who is this guy? b.a. chemistry ‘79 baylor university m.d. and residency ‘87 utmb - galveston...
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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
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Clinical and Practice Management Tips
Scott M. Dinehart, MD
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“Realize that acne can be made worse by refined carbohydrates and certain dairy products, particularly skim milk”
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“Facial acne severity improved more on the low glycemic index diet” Reynolds, et al.
Nutrients.Oct 2010;2(10):1060-72.
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“Glycemic load and frequency of milk and ice cream ingestion were positively associated with acne” Ismail, et al.
BMC Dermatol. 2012;12:13.
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“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.
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“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.
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Causes
• Lactoferrin, an anti-inflammatory milk protein
• Hormones in milk
• Insulin?
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“Substitute high glycemic index foods for low glycemic index foods, and avoid refined carbohydrates whenever possible” Scott Dinehart, MD
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Clinical History
• A 44 year old physician has a changing mole on his back
• You decide to biopsy the lesion using a shave technique
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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
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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
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Re-excision of Dysplastic Nevi
• Pathologist deserves a vote
• Clinician deserves a vote
• But in general….
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“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
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• 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
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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!
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Wet hair in high risk scalp cancer patients
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Use of a hair dryerUse of a hair dryer
• Hair dryers on “warm” can dry the Hair dryers on “warm” can dry the scalpscalp
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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
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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
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“There are only two times when you need to consider doing a KOH examination”
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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)
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Identify the “red dot” Identify the “red dot”
basal cell carcinomabasal cell carcinoma
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