The Second Edition

 

December 7, 2017

 

Back in August of 2017 I launched a dermatology tool named "Dermatology Dosing, Workup, & Management Card." Before I ever launched this pocket card, as I was compiling its contents, it was only ever intended to be used for personal use. However, I thought it may be of help others so I made it available to residents, medical students, and practicing dermatologists around the country. The demand for the pocket card has been positive, so I decided to continue to refine it. I've since updated the card by adding more content, improving existing content, and making the card more easily readable.

 

The proceeds of the dosing card are used for a larger cause. Revenues go directly into funding website hosting for dermeducate.com, a free board review question bank and mnemonics library. At Derm Educate, my co-residents and I write challenging board review questions that require multi-step reasoning. Most of these test questions require the recognition of high-quality images (kodachromes).

 

New additions to the 2nd Edition Dermatology Dosing, Workup, & Management Card include:

 

·         New dermoscopy section for melanoma & NMSC

·         Expanded antifungal medication interactions

·         HSV prophylaxis for dermabrasion, lasers, chemical peels

·         Expanded antibiotic prophylaxis instructions

·         Ruler for measuring excisions & pigmented lesions

·         New suggested suture removal times

·         Organized box for post-inflammatory hyperpigmentation, hyperhidrosis, and vitiligo depigmentation

·         New angioedema section

·         New auto-immune connective tissue diseases section

·         New urticarial vasculitis section

·         New pseudoporphyria culprit drugs
 

Improvements to the card include:

 

·         Color-coded treatment tables, easier to read

·         Updated acne, rosacea, psoriasis, and atopic dermatitis pathogenesis.

·         Updated actinic keratoses treatments and efficacies

·         Updated melanoma mutations

·         Updated anti-histamines

·         Updated alopecia workup

·         Updated topical antiseptics

·         STDs reorganized & treatments updated

 

Detailed contents of the card are listed below.

 

 General Dermatology:

 

·         Atopic dermatitis: cytokines involved, treatment ladder & management for mild to severe atopic dermatitis.

·         Acne: cytokines involved, subtypes & treatment ladder & management

·         Rosacea: subtypes & treatment ladder & management

·         Psoriasis: cytokines involved, treatment ladder for mild to severe psoriasis

·         CTCL: workup, biopsy technique & treatment ladder & protocols

·         Actinic keratoses: monotherapy & combination therapy protocols

·         Surgery: proper surgical margins, Langer's lines diagrams, 5-year survival data for melanoma depending on Breslow thickness, suture removal times

·         Topical corticosteroids: most commonly used classes & formulations

·         Topical steroid sparing agents: Tacrolimus & Pimecrolimus formulations

·         Topical antibiotics for acne & rosacea, formulations & dosing

·         Antihistamine options & dosing

·         Antipruritic drugs & uses

·         Cryotherapy protocols depending on lesion treated

·         Post-inflammatory hyperpigmentation treatments

·         Hyperhidrosis treatments

·         Vitiligo depigmentation
 

Workup Boxes:

 

·         Unknown Rash differential diagnosis

·         Generalized pruritus workup

·         Urticaria workup

·         Angioedema workup

·         Alopecia workup

·         White macule workup & differential diagnosis

·         Pustular eruption workup & differential diagnosis

·         PG-like ulcers workup & differential diagnosis

·         Biopsy sites for DIF

·         Auto-immune connective tissue disease workup for: photosensitivity, lupus, dermatomyositis, scleroderma/CREST syndrome

·         Cutaneous vasculitis (purpura) workup

·         Urticarial vasculitis workup

·         Retiform purpura workup

·         Erythema nodosum workup

·         Stevens Johnson Syndrome/Toxic Epidermal Necrolysis prognostication (SCORTEN) and treatment.
 

Anti-Microbials:

 

·         Topical antifungals: best and most commonly used formulations, listed in progressive order.

·         Systemic antifungals for tinea pedis & corporis: proper dosing, duration, and treatment outcomes

·         Systemic antifungals for onychomycosis: dosing and duration

·         Systemic antifungals for tinea capitis: dosing, duration, & selection based on organism

·         Systemic treatment options, dosing, & duration for HSV infections (labialis, genital HSV, & Zoster)

·         Verruca Vulgaris & Condyloma Accuminata most common organisms and treatment ladder

·         Molluscum contagiosum treatment ladder

·         Antiparasitic topical and systemic treatment dosing & duration.

·         Systemic bacterial antibiotics most commonly used in dermatology & dosing.

·         Pre-op antibiotic prophylaxis dosing & timing.

·         Topical antibiotics for impetigo, wound infections, nasal MRSA eradication, pseudomonas, cutaneous MRSA, fungus, & yeast.

·         Sexually transmitted diseases, their presentations, first line treatment, & second line treatment.
 

Complex Systemic Medications:

This section includes the dosing, labs to order before & during therapy, side effects,interactions with other medications, mechanism, pregnancy category, & cost of the following commonly used complex systemic medications in Dermatology:

 

·         Isotretinoin

·         Acitretin

·         Bexarotene

·         Prednisone

·         Methotrexate

·         Azathioprine

·         Cyclosporine

·         Mycophenolate Mofetil

·         Hydroxychloroquine

·         Thalidomide

·         Dapsone

·         Colchicine

·         Cyclophosphamide

·         IVIG

·         Apremilast

·         Etanercept

·         Infliximab

·         Adalimumab

·         Ustekinumab

·         Secukinumab

·         Ixekizumab

·         Rituximab

·         Omalizumab

·         Dupilimab

·         Targeted Immunotherapies: Ipilimumab, Prembrolizumab, Vismodegib, costs, side effects & mechanism
 

Physical Modalities in Dermatology:

 

·         PUVA: ideal candidates, protocol, starting dose & dose escalation based on skin type, dosing of 8-methoxypsoralen, clearance schedule, maintenance schedule, adverse effects.

·         nbUVB: protocol, starting dose & dose escalation based on skin type.

·         Photodynamic Therapy (PDT): protocol & adjuvant therapy

·         LASERs: the most commonly used lasers, their wavelengths, indications, & off-label uses. Also includes all the treatable chromophores, thermal relaxation times (TRT) & pulse duration required to destroy chromophores.
 

Drug Rash Section:

The most common drug rashes and their culprit medications

 

·         Exanthematous

·         Urticarial

·         Fixed drug eruption, 

·         AGEP 

·         DRESS/DIHS

·         SJS/TEN

·         Photoallergic 

·         Vasculitic

·         Linear Ig-A bullous dermatosis

·         Pseudoporphyria

·         Drug-induced systemic lupus 

·         Drug-induced SCLE

·         Drug-induced psoriasis

 

The Start

 

August 2, 2017

 

My name is Tarek Shaath. I’m a 2nd year dermatology resident at Florida State. We’re a new program at FSU and I was one of two inaugural residents. With that, my co-resident and I had no senior residents to help guide us with respect to managing patients, prescribing medications, or studying. We had to navigate clinics and find resources on our own, without help from people in our shoes. Nothing was handed to us.
 

One of the most daunting tasks as a new resident is knowing what to do when a patient presents with something as simple as advanced acne or rosacea, or as vague as diffuse pruritus, or as complex as vasculitis or lower extremity ulcers. For something even as simple as tinea capitis, which antifungal should you prescribe? Which labs do you want to order before starting someone on azathioprine, or cyclosporine, or a biologic? There is an enormous fund of knowledge young physicians need to have at their disposal in order to practice dermatology. I knew I couldn’t absorb all of this information quickly, so I started creating a dosing card early in my residency. Over the past year and a half I’ve scoured recommendations from authoritative textbooks and articles in dermatology from Bolognia, Wolverton, and others. What I came up with is a broad and detailed pocket card that explains how to manage common dermatologic conditions, how to workup complicated presentations, and how to dose and manage complex systemic drugs. Another important section includes physical treatment modalities. How to start a patient on phototherapy (PUVA/nbUVB), photodynamic therapy (PDT), and which lasers to use for different conditions are all important.
 

Dermatology residency is a quite the humbling experience. It is one of the few fields where young residents who have previously been at the top of their class in medical school arrive on day one and feel completely lost. I created this dosing & management card from that exact perspective--from the viewpoint of a first year resident who did not know how to practice dermatology. Although this card is intended for dermatology residents, it will unquestionably help any medical student raise their capability to take care of patients and thus shine on a rotation. As a medical student on dermatology rotations I was dumbfounded with complex patients and medicines. I had no clue where to start or what to do. Its questions like these that this dosing card answers.
 

This card is exquisitely detailed and has over 4700 words; it is not meant to be read from start to finish. It is meant to be used as a reference tool in the clinic on a case by case basis. Once you know with which disease process or symptom your patient presents, proceed to finding the corresponding diagnosis or presentation on the front side of the card, and follow the recommended management and treatment steps. When you intend to prescribe a complex systemic medication, find the medication on the back of the card and make sure to order the recommended baseline labs prior to starting the medicine while also understanding the medication’s side effects and interactions.

 

With your purchase of this reference card you are supporting my passion to create valuable learning tools and disseminate knowledge in a digestible, accessible manner. I would appreciate you sharing this card with your colleagues. My intention is to raise awareness about this pocket resource since no such resource exists specifically for dermatologists and those pursuing the field. I will always keep the price low, and the little proceeds generated will be given to charity.
  

This reference card lead to the development of this website, where I intend to create free learning tools for dermatology residents and medical students.