Bringing basic dermatology to the pediatric medical home session 4 wrapup

Bringing Basic Dermatology Care to the Pediatric Medical Home:

A PPOC/CHICO Learning Community & Integration Program

Derm 1.0 Wrap-up Session Didactic Webinar

Thursday October 27, 2016

© 2014 Pediatric Physicians’ Organization at Children’s (PPOC). For permission please contact [email protected]

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We have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on,

patients relevant to the content we are planning, developing, presenting, or evaluating.

Off-label uses of medications will be discussed.

Disclosure


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Glenn Focht, MDPPOC Chief Medical Officer Karen R. Barnett, MD, FAAP

Pediatric Physicians’ Organization at Children’s


Madeleine Kuhn, MPHCHICO Program Coordinator

Faculty

Stephen E. Gellis, MDProgram Director, Dermatology

Boston Children’s Hospital

Sophie Delano, MDDermatology


Sadaf Hussain, MDDermatology


mailto:[email protected]

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Learning Community Schedule

Date Content

Thursday, May 19, 2016 Atopic Dermatitis

Thursday, August 4, 2016 Acne

Thursday, September 1, 2016 Warts, Molluscum, Hives

Thursday, October 27, 2016 Wrap-up

Didactic Webinars7:30am – 9:00am


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Coursework

• Qstream• Case Reviews • Follow the

instructions on the first page

• Submit on Blackboard or email or by fax to Madeleine Kuhn

• Process Maps, due by 11/11/2016

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Qstream Finish Line!

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Process Map Presenters

Dr. NelkenAndover Pediatrics

Dr. HydeWestwood-Mansfield Pediatric Associates

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Patient Calls for

acne appt or derm referral

Front desk schedules Appt. within a few days

PCP/PNP examine patient

Severe cystic

scarring acne

Start topical or oral medicationF/U in 6-8 weeks

Refer to Derm

Adjust meds if needed

YES

NO

What happens to patient after

referral?

Address Acne at well/sick visits?

CURRENT PROCESSAndover Pediatrics

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Patient Calls for sick/well

visit

Front desk schedules Appt.

PCP/PNP examine patient including

skin exam (starting age 11)

Severe cystic

scarring acne

Talk with patient about acne and

potential treatment options

Offer Rx that day or reschedule for visit dedicated to

acne

Refer to Derm

YES

NOStart topical or oral medication

Follow-up in 6-8 weeks to reassess

Patient improving

Follow-up in 6-8

weeks to reassess

Follow-up in 6-8

weeks to reassess

Adjust meds Patient improving

YES

YES

NO

NO

NEW PROCESS

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Annual well visit 13 and up

Questionnaire given that inquires about acne and

desire to treat

Patient has acne and

wants to treat

Do not discuss Discuss and make treatment plan

Follow up in office in 8

weeks

Are we missing patients who might not be ready but become so during year – Can we give them education and let them know about our ability to treat

effectively?

No Yes

CURRENT PROCESS Westwood –Mansfield Pediatric Associates

Karen Halle, MD; Jen Hyde, MD; Jill Fischer, MD; Erin Kish, MD; Helen

Lyon, MD; Sandra Ventura NP; Meridith Liebman, MD

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Annual well visit 10 and up

All patients receive handout on good skin care and basic acne

treatment

Discuss acne management and make treatment plan. Acknowledge need

for and ability to recommend changes if initial treatment not working

Providers routinely identify and document patients with acne on physical

exam

Patient with acne

Provider educates patient and family about calling

office if acne develops and otc treatments not

working

Make follow up visit in 8 weeks

no

yes

NEW PROCESS

Patient reports interest in treatment

yes

Provider educates patient and family

regarding availability of acne treatment if and when they consider

no

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Process Map Coursework Q & A1. How will you implement your new process? What do office-staff need to

know about it and how will you train them on the new process? We will need to develop a handout to be placed in our well child packets (both online and in office) and make sure that the office staff responsible for these are aware. We will need to train our providers through provider meeting and in office memo that this handout is being provided and that documenting and discussing basics of acne treatment will improve the care of our patients. We will inform front desk staff of the 8 week follow up on initial acne management.

2. Will your new process require any patient/family outreach or education? If so , how will you accomplish the necessary patient/family education? We will need to develop the handout and formulate anticipatory guidance for well visit discussion on acne. We will need to educate providers on such.

3. How will you monitor that the new process is happening correctly over time in your practice? We will check website and packets and will monitor referrals to dermatology for patients we could have likely managed.

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Itchy eruption in classic areas Assess for complicating factors

like contact dermatitis (airborne, saliva) and infection

When treating, remember to treat both the barrier dysfunction and the immune system upregulation

Don't be afraid to use a higher potency topical steroid-when in doubt, schedule frequent follow ups and limit quantities and refills

Atopic Dermatitis

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Atopic Dermatitis Exacerbators:Saliva

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Atopic Dermatitis Exacerbators:Cocamidylpropyl Betaine

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Atopic Dermatitis Exacerbators:Fragrances and Airbone Contactants

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Atopic Dermatitis Exacerbators: Molluscum

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Atopic Dermatitis: Treatment Goals

Barrier: gentle skin care, moisturizing creams/ointments

Immune: topical steroids/calcineurin inhibitors

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Acne Treatment: Benzoyl Peroxide

Initial treatment for any patient with acne:

– My preference: once daily wash– easier to get chest and back as well– Panoxyl 4% creamy wash (or generic) = less drying

• BP creams an alternative to entire face• Gels can be drying

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Acne Treatment

• Mild: Benzoyl peroxide wash QD & topical retinoid, topical antibiotic if inflammatory

• Moderate: Mild + oral antibiotic +/- OCP• Severe: Moderate + consideration of isotretinoin if scarring or

refractory• Isotretinoin: Best bet for curing scarring acne

– Females need to be on two forms of birth control– Not associated with increased risk for inflammatory bowel

disease

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Acne Treatment CommandmentsAll acne patients should be using a benzoyl peroxide and topical retinoid.

All patients on an antibiotic should also be on a benzoyl peroxide.

Refer to Derm early for isotretinoin discussion if scarring.

Consider OCPs in female patients with acne.

Manage expectations for results that may take months.

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Questions: Acne ComplicationsDiscoloration

Post-inflammatory Hyperpigmentation and Hypopigmentation

– Sunscreen!– Tretinoin targets this as well– Pulsed dye laser decreases

redness– Chemical peels and bleaching

agents may play a role

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Acne Complications: Scarring

• Remodel and improve in appearance over time

• Chemical peels, laser resurfacing, surgical procedures (subcision) may play a role once acne is well controlled

• Tretinoin has a modest role in the remodeling of acne scars

http://acner.org/img/care_and_prevention/acne-scars-and-pitting_2_3157.jpg

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Acne Complications (contd.)

Keloids: aberrant scar tissue that grows beyond the direct area of tissue damage

Common sites: shoulders, chest, back, jawline

Treatments: PREVENTION IS KEY (treat acne aggressively)

Intralesional kenalog (steroid injections), radiation therapy

DO NOT EXCISE without a game plan!

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Questions: Acne and Oral Contraceptives

3 FDA approved OCPs for treatment of acne: Ortho Tri Cyclen (norgestimate/ethinyl estradiol) Estrostep (norethindrone acetate and ethinyl estradiol) Yaz (drosperinone/ethinyl estradiol)

For moderate-severe acne in females who have had their menses for 1 year

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Oral Contraceptives and Acne (Contd.) Pertinent History that Should Be

Elicited Family history of thrombotic

events Smoking history (Migraine with aura)

Thrombotic events are rare in adolescence

Most common side effects: nausea, vomiting, breast tenderness, headache, weight gain, breakthrough bleeding

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Oral Contraceptives and Acne: Important Consideration

Maximization of bone mineral density 50% bone mass accrued between 12-18

years of age 24 month study of postmenarchal girls on

OC did not reveal osteopenia; BMD femoral neck 4.2% compared to 6.3% in control; conclusion was effects of OC unclear

Prescribing of OC based on provider level of comfort

Fertil Steril. 2008 Dec;90(6):2060-7. doi: 10.1016/j.fertnstert.2007.10.070. Epub 2008 Jan 28.

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Salicylic acid + duct tape at all times. Goal is maceration

Pare down before treatments to get to affected keratinocytes

Cryotherapy: 2 cycles of 7 seconds with slow thaw in between

Tretinoin cream for facial flat warts, imiquimod for genital warts

May take months of treatment

Potential benefit of HPV vaccine

Genital warts red flags: Child>4-5, out of diapers with no known non-abuse exposure route)

Wart:Treatment

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Questions: CRYOTHERAPYCryotherapy Costs

Liquid nitrogen (10L): $128.36 Dewar (container): $200-$900+ Stryofoam cups and cotton-tip

applicators: negligible Cry-ac: ~$750-800 (optional)

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Questions: Cryotherapy Practical Considerations

Various methods (Cry-ac, Q-tip, Q-tip with cotton

“10-15 second” cycle The margin around the

lesion correlates to the depth of your freeze

Complications include blister formation, hyperpigmentation, hypopigmentation and ring wart formation

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Questions: Cryotherapy Billing CPT codes

17110 (Destruction of flat warts, molluscum or milia up to 14 lesions)

17111 (Destruction 15 or more lesions)

ICD10 codes B07.0 plantar warts B07.8 other viral warts B07.9 viral wart, unspecified B08.1 molluscum contagiosum

Procedure only v. procedure and an office visit Follow up treatment for destruction

only: bill the CPT code only Destruction and addressing of other

issues: bill the office visit and the CPT

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Molluscum Treatment

• Resolves 6-24 months• Treat molluscum dermatitis with

emollients and lower potency topical steroids

• OTC Treatment: tea tree oil, apple cider vinegar, tape stripping

• Rx: Cantharidin, light cryotherapy, extraction/curettage

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Questions: Imiquimod (Aldara) for Molluscum

• Imiquimod still used by Derms and PCP for molluscum

• Based on 2 unpublished RTC, in 2007 FDA changed imiquimod prescribing info to state that it was not effective for molluscum.

• Concern that relative expensive med used when not effective

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“Newbies”

Questions on disease entities not yet covered• Gianotti Crosti• Papular Urticaria

For more dermatologic conditions, stay tuned for Derm 2.0!

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Gianotti-Crosti

Tx: Topical steroids don’t help pruritus much but lower potency (desonide triamcinolone) likely doesn’t hurt BID for 1-2 weeks

Resolves in weeks without scarring

Triggers: EBV, HepB, entero, CMV, RSV, echo, vaccinations

Symmetric papules on extensor knees, elbows and buttocks

Localized id reaction

Papular Acrodermatitis of Childhood

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Gianotti-Crosti

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Gianotti-Crosti

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Gianotti-Crosti

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Gianotti-Crosti

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Papular Urticaria

Tx: topical steroids, antihistamines, evaluation of home for infestations

Can wax and wane for weeks to months

Id response to arthropod bites

Misnomer: Lesions last > 24 hours

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Papular Urticaria

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Papular Urticaria

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Diaper Dermatitis

• Irritant contact dermatitis• Potential for secondary bacterial and fungal infections• Typically need a multiple-prong:

– Barrier Cream– Antifungal given risk of candidiasis– Lower potency topical steroids (Hydrocortisone 2.5% or

Desonide)– Antibacterial if concern for infection

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Barrier Creams

• Thicker = Better.• If you see the rash without wiping, it isn’t thick enough• Wet diapers pat dry and apply more gobs of cream• Soiled diapers wipe off soiled portions and apply more gobs of

cream • Vaseline, Desitin, Triple Paste, A&D.

– Basically anything that is thick and non-irritating is ok.

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Bacterial Infections

Signs: spreading erythema, pustules, peri-anal erythema

(think strep)

Add mupirocin BID to topical

applications. Can be mixed with

other treatments (antifungal or

barrier)

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Diaper Derm Mimics

• Psoriasis – Typically will improve once out of diapers.– Should improve with basic treatments (barrier, topical barriers)

• Langerhans cell histiocytosis (LCH)– Petechial/non-blanching, favors inguinal creases– Similar lesions on scalp, post-auricular– Can have visceral lesions, including osteolytic lesions and

diabetes insipidus– WONT RESPOND TO TOPICAL DIAPER TREATMENTS

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LCH

Source: http://www.psychiatrictimes.com/allergy/can-you-distinguish-among-these-diaper-dermatoses/page/0/7

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Learning Community Schedule

Date Content

Thursday, May 19, 2016 Atopic Dermatitis

Thursday, August 4, 2016 Acne

Thursday, September 1, 2016 Warts, Molluscum, Hives

Thursday, October 27, 2016 Wrap-up

Didactic Webinars7:30am – 9:00am


You will receive the slides, handouts, the webinar recording and the survey via email. All course information will be posted

on Blackboard by 10/29/2016 at 5 pm.

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Your Feedback Helps Us Succeed!

You will be receiving your MOC Attestation form and survey directly after this session

Please make sure to fax back the form with your signature and fill out the survey. We will need this

information by 11/11 to guarantee that the credits are added in a timely manner



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We hope you enjoyed the

course!

Thank you!

For questions please email Madeleine Kuhn, Course Director

[email protected]


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Bringing basic dermatology to the pediatric medical home session 4 wrapup