Discover and read the best of Twitter Threads about #dermatology

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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).
Read 14 tweets
In spite of the atrocious and impolite behavior of dermatologists in my global region, I still promote their #BIGPHARMA consensus of HS. 😎 #HidradenitisSuppurativa
I don't hold a grudge. It's the HS community that does things like that. I'm here for the greater good. And it has cost me. Bigtime.
So dudes, when you publish stuff about the VOICES of HS patients and how inclusive you are in regards to patient involvement in research, all I hear is a public relations exercise.

Not just a personal opinion.

I have lived experience.

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Hello #medtwitter & #dermtwitter, time for another #dermatology #tweetorial! Let’s go back to the basics and talk about:


Hopefully this #meded/#foamed moment is helpful for all the #maskne in the #covid19 era!

Let’s start with a simple question:
What causes acne?
All of the above! Often, every one of these factors plays some role. What’s important is knowing what treatment to emphasize based on what factor seems to be the biggest influencer.

For example:
-Retinoids for cell turnover
-Ocps for hormones
-Antibiotics for bacteria!
Let’s talk exam. When I see an acne patient, I’m looking for what lesion I see most: comedones (white/blackheads), inflammatory papules, or cysts.

I’m also looking at distribution (where on the body) and the severity.

It’s critical to ask if it’s a good, typical, or bad day!
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#Meded faculty: please stop actively discouraging your #URM #medicalstudents from pursuing competitive specialties! I hear this almost weekly & it never ceases to shock me to hear how often medical educators kill students' dreams.

I've lost count how many times I've had a #URM / #UIM #medicalstudent tell me they were discouraged from pursuing a competitive specialty and should pursue primary care.

I've lost count how many times I've had a #URM / #UIM #medicalstudent tell me that their #Step1 score is why they aren't pursuing #dermatology. And in the majority of these times, the score is >220, often >230.


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A #medtwitter #dermtwitter #tweetorial! #MedEd #FOAMEd

This is a drug reaction that we can see on inpatients, with an exam full of pustules!

Let's start with a question - How long after drug exposure does AGEP appear?
The correct answer is 24-48 hours!

The other answers are typical time frames for other types of reactions.
Urticaria usually manifests minutes to hours after drug exposure.
Morbilliform drug eruptions occur 4-14 days after drug exposure.
DRESS occurs 2-6 weeks afterward!
Unlike DRESS and morbilliform eruptions, AGEP doesn't require repeated exposure of drug. So one single dose can definitely cause AGEP. A typical place we see this is with perioperative antibiotics!

Common culprits are Penicillins, quinolones, sulfa, antifungals, and CCBs!
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I want you to do a thought experiment, and it'll show how disparities have been baked into #dermatology education. Imagine you're learning about atopic dermatitis for the first time. You've never seen it before. This is what your instructor shows you: #dermtwitter #medtwitter
The next year, you have a different lecture, and these are the photos you see:
Great, now you feel confident with diagnosing atopic dermatitis! You go to clinic and see this... wait what?
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#Doctors and #Medicine need an #AI update.
Bold and convincing book.

#ArtificialIntelligence has the ability to bring the fourth industrial revolution. Healthcare is deemed to be an industry which can get transformed the most.

@EricTopol is a #cardiologist, historian of the present and a #MedicalFuturist.
He believes that the way we practice medicine now ( #ShallowMedicine ) relies too heavily on human inputs and is thus plagued by human biases and imperfections.

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"Ever get the feeling you've been cheated?" (John Lydon)

The publication of this letter & the nature of its correction raises questions about the reliability of the academic record.

@llantwit @FFLMUK @RCPath @AAPTTweets @mike4path @Richard56 @JJPJ #autopsy


When the letter by Won Sriwijitalai & Viroj Wiwanitkit was published in #JFLM, fact-checking journalists @SureAndShare in Thailand shared their concerns about it on @Twitter & @Facebook.

@SureAndShare were concerned that they were unable to verify who the 1st author was (or where they worked), or the death of a #forensic #medical professional from #COVID19. They cautioned against sharing the story.

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Currently here and hoping to livetweet as much as I can. Discussing interferon-mediated disease and what role these pathways may play in #COVID19.
In SAVI and CANDLE syndrome, which are mediated by the interferon pathway, Jak inhibitors help inhibit the positive feedback loop.
How do we think about the pernio-like lesions associated with #COVID19? Note, we are still trying to establish the causal relationship. But this @JAADjournals paper had some interesting thoughts:…
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My take on POTUS and his announcement that he's taking prophylactic #Hydroxychloroquine :

We have no idea if he is actually taking it. His track record for truth telling is...well...nil. We can speculate on why he would say it though...

Regardless, 2 points:
#Hydroxychloroquine is a life-saving drug that is prescribed by many doctors for many different patients who actually need it for serious illness.

In #dermatology, we are very, very familiar, and comfortable, with this drug.
Does it have potentially deadly side effects?
Does nearly every drug?
Yes. Including tylenol and ibuprofen.

The conversation around HCQ muddies up the waters around the actual benefits of this drug for inflammatory and autoimmune diseases (ie, lupus).
Read 13 tweets
All right #dermtwitter & #medtwitter, it's time for the...

@MedDermSoc & @DermHospitalist Mini-Symposium on #COVID19 & #dermatology!!

I will be attempting to #livetweet the Zoom meeting!

Join along if you'd like. I will be using the h/t #COVIDDerm!

@RoxanaDaneshjou @dschless
Let's get started!!!!

Your cohosts are super excited to have you join. To give a little background, this meeting was planned in ~1 week, and we have over 500 RSVPs!

@MishaRosenbach now kicking us off with #COVIDDerm! Image
.@DrEstherFreeman is speaking and reminding us all to register our #COVID19 #dermatology cases in the @AADskin #COVID registry!

Reminder to do so here:

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It is an enormous pleasure to be part of this #paper: #COVID-PIEL, the Spanish muticentric study of the #cutaneous manifestation of #COVID19 has just been published in the prestigious journal British Journal of Dermatology! 375 patients included! Conclusions here 👇 (#thread)
A new classification of #skin manifestations of #COVID19 is proposed: 1. Acral areas of erythema-oedema with some vesicles or pustules (19%); 2. Other vesicular eruptions (9%); 3 Urticarial lesions (19%); 4. Other maculopapules (47%) and 5. Livedo or necrosis (6%)
1⃣ Acral lesions, #COVIDtoes, pseudo-chiblains..., affected young patients and lasted a mean of 12,7 days to appear in the course of COVID. They were associated with less severe disease. Itchy (30%) or painful (32%).
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Alright y'all, whose hands are taking a beating from #COVID hand-washing, or face acting up with breakouts?

BC if you’re like me, your skin might be needing some extra TLC right now.

Here's a fun tweetorial on some tried & true, dermatologist-recommended skin care tips:
So, why can I tweet about this & why am I tweeting about this?

✅Well, it’s what I do for a living. I'm a board-certified dermatologist, 10 years in. Dermatology isn’t just skin care & acne, but it’s a lot of skin care and acne, so us #dermatologists are really good at it./2
✅I know you probably can’t get easy access to your doctor right now. Between #SocialDistance & doctors’ offices in essential-care-only mode (& much of this is not "essential care"), access is harder. I want you to have the information you need right now but can’t get as easily.
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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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Dermatologist are seeing more and more #skin symptoms related to #COVID19 . Acral lesions (i.e. hands and feet) are particularly frequent, specially in #children and #youngadult with no or few COVID symptoms. After seeing many cases, here is my vision: #Thread 👇
I think that these kind of lesions can be classified in four types. 1. Chilblain-like lesions, which are the most described, usually affecting many fingers / toes, either symmetrically or not. Pruritic and/or painful.
2. Insect-bite like lesions, that may also appear in the palm and the soles. Very #itchy and persistent (more than 2 weeks in some cases)
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🗂️THREAD: U.S./global #COVID19 clinical/research patient/healthcare worker registries seen on #medtwitter

Many specialty-society/focused registries launched in last few weeks, attempt to collect them here

List 👇🏽

2/n: @SCCM's VIRUS: Viral Infection and Respiratory Illness Universal Study @covid19registry

Inclusion criteria 👇🏽…

Find out if your site is already enrolled:…

#Pulmonology #Pulm #CriticalCare #PCCM
3/n: International #COVID19 Dermatology Registry led by @DrEstherFreeman @AADskin

Looking for:
1. #COVID19 pts who develop #skin findings
2. #dermatology pts who develop #COVID19

h/t @DrStevenTChen #dermtwitter
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Patients with autoimmune diseases, such as #lupus and #RheumatoidArthritis, are having trouble filling their prescriptions since Trump touted their medicine as an experimental treatment for #Covid19. /thread…
“The hasty and inappropriate interpretation of the literature by public leaders has potential to do serious harm" write 2 rheumatology experts in the Annals of Internal Medicine.…
FL pharmacists report "nearly all of the new prescriptions for #hydroxychloroquine are being issued for the prescribing practitioners themselves or family members of the prescribing practitioners." Some drs are prescribing it to healthy people as a #Covid19 preventative.
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2nd installment of #dermtwitter #DistanceMedEd. Today's #tweetorial will be a brief one on...


#MedEd #FOAMEd #dermatology #medtwitter

PC: @dermnetnz
First things first - some definitions:
Vesicle: fluid filled <1 cm
Bulla: fluid filled >1 cm
Pustule - Filled with pus
- Ahem, the word you're looking for describe something with a lot of pus is "purulent," not what you're thinking....🤨
Next, the name is self explanatory. The vesicobullous pattern implies you're seeing vesicles or bullae. There is one very important exception:

If you see COLLARETTES of scale (round pattern of scale remnant), these can indicate a prior vesicle or bulla (like an old footprint)
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In an effort to conserve #PPE & increase #socialdistancing, many #dermatology services have switched to a heavily #telemedicine model. So today, I present to you:

HOW TO TAKE PHOTOS & CALL A #DERM CONSULT - a #covid19 era #tweetorial.

#MedEd #FOAMEd #dermtwitter #medtwitter
Let's start with appropriateness of consult. We are trying hard to limit nonurgent consults for the above reasons. The following can wait for when #coronavirus isn't everywhere.
- nonmelanoma skin CA
- old rashes with a known dx
- missed a derm appt and happens to be in house
If it's an urgent issue, it's helpful to start with the photo. Any camera phone should be fine. If on Epic, you can use Haiku to upload directly the the EMR.

NB: texting photos isn't HIPAA compliant. We'll usually refer to the EMR, or email the photos in a secure system.
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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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STAPHYLOCOCCAL SCALDED SKIN SYNDROME - A #dermatology/#dermtwitter #tweetorial!

Let's start with a question: You are seeing a new patient with a rash you suspect of being SSSS, but aren't sure if it might be bullous impetigo.

What test will help you differentiate the two?
The correct answer is wound culture! SSSS should be sterile or skin flora; bullous impetigo will have lots of staph grow out. Keep reading to find out why! 👇

But before we get there, let's talk about the SSSS exam. The pic is a good example of "sad facies." pc:@dermnetnz
The other great clue you are dealing with SSSS is the predilection for skin folds. This eruption can cause a high BSA of erythema --> desquamation.

SSSS is more common in the #pediatrics population, especially in kids <5 years of age (for all the #tweetiatricians out there!)
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