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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?
Read 18 tweets

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
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!
Read 16 tweets
My rules for writing academic manuscripts: a #tweetorial

I love writing, and write with students/colleagues constantly, and yet the same issues pop up again and again.

Sharing this thread if useful. My take, everyone has a different style. #medtwitter #dermtwitter #meded
1. Communication is your number one priority.

The point of your manuscript is to tell a story or argument that the reader will receive. Your writing should easily walk the reader through your research or editorial. Never forget that.
Many people, especially students, have a “show all your work” mentality, perhaps afraid the reader won’t trust their authority. Data is important (yes, do the work), but only show as needed or you will bore the reader. You need a narrative, or you’ll lose people’s attention.
Read 26 tweets

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!
Read 12 tweets
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?
Read 7 tweets
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:…
Read 31 tweets
Recently, I had the opportunity to help create some LGBTQ curriculum for the @harvardmed derm program with @EricaDommasch and @DrKlintPeebles. Since I've been getting some questions about the topic, I figured I'd make a tweetorial 🧵

#MedTwitter #MedStudentTwitter #DermTwitter
This will focus on the derm issues that the transgender community may face. Some disclaimers to start with: just as gender identity exists on a spectrum, these manifestations may present in a variety of gender identities and should be considered as such. 2/
Additionally, for the ease of organization, they are presented in “transmasculine” and “transfeminine” categories, but these conditions are not necessarily exclusive to any one gender identity. So let's begin with derm conditions affecting transmasculine persons... 3/
Read 29 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:

Read 39 tweets
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.
Read 48 tweets
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.
Read 12 tweets
🗂️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
Read 11 tweets
Day 3 of #DistanceMedEd for #dermtwitter and #medtwitter! We've done 2 of the 5 reaction patterns so far, so let's focus in on the....

DERMAL reaction pattern!

#MedEd #FOAMEd #tweetorial #medthread PC: @dermnetnz
As opposed to the papulosquamous reaction pattern, the dermal pattern implies the action is DEEP in the DERMIS. This means that without epidermal alteration, you shouldn't see scale!

There is of course an exception with overlying xerosis or if you have another process on top!
When you see something dermal, you have to think about what is infiltrating the skin. A few possibilities/examples:

Edema/fluid 👉 urticaria (1)
Inflammatory cells (reactive) 👉 granuloma annulare (2)
Inflammatory cells (cancer) 👉 CBCL (3)
Collagen 👉 Morphea (4)
Read 8 tweets
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)
Read 10 tweets
Motivated by @TedWJamesMD to put together a #dermtwitter/#medtwitter #tweetorial for #DistanceMedEd today.

Let's do one about PAPULOSQUAMOUS DISORDERS of the skin.

What would be a good example of a papulosquamous rash you might see on #skinexam?

PC: @dermnetnz
Psoriasis is the perfect example of a papulosquamous disorder. Before we break down what this means, let's start with the basics. I was taught that skin rashes & lesions fall in one of 5 reaction patterns:
- papulosquamous
- eczematous
- vesicobullous
- dermal
- red (vascular)
By knowing which category each rash/lesion is, you can limit your Ddx.

For example:
If something is both vesicobullous and eczematous, you're probably dealing with some type of eczema.
If you're dealing with something dermal, you can probably take psoriasis off your ddx!
Read 9 tweets
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.
Read 9 tweets
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.
Read 13 tweets
A Dermatologist's Survival guide to #COVIDー19 handwashing. Your hands are probably raw from water, soap, hand sanitizer. All of the above can be irritants, made worse if you already suffer from eczema. So here are some tips! #medtwitter #dermtwitter #CoronaVirusUpdates
1) Try to avoid scented products if possible. Many of the ingredients used in scented products can be irritated or cause an allergic reaction. Unscented Dove bar soap is a good place to start for sensitive skin.
2) Have thick emollient available - something that is thick and comes in a tub (Cetaphil, CeraVe are options). Personally, I go for GREASY because that is most protective. Yup, I go straight for the vaseline. Nothing that comes in a pump bottle or is runny.
Read 6 tweets
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
Read 13 tweets
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!
Read 16 tweets
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!)
Read 14 tweets
Why exactly do the lesions in pityriasis rosea appear in the “Christmas Tree” pattern?

Well, in honor of today being #Christmas, let’s do a brief #dermatology/#dermtwitter #tweetorial on…


So what say you? What’s the reason for the Xmas Tree pattern?
PR presents in "Langer's Lines," aka the skin tension lines. This paper notes diseases in this pattern seem to have activated leukocytes in the pathophy, which could be explained by other papers looking at how skin stretch impacts immune response!…
This same paper points out a limited group of skin diseases that can have this distribution:

- PR
- Secondary syphilis
- Sign of Leser Trelat
- Mycosis Fungoides

Ultimately, the cause of this distribution might have to do with skin tension, but is best described as unknown.
Read 11 tweets
“The Erythemas” – A #dermatology #meded #FOAMEd #tweetorial. pc:@dermnetnz

Ever get all the different #dermatologic terms jumbled up? Was it erythema nodosum, erythema migrans, or erythema multiforme?

Honest poll – Ever write “rash” b/c you couldn’t remember the diagnosis?
All kidding aside, these terms can get confusing. Remember though, derm terms are usually just descriptors of what you see. The name tells you all you need to know.

For example: Acute Generalized Exanthematous Pustulosis (AGEP) = pustules suddenly appeared everywhere!
So, the “erythemas.” First off, what does “erythema” actually mean? Well, according to my Google machine, it's from the Greek root “eruthros” meaning “red.” So "erythema" doesn’t add much to our knowledge of what the rash looks like other than it’s red, and so, likely inflamed
Read 15 tweets

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