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Nutritional aspects of Dermatology (Skin and Food – is there a link?)
Matthew Strack
Dermatologist
Marinoto Clinic
Dunedin
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GP registrar year 1989
Fellow Royal Australasian College of Physicians
International Fellow American Academy of Dermatology
Matthew Strack - Dermatologist
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Conflicts
Have given talks and accepted travel grants from:
Roche - Roaccutane
Novartis - Cyclosporin
Sell Cetaphil cleanser at my office
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• Eat Good things
• Avoid Bad things
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Performance
Culture
Social Interaction
Addiction
Cost
Availability
Technology
Habit
Influences on Diet
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Food and Dermatology Sugar Dairy Gluten Nightshades
Vitamin D
Adverse Drug Reactions Aspirin Thiazides Statins (x2) Topical Steroids Biologics
Outline
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“Venous Eczema”
Acanthosis Nigricans
Psoriasis
Sugar/Fructose
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Family Trip to Disneyland
Swelling in both legs
Clot rulled out
10 months
Mr M G
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breakfast - apricots, honey puffs, toast margarine, honey, coffee with milk
morning tea - coffee with milk lunch - sandwiches with honey, coffee with milk
dinner - various - meat with plenty of veges, ice cream, apple crumble, coffee with milk
supper - some biscuits
Mr M G - Food
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Fructose
Insulin
Gut
Bacteria
Leptin
“Empty
Calories”
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Has lost 10kg
Skin 90% clear
Occasional use of topical steroid
Mr M G - Follow Up
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F,30’s
Ref:dermatitis axillae
Things are not what they seem
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Hyperinsulinaemia
Difficulty Washing Neck
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Diet – try sugar free
Acanthosis Nigricans
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ACCORD Study
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Randomized multicentre study
N=10,251
Type 2 Diabeties
38% F, 35% previous cardiovascular event
Average age 62y
Glycated Hb at entry 8.1% (65 mmol/mol)
2 arms: Standard 7-7.9% (53-63 mmol/mol) Intensive < 6% (42 mmol/mol)
Accord 2
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Accord 3
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5.0% Intensive group
4.0% Standard group
P= .02
Accord - Rate of death 4
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50y M
Police officer – physically active
Medicines: diltiazem, bendrofluazide, betaloc, vit d, simvistatin, allopurinol
Weight 112kg, BMI 29
Palmar Psoriasis
Methotrexate
Potent topical Steroid
Mr RC – Insulin 1
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Fasting Glucose 5.0 mmol/L (n3.5-6.0)
Fasting Insulin 116 pmol/L (n10-80)
Offered low sugar diet
Mr RC – Insulin 2
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Weight 112kg -> 103kg
BMI 29 -> 26.7
Fasting Glucose 5.9 -> 5.6mmol/L (n3.5-6.0)
Fasting Insulin 116 -> 80 pmol/L (n10-80)
Reduced need for topical treatment
Palmar psoriasis improved
Mr RC – Insulin 316 month follow up
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Remains on 1 of 4 antihypertensive meds
Dose of remaining antihypertensive reduced
BP 145/95 pre diet -> 130/70
Improved exercise tolerance
was starting to wheeze with walking
Mr RC – Insulin 4
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Effect of Weight Loss on the Severity of PsoriasisA Randomized Clinical Study
Peter Jensen, MD, et al JAMA Dermatol. 2013;149(7):795-801. doi:10.1001/jamadermatol.2013.722
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Adipocytes
More than just fat storage cells
Release a rance of inflammatory chemicals
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Psoriasis is a chronic inflammatory systemic disease
Cardiovascular risk is increased in chronic inflammation
Severe disease is associated with increased risk of cardiovascular death
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Adam and Eve', by Lucas Cranach the Elder, 1526
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Emeritus Professor John Hunter
(1925-2003)
“Half of what you learn at this medical school will be proved to be wrong. The trouble is that we do not know which half. “
Opening Lecture, first day at Otago medical school 1982
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Acne
Dairy
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HyperkeratizationSebum Production Colonization
Acne
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Possibly a corruption of “acme”
Acme = latin for a point or high spot
Acne
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Miley Cyrus Admits She's 'Struggled With Depression,'
Miley Cyrus is opening up about getting through a dark period in her life in Elle magazine . …
"It was a lot to do with, like,I had really bad skin, and I felt really bullied because of that.”
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Journal of the American Academy of Dermatology 2005
Effect was stronger for low fat dairy products.
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Several studies now confirm a positive link
Males show trend more strongly than females
Low Fat/Skim Milk shows strongest association
Positive association with BMI
Negative association with fish
Acne and Dairy
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Kativan Islanders
Population 2250 Subsistence horticulture and
fishermen 1990 all homes visited 1200 subjects over age 10y Included 300 aged 15-25
Cordain et al, Archives of Dermatology, 138,Dec 2002, 1584-1590
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Normal weight
No hypertension
Low Insulin
Low leptin
No Acne
Kativan Islanders
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23 y f
3 courses isotretinoin in past
Doses ranging from 5-40mg
Currently on 4th course – has been on for 1 year,
acne not settling
Seen by two dermatologists
Acne – Case SW 1
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Otherwise healthy
Normal build/BMI
Medication: Combined Oral Contraceptive
Nursing Student
Options?
Acne – Case SW 2
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Offered Gluten Free Dairy Free diet
Six month follow up:
Skin clear
Has reduced sugar intake as well
Off Isotretinoin
Placed on 1y review
Acne – SW 3
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Increasing in post adolescent patients
Recent studies show a role for diet change
Worse with dairy
Better with fish and unprocessed food
Severe cases need medical treatment
Acne - Conclusions
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Source:Melnik ADV 2013
Treat Acne / Save the World?
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• Celiac Disease – Dermatitis Herpetiformis
Eczema
Lupus
Rosacea
Gluten
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Ground Zero
61y Male Eruption natal cleft also
elbows - settles with do -vesicles noted ? herpetic
Meds: simvistatin, quinapril, aspirin, citalopram, metformin, gliclazide
nonsmoker wt 109kg - stable
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anti TTG IgA: *** > 150 units (0 - 20)
Endomysial Ab: *** POSITIVE
Comment:
These results support a diagnosis of coeliac disease
Blood Tests
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Clinical and Biopsy
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IgG autoimmunity
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Small bowel biopsy
Strict Gluten Free diet
Review with dietician
Even stricter gluten free diet
Lost 6kg in 3/12 and 10cm around abdomen
No visible skin lesions, no therapy required for skin
Follow Up
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Fasano
Scientific American
2009
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1st Degree Relative 1:22
2nd Degree Relative 1:39
Symptoms 1:56
Not at risk 1:133
Family History
Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study.Allesio Fasano: Archives of Medicine 2003
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1914-2009
Father of the Green Revolution
Nobel Peace Prize 1970
Dwarf Wheat
Norman Borlaug
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Alopecia areata
Aphthous stomatitis
Atopic dermatitis / Eczema
Cutaneous vasculitis
Dermatomyositis
Dermatitis herpetiformis
Oral lichen planus
Prurigo nodularis
Psoriasis
Urticaria
Vitiligo
Celiac disease and Skin disease
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Eczema
Female, 30’s Lifelong Atopic Eczema Worse since shifting from
Scotland 3y ago Cyclosporin – no help Methotrexate Helped but
stopped prior to pregnancy Patch testing – neg HLA DQ -pos TTG - normal
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40% erythema during pregnancy
Using topical Steroids
Striae
Azathioprine started post partum
Monitoring Bloods normal
Gluten free diet suggested
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Progress
Significant improvement in eczema
Breast fed child’s eczema also cleared on gluten free diet!
Further improvement in patient/mother with elimination of rolled oats
Azathioprine dose halved and then stopped
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Eczema Before and after
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65y F referred by GP
“Intensely itchy”
Dermatologist 14y ago:
Punch biopsy “inconclusive”
Meds: thyroxine, hrt, omeprazole
O/e – 25 x 15 cm right pretibial
Lichen simplex
Thickening
Eczema, unresponsive to topical steroids.
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Consultation
“I have an intolerance to bread and scones”
Bloating
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Follow up
Able to stop omeprazole
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Lupus
Systemic
ANA+
Immune complex
Skin sometimes
Systemic Joints Internal organs
Antimalarial effect Weak/moderate
Cutaneous
Often negative
Cell mediated
Always Skin
Can have SLE as well
Strong
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Lupus
58y F
2 biopsies confirm Lupus
Sb 2 dermatologists
Resistant to topical, and antimalarial
Works in science
F hx nil of note
Vegetarian / Piscatarian
ANA neg
Ttg 3 (0-20)
Gliadin IgG: 25 units(n<70)
Gliadin IgA: 5 units(n<15)
HLA DQ 2.2 and 2.5 pos
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Lupus
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RA/Lupus
42y F TF
GP: Psoriatic Arthritis/Sjogrens
Rheumatology “RA/Lupus Cross”
2-4/12 lesions on toes
leflunomide, diclofenac, omeprazole
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RA/Lupus
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Skin much better but not fully settled
Could not take zinc
Eating more on GF diet
Has been able to stop omeprazole
RA/Lupus
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Psoriasis 43y m
Smokes 20/day
Meds: Salbutimol Inhaler
15% e2/3 s2/3 t2/3
Includes face and genital areas
Flare with URTI
Disease on elbows 10y
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Psoriasis 43y m
Strep Serology negative
HLA DQ – 8 positive
Anti TTG IgA 16 (n 0-20)
Topical Steroid
Penicillin
Acetretin
Gluten Free diet
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Psoriasis 43y m
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Odds ratio of increased IgG anti-gliadinDiet and psoriasis, part II: Celiac disease and role of a gluten-free diet
Bhavnit K. Bhatia et al JAAD 2013
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Rosacea 65y M
GF
Lost 15kg 90->75kg
No minocycline last 3/12
Added Zinc last 3/12
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Rosacea
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Breakfast Toast, Muesli, lite margarine, coffee
Morning Tea Coffee with Apple
Lunch Soup with toast
Afternoon tea Biscuit and coffee
Dinner Chips, meat, packet gravy and veges
No desert/supper
Known Egg Allergy
Rosacea
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Before and after #1
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Before and after #2
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“Mostly Gluten Free”
Breakfast – muesli
Lunch – Sandwich
Dinner – Pasta “a lot”
Snacks – includes cakes and biscuits
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Breakfast
Morning Tea
Lunch
Afternoon Tea
Dinner
Supper
Snacks
Dietary Questionnaire:
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F 30’s
Well educated health professional
Sarcoidosis with hand arthralgia
Hashimotos Thyroiditis – carbimazole
Acne – starting to settle with topical rx
Low fe
Case to Discuss
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Hand arthralgia – cleared
Thyroid
Bloods normal
Carbimazole halved
Acne
Further improvement
Fe – normal
Case to Discuss
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Case to discuss - Radioiodine
Should She have it?
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History
Family History
Celiac
Wheat Allergy
Gluten Intolerance
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22y M, ref “bothersome dermatitis”
Several courses of prednisone for skin
Pentaza for Crohn’s disease
F Hx: Grandfather, uncle, cousin – celiac
Results:
TTG 1 (n0-20)
HLA DQ 2.5
Family History
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Skin almost clear
Prednisone not needed
Pentaza not restarted
Feels better in self
Now on 2 topical steroids and 6 monthly review
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Gluten Gene Tests: HLA DQ 2.2, 2.5, 8
TTG n=0-20
(Anti Gliadin IgG n=0-70)
(Deamidaded Gliadin Peptide)
?ANA
Unexplained Low Fe
Tests
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Commit to a strict 2 month trial
If you don’t want to do it, don’t do it!
Don’t eat too many “Gluten Free” Food
Fresh Food: Meat, vegetables and fruit
Eat fat, including Saturated fat – see next slide
Avoid Vegetable oils – exception: Olive Oil
Avoid Rolled Oats
Gluten Free – Dr Strack's WaySummary of Patient Handout
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Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease.
Siri-Tarine et al, Am J Clin Nutr 2009.27725
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Things Change: 1984-2014
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Have You Seen this?
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Nicotine
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Tobacco Potatoes Tomatoes Eggplant Peppers (bell peppers, chili peppers, paprika, tamales, tomatillos, pimentos, cayenne, etc) Goji Berries
Nightshade (Solanaceae) Family:
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Deadly Nightshade / Belladonna
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Steroid mimics Muscle tremors – cholinesterase inhibitors Only partlt removed with cooking Tobacco – Nicotine Potato, Tomato - Solanine Deadly Nightshade – Scopolamine
- Atropine
Nightshade Alkaloids
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48y male
Health care professional
Referred for skin check – past history includes nonmelanoma skin cancer
F hx 1 daughter with celiac disease
No current medications but for last 5y has developed generalized arthritis over winter each year
Mr D S - Presentation
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Rheumatologist – psoriatic arthritis
Has had steroid injections in ankles several times
Recently offered methotrexate by Rheumatologist
Skin check shows no skin cancers
Also lesions on arms that could be psoriasis
Mr D S - Arthritis
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Gene positive for Gluten sensitivity
Strongly positive anti-Gliadin antibody
Mr D S - Investigation
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Seen 9/12 later
No arthritis this winter
No ankle swelling
Has not needed steroid injections in ankles
More energy
Mr D S - Follow up
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Vitamin D – Controversy
Low vitamin D levels associated with increased risk of melanoma, thicker melanomas, higher relapse rates and reduced survival.
Newton Bishop et al., 2009, Gambichler et al, 2012, Gandini 2013.
High vitamin D levels associated with increased risk of NMSC and melanoma. Jolieke et al., 2013,Eide et al., 2011, Asgari et al.,2010.
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Vitamin D
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The Skin is an Endocrine Organ
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Vitamin D – is the Sun Friendly?
<10% from diet
Most efficient midday
UVB strongest midday
No lower threshold for UVB and skin cancer
Recommendations?
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Dermatology Patients
Melanoma
Multiple Skin Cancers
Immunosuppressive Drugs
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Drug Reactions
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Rash on Neck and Chest
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inhibition of TXA2-dependent platelet aggregation
Blood half life 20min
Platelet life 10 days
Platelet recovery 10% per day
Aspirin
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? Venous Eczema
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2y + leisons arms and legs.
Referred by gp 66y M Irritating Cryotherapy – no response Interests
Gardening Bowls – x3/week
Meds Vit D Ranitidne Atorvastatin Bezalip Metoprolol Aspirin
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Presentation
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Follow Up
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Follow Up
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74y M
Lifelong dry skin – much worse last 6/12
Mother and brother also dry skin
Statin Stopped
Suggested two eggs for breakfast
Very Dry Skin
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52,000 Norwegiens aged 20-74Petursson H et al, Journal of Evaluation in Clinical Practice 18 (2012) 159–168
Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the
Norwegian HUNT 2 study
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Topical Steroids
Acne
Unwanted Hair
Skin Thinning
Stretch marks
Red facial veins
Allergy (!)
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Using Topical Steroids
Teenagers – Care!
Sensitive areas – Care!
Advise Quantity
Arrange Follow up
Low Risk areas Hands, Feet
Back
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Biologic Therapy
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Find what is important
Find points of resonance
Hand outs can help here
Be prepared to be surprised
Get partners/family on board
Accept self abusers
Conclusion
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Junk Food
Sugar
Gluten
Carbohydrates
Levels of Intervention
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Share Positive Emotions
I am very pleased with your progress and I think you are doing very well.
This is great!
It has been a pleasure to treat you.
This has made my day!
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Skin Disease may a marker of deeper problems caused by food
Changes in diet can improve skin disease
Use a diet questionnaire
Family History – ask about:
Celiac
Gluten intolerance
Enlist Support from family – but don’t undermine
Be Nice!
Take Home Points
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We are all different
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