Discover and read the best of Twitter Threads about #dermatologist

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A #tweetorial for #medtwitter, #dermtwitter, & #medstudenttwitter!

I'm no pharmacologist, so this is written from a #dermatologist's POV!

Let's start with a question that still haunts med students today:
What is the mechanism of action of methotrexate (MTX)?
MTX inhibits dihydrofolate reductase in the folate pathway, which is needed for DNA/RNA ➡️ inability for cells to rapidly divide!

Given similarities in mechanism with other drugs in this pathway, caution should be used when adding MTX on top of them, especially TMP-SMX!
Since MTX is an antifolate, remember that Folinic Acid (Leucovorin) is used as a "rescue" when side effects go crazy. But at the doses we use in #dermatology, I've never needed it. Plus, we give folate with MTX to prevent these effects!

Which of 👇 doses is typical in derm?
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A #dermtwitter, #medtwitter, and #medstudenttwitter #tweetorial! PC: @dermnetnz. Let's kick off this #MedEd #FOAMEd #medthread with a question.

With LP, which one of the following body sites is most commonly involved?

The correct answer is wrists! LP lesions are most commonly seen on flexor wrists, trunk, medial thighs, and shins. It very rarely involves the face.

The mnemonic for the clinical appearance of LP is to remember the "Ps."
Pruritic (!!!)

You can also make out white and gray lacy streaks and puncta. This is called "Wickham Striae" which helps confirm the diagnosis (1).

Notably, LP also can go to the oropharynx, which can cause erosive lesions that are painful. Wickham Striae are easier to see in the mouth (2).
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Okay #medtwitter and #dermtwitter, you knew it was only a matter of time, didn’t you?! Let’s do this #COVID19 themed #medthread:


#MedEd #FOAMEd #dermatology #dermatologia @AADskin @AADMember @Meddermsoc @dermhospitalist
First, a word of caution – this is one person’s thoughts on a new skin finding reported in a new disease that the medical community is still learning about! As such, nothing in the #tweetorial should be regarded as definite. Just wanted to share a thought process!
So, who cares? #COVID19 is devastating, at times even for the young & healthy! But it’s all respiratory, right?

Well, as we're learning, there's so much more to #SARScov2, and as a #dermatologist, this is the perfect example of how the exam helps frame possible mechanisms.
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Wondering what's going on with your doctors' offices and clinics?

How are you supposed to see the doctor or other care provider if you're also supposed to #StayAtHome?

What even is #telehealth?

Let's talk a bit about what's going on in outpatient medicine during #COVID19.
You've heard a little (though probably not the worst parts) about what our frontline #healthcareworkers are experiencing. It’s harrowing at best, and in reality, it's a complete crumbling of our healthcare system to take optimal care of its patients and its workforce.
What you may not be hearing as much about in the media, but will affect every one of you, is what’s happening with clinics and outpatient care.

Because almost everything has changed.
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HOW TO TREAT ACTINIC KERATOSES AT HOME, a #tweetorial/#medthread

AKA:how to keep practicing #socialdistancing in the era of #COVID19 by staying at home and taking care of those precancers without having to come to clinic!

#dermtwitter #medtwitter #MedEd #FOAMed pc:@dermnetnz
1st, a caveat. Nothing subs for an in person exam, so this is not free license to tx things without a derm eval.

The reason for this #thread is that as the doctor seeing all urgent #dermatology pts today, I've gotten MANY calls from pts hoping to come get their AKs treated.
Before we get to txs, let's start with the basics. What is an AK?

Clinically they are erythematous papules & plaques with gritty (sandpaper-like) scale. Some can be quite big. Then we call them "hypertrophic AKs."

These are precursor lesions to squamous cell carcinomas.
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BULLOUS PEMPHIGOID, a #dermatology #tweetorial!

#MedEd #FOAMEd #medtwitter #dermtwitter #medthread pc:@dermnetnz

A patient with active bullous #pemphigoid comes to see you. What do you expect on your exam?
#bullouspemphigoid (BP) is an autoimmune blistering disorder where the pt's immune system makes auto-antibodies targeting BPAg 1&2 (BP230/BP180). Since these Ags are in the hemidesmosome, the split is lower in the skin, making for tense blisters.

Clinically, tense blisters (as seen in BP) usually go with a negative nikolsky, whereas flaccid blisters (seen in pemphigus) would have a positive nikolsky.

An easy mnemonic is:
pemphiguS = Superficial
pemphigoiD = Deep
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ATOPIC DERMATITIS - a #dermatology #tweetorial/#medthread!

For all the #tweetiatricians, #primarycare, #medtwitter, & #dermtwitter! #MedEd #FOAMEd pc:@dermnetnz

1st, a question:
How do you think of the term atopic dermatitis (AD) in relation to the term eczema?
If you're a purist, "eczema" is a description. When a #dermatologist says something looks eczematous, it doesn't mean it's AD. It means it has a certain appearance.

So the right answer for purists is "AD can cause eczema."

That said, we so often just use eczema to mean AD🤷🏻‍♂️
As annoying as that might be, it's an important distinction. If you see an eczematous rash, you need to consider possible causes:

- Atopy
- Allergy/irritant contact
- Medications
- Venous stasis
- Dry skin

For more on contact dermatitis, check out @patchtestYu!
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A #tweetorial for the #dermtwitter, #medtwitter, #medstudenttwitter, and #hospitalist crowd. 📸:@dermnetnz #medthread

Let's start with a question - What percentage of leg ulcers do you think is caused by venous stasis?
Roughly half (40-50%) of all leg ulcers are the result of venous stasis! Since 1% of the population will get stasis ulcers at some point, it's quite common, both in the inpatient & outpatient settings!

While some say they aren't painful, many of my patients would disagree....
Let's talk exam. These ulcers are predominantly on the lower legs, and often near the medial malleolus. They're usually chronic, so they may have a base covered by yellow fibrinous debris. They tend to be shallow, and given the pathophysiology, quite exudative.
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Bit of a different #tweetorial today, on:


- TIPS for the PRIMARY TEAM calling the consult.

Caveat: Some examples are a little #dermconsult specific, but can be extrapolated to others!

#medthread #dermtwitter #medtwitter #meded #FOAMEd #tipsfornewdocs
As both a #dermatologist & a #hospitalist, I have the pleasure of being on both ends of the #consult game.

So, your team has decided to call a consult, and you are the intern or student who has been tasked with contacting the team. Don't be nervous! Try these tips!👇👇👇
First of all:

1)Have a consult question

Asking a consultant to see a pt w/o a ? is like having a pt see you w/o a chief complaint! The ? helps the consultant frame the note in a way that is most helpful for you & your team. Otherwise, I'm guessing at what you want to know.
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All right #medtwitter, ready to feel itchy? Get your Sarna ready and read on for a #tweetorial/#medthread on....


#dermtwitter #dermatology #MedEd #FOAMEd pc: @dermnetnz #derm #itch #pruritus
What exactly is scabies? Sarcoptes scabiei var. hominis is the technical name of this parasitic mite that burrows into the skin (itchy yet?😆). It is notoriously difficult to diagnose, and has humbled many a #dermatologist.

It has a very characteristic look under the scope!
On exam, most know the classic distribution: interdigital spaces (pic1). However, other places to look include the areola, axilla, and umbilicus. In kids, the lesions tend to be all over the place (perhaps because they aren't as good at scratching them off! - pic2).
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Hello new followers!👋 In honor of your joining me on Twitter, I thought I'd put together a new #dermatology #tweetorial/#medthread. This time, on a topic near and dear to my own clinical practice:


#MedEd #FOAMEd #Dermtwitter #Medtwitter pc: @dermnetnz
Let's start w/ caveats:
1-#MycosisFungoides (MF) isn't the same as Cutaneous T-cell Lymphoma. MF is a subtype of #CTCL; there are many other types of CTCL that aren't MF.
2-I co-direct the Skin Lymphoma Program @MGHCancerCenter, so some of this is institutional preference.
There are roughly 80,000 new cases of #lymphoma a year in the US, and only 3% are primary cutaneous. Within that ~2500 cases, MF makes up almost half (~44%)! The overall classification schema for these diseases was recently updated by the WHO:…
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All right #medtwitter, you asked, & I'm going to try to deliver. Here's a #tweetorial/#medthread on...


***I'm not a hair expert, but hopefully this will just provide a framework to think about this problem***
#dermtwitter #MedEd #FOAMEd #dermatology pc:@dermnetnz
Let's say a patient complains of his/her hair falling out. In the spirit of examining first as #dermatologists tend to do, let's start with the exam. This is the easiest way to differentiate between the two types of alopecia: scarring and non-scarring. What do you look for?
While all the above options can help with the ultimate diagnosis, it's the preservation of follicular ostia (or loss of said finding) that helps point you in the right direction. Whether it's scarring or non-scarring can really help narrow your differential.
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It's #tweetorial time! Read on for a #medthread on:

Cutaneous Small Vessel #vasculitis (CSVV)!

#MedEd #FOAMEd #dermtwitter #dermatology #medtwitter #rheumtwitter pc: @dermnetnz
I've heard different ways to organize the vasculitides over the years, but by the far the most common is by vessel size. As a #dermatologist, I see the small vessel vasculitides most often, so we'll focus on that today. Yes, Takayasu's important, but I'll save that for later!
There is a relatively limited list of possible diagnoses with CSVV. I've included the most common below.

The blue I lump together as they are similar, and biopsy results help you differentiate.
The red are the ANCA-associated.
The green are the unique ones.
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In honor of my recent trip to Taiwan, where I was eaten alive by mosquitoes, I thought I'd put together a #tweetorial/#medthread on...


#dermtwitter #dermatology #dermatologia #medtwitter #MedEd #FOAMEd pc:@dermnetnz
First of all, did you know that #dermatologists refer to bug bites and stings as an "arthropod assault?" In case you ever wanted to throw that into your next conversation....
While there are some rashes that can be classic for certain types of bites/stings, many are rather nondescript. So when you see a #dermatologist with what looks like bug bites, we are often making an educated guess. Classically, you see pink edematous papules/plaques.
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In honor of #skin #cancer awareness month, here's a #tweetorial on #SKINCANCER!

There is SO much we could talk about, so I'm going to keep it basic. #Dermtwitter, please add more!

#MedEd #FOAMed #dermatology #medtwitter @aadmember #dermatologia pc: @dermnetnz & @aadskin
There are many types of skin cancer, but we'll focus on the big 3 in this #thread. We'll discuss basal cell carcinoma (BCC), Squamous cell carcinoma (SCC) & melanoma. The first two are types of "non-melanoma skin cancer (NMSC)," or more aptly named "keratinocytic carcinomas."
BCCs are the most common cancer diagnosed. Classically described as "pink pearly papules," they often have "arborizing" (tree-like) telangiectasias. But, they don't always have to look classic. The 1st pic is the classic, but the others are also BCCs (superficial & pigmented)!
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Get your #dermatology jokes out now, because this is a #tweetorial/#medthread on....


Read on for tips on how to prescribe them, which one to choose, when does it matter, etc.

#MedEd #FOAMed #dermtwitter #medtwitter #dermatologia pc:@dermnetnz
Truly the workhorse of the #dermatologist's medicine chest, topical steroids are great for a multitude of reasons:
- Delivery straight to the organ of interest
- Systemic absorption is usually minimal
- Can be cheap (usually)

What on skin exam best suggests steroids may work?
Erythema is a great indicator that there is inflammation. As such, topical steroids may be a good treatment option. However, there are some reasons NOT to use topical steroids. For example, if the rash is infectious (eg: tinea in photo1, herpes in photo2), steroids = no bueno.
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#Dermatology #tweetorial time! Let's spend some time on the autoimmune blistering diseases. There are many, so this will be a broad overview of the approach to a the bullous disease patient.
#dermtwitter #FOAMed #medtwitter #medstudenttwitter #MedEd @healourskin pc:@dermnetnz
The first ? we usually ask: "What is the level of the split?" That helps to distinguish between the #pemphigus group of diseases where the desmosome is involved in the epidermis, and the #pemphigoid group where the hemi-desmosome is involved at the basement membrane zone.
This correlates with the exam! Higher up in the epidermis means a thinner walled blister that's more fragile. So these are usually flaccid bullae. Deeper down means tense bullae. Photo 1 is pemphigus - see how droopy the bulla is? Vs photo 2 of pemphigoid, which stands up.
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OK #hospmed19, I had told myself I wasn't going to make another #tweetorial until next week to give myself a break, but I can't help but be motivated by all the amazing #tweeps at this meeting. Long story short, here's a #medthread on #PSORIASIS!

#MedEd #FOAMed PC:@dermnetnz
More and more, we are recognizing psoriasis to be a systemic disease. Aside from the psoriatic #arthritis we all know and love, there is more convincing evidence that psoriasis is linked with #cardiovascular disease and risk. As such, #multidisciplinary care is important!

There are many different variants of psoriasis. The most classic is plaque psoriasis, described commonly as "salmon colored plaques with micaceous scale."

Q: Ever notice how psoriasis doesn't really get impetiginized/superinfected but eczema does? Why do you think that is?

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