punch biopsy (Figures 1A and 1B below). This “punch plug material component” is then placed on the patient in conjunction with our standard series and shoe tray.

Sharon E. Jacob, M.D., and Paola Chamorro
San Diego, CA


TIP 6: What Patients Say, and What They Really Mean

Early in my residency I would ask patients whether they were healthy. They uniformly responded in the affirmative. When I then asked whether they took any medications, they would reply, “Oh, just metformin, ramipril, and L-thyroxine.”

I would then have to go back to my notes and cross out “healthy” and “no meds.”

I now ask the list of medications first, and then add the past medical history adjacent to the medications.

Benjamin Barankin, M.D., FRCPC
Toronto, Ontario, Canada



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