who is this guy? b.a. chemistry ‘79 baylor university m.d. and residency ‘87 utmb - galveston...

Who is this Guy?B.A. Chemistry ‘79

Baylor UniversityM.D. and Residency ‘87

UTMB - GalvestonMohs Fellowship ‘88

Duke UniversityProfessor of Dermatology

University of ArkansasPrivate Practice

Little Rock, Arkansas Scott Dinehart, MDScott Dinehart, MD

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Conflict of Interest

Speaker and Consultant for Genentech

Clinical and Practice Management Tips

Scott M. Dinehart, MD

“Realize that acne can be made worse by refined carbohydrates and certain dairy products, particularly skim milk”

“Facial acne severity improved more on the low glycemic index diet” Reynolds, et al.

Nutrients.Oct 2010;2(10):1060-72.

“Glycemic load and frequency of milk and ice cream ingestion were positively associated with acne” Ismail, et al.

BMC Dermatol. 2012;12:13.

“Subjects adhering to a LGL diet resulted in clinical and histopathological improvements of acne” Kwon, et al.

Acta Derm Vener. 2012;92(3):241-6.

“Regular consumption of sweets, nuts, chocolate, and oily foods were recognized as risk factors for acne while spicy foods and fasting were not associated with acne severity”

Ghodsi, et al.

J Invest Dermatol. Sep 2009;129(9):2136-41.

Causes

• Lactoferrin, an anti-inflammatory milk protein

• Hormones in milk

• Insulin?

“Substitute high glycemic index foods for low glycemic index foods, and avoid refined carbohydrates whenever possible” Scott Dinehart, MD

Clinical History

• A 44 year old physician has a changing mole on his back

• You decide to biopsy the lesion using a shave technique

You Make the CallA. The lesion needs no re-excision

B. The lesion can be re-excised but only needs a wider shave because the deep margin is clear

C. The lesion needs full thickness excision

D. A and B are correct approaches

You Make the CallA. The lesion needs no re-excision

B. The lesion can be re-excised but only needs a wider shave because the deep margin is clear

C. The lesion needs full thickness excision

D. A and B are correct approaches

Re-excision of Dysplastic Nevi

• Pathologist deserves a vote

• Clinician deserves a vote

• But in general….

“there is mounting evidence that re-excision of lesions with low-grade atypia (mild and moderate DN) may not be necessary, even when positive margins are found; the recurrence rates of these nevi are low, and there are no reports of subsequent development of melanoma in these lesions” Duffy et al. Arch Dermatol 148:259, 2012

• May not need to re-excise mild to moderate dysplatic nevi

• If you re-excise it is important to know if deep or lateral margins involved

• If lateral margins present, can re-shave

• Severely dysplastic nevi need full thickness re-excision with minimal margin

Dysplastic Nevi• Tip #1: Trend is not to re-excise mild and

moderate dysplastic nevi

• Tip #2: Work with your dermatopathologist. A shave removal can often work for mild or moderate dysplastic nevi that you want removed if only the lateral margin is involved

• Tip #3: Start the shave removal more lateral to avoid lateral margin positives!

Wet hair in high risk scalp cancer patients

Use of a hair dryerUse of a hair dryer

• Hair dryers on “warm” can dry the Hair dryers on “warm” can dry the scalpscalp

Use of a hair dryerUse of a hair dryer• Hair dryers on “cold” can be used to Hair dryers on “cold” can be used to

EXAMINE the scalpEXAMINE the scalp

Use of a Use of a hair dryerhair dryer

• Only needed on Only needed on selected selected patients to find patients to find lesions on the lesions on the scalpscalp

“There are only two times when you need to consider doing a KOH examination”

KOH Preparation• Use KOH with DMSO (no need to

heat)

• Dip blade in KOH prior to scraping lesion (scale will stick to the blade)

• Look on high power for hyphae (look like thin black lines)

Identify the “red dot” Identify the “red dot”

basal cell carcinomabasal cell carcinoma