© 2007 fitzgerald health education associates, inc© 2007 fitzgerald health education associates,...

© 2007 Fitzgerald Health Education Associates, Inc

Fitzgerald Health Education Associates, Inc. 1

The Latest Advances in Dermatology

Victor Czerkasij, MA, MS, FNP-CAssociate Lecturer,

Fitzgerald Health Education Associates, Inc.North Andover, MA

Histotechnologist/Family Nurse PractitionerSkin Cancer and Cosmetic Dermatology, PC

Dalton, GA and Cleveland, TN

Objectives

• Having completed the learning activities, the participant will be able to:– Understand best practices in

continual dermatology training.– State updates that affect the public

in general, providers in particular.



• Having completed the learning activities, the participant will be able to: (cont.)– Be familiar with common diagnosis

with new approaches.

Objectives (continued)


Dermatology Breakdown

• Cosmetic dermatology• Dermatopathology• Mohs surgery• Pediatric/geriatric emphasis• Immunodermatology• Radiobiology in dermatology• Teledermatology


Skin Care is Attention to Detail

• Balanced nutrition and hydration• Cool bathing and moisturization• Sleep and rejuvenation habits• Accepting intrinsic aging (i.e. normal

maturing with prevention)• Limiting extrinsic aging (i.e. UVR,

pollution, smoking, drugs, etc.)


Skin of Color Update

• Aging rate is clearly delayed.• Pigmentation issues are paramount.• Laser hair removal (LHR) gold

standard is Nd:YAG laser.• Discoid lupus erythematosus (DLE)

much increased in ethnic women• Exercise keloid awareness



Nuances of Skin Color


Type I II IIII IV V VIThis is the classic Fitzpatrick skin

ranking chart which ranks depth of melanin from “fair and flawless” to

“black and beautiful.”

Lupus Erythematosus

• Blacks and Hispanics are 4x more likely to develop DLE, have poorer prognosis, and higher mortality than Caucasians.


Keloids


• Tribal tattooing and subsequent scar formation is understood as desirable in certain cultures.

• Darker skin types are prone to keloid development due to high collagen levels.


Keloids(continued)

• Hyperproliferative collagen response

• Hypertrophic scars are limited.

• Keloids take a life of their own.

• Withhold elective cosmetic piercing where possible.


• Use normal tension in surgical closings as tighter suturing may trigger the keloid cascade.

• Mid-chest and scalp are often classic areas for keloid development.


Keloids(continued)


Keloids(continued)



© DermAtlas

• Pseudofolliculitis barbae contributes to keloid formation in certain men. An approach of hydrocortisone 1% cream QHS and clindamycin 1% gel post shave prevents development.

Keloids(continued)

• Common piercings contribute to keloid development.

• Excision is exactly what not to do.

• Series of 40 mg per cc IL suspension triamcinolone very helpful


Keloids(continued)

Compact Fluorescent Light (CFL) and Ultraviolet Light

• Two studies, European and American, replicated findings that showed considerable UV emissions from CFL bulbs that damaged healthy human skin.

• Incandescent bulbs demonstrated no damage to skin except to touch.



CFL Bulbs and Harmful Effects

• Engineered to produce light at lesser energy

• Phosphor coating on every bulb studied cracked with use.

• UVA and UVC leakage significant within four feet


CFL Bulb Best Use Policy

• Avoid use within four feet.

• Place glass between bulbs and people.

• Check bulbs for titanium dust cracking on surface.


The Sun, Skin and Vitamin D

• Flawed reasoning: “We are a vitamin D deficient society.”

• Worse: “Sunscreens rob us of important levels of vitamin D, so sunscreen is useless.”

• “Tanning beds increase vitamin D.”



Vitamin D

• Added to more foods than ever

• Vitamin D levels now a routine test for some.

• Vitamin D sales rose 82% from 2008-2009.


Harvard School of Public Health Study March, 2011

• Our society is deficient in vitamin D, and associated with many illnesses.

• 1-2,000 IU vitamin D per day safe• Sunlight not the best source for

vitamin D • Only 5 minutes per day required at

noon for Caucasians in summer. The shocking finding...


The Perils of Too Much Sun

• Once exposure is met further UVB radiation causes vitamin D to break down into inactive compounds.

• Safest course is diet and nutritional supplementation



FDA Final Sunscreen Rules

• Effective December 2012• Product must pass broad-spectrum

tests.• Must prove anti-aging and skin

cancer prevention claims• “Waterproof” and “sweat proof” no

longer allowed.


The FDA Mathematical Formula to Determine Sunscreen

Effectiveness


http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm330694.htm, accessed 3.10.13.

FDA Final Sunscreen Rules (continued)

• If the product is not deemed broad-spectrum, a warning must be placed on the product which states it can only protect against sunburn, not skin cancer or photo aging.



Tattoos Have Been Around a Long Time, but Evolving


Tattoos Pose Health Risks

• 1 in 5 U.S. adults (approximately 60 million people) has at least one tattoo.

• Inks and the pigments used to color them can become contaminated by bacteria, mold and fungi.

– Source-http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm316357.htm, accessed 3.10.13.


Tattoos Pose Health Risks (continued)

• Nontuberculous mycobacteria (NTM) has been found in contaminated tattoo inks.

• Can cause lung disease, joint infection, eye problems and other organ infections



• Reactions are often color specific.



• Granulomatous reactions, impetigo, cellulitis, herpes simplex virus, viral warts, syphilis, leprosy, hepatitis and HIV have all been reported.



• Infections can be difficult to diagnose and can require treatment lasting six months or more.

• Keloids and scarring: White and yellow most difficult to laser




Henna Reaction

• Henna reactions are increasing when mixed with PPD (paraphenylenediamine), the so-called “black henna.”


Tattoos Require Sunscreen

• Often blistering and burning may result as the darker pigmentations will absorb more ultraviolet rays.

• This usually occurs in the early stages.


Contact Dermatitis in Tattoo



General Treatment Recommendations

• Simple dermatitis: High potency steroidal ointment BID on affected site x seven days

• Bacterial: Consider culture and sensitivity first


General Treatment Recommendations

(continued)

• If resistant and site is small and “flat plain,” consider simple excision.

• Laser: Advise the Medlite® C6 as it covers most colors.

• For future tattoos, rethink the ink: Freedom 2® and the One Pass®

laser. Fitzgerald Health Education Associates, Inc. 35

Tattoos


• 50% of people with tattoos will seek to have the body art removed sometime in the future.


Tattoo Removal

• Tattoo removal costs an average of $50 per square inch.

• Depending on the laser used can take at least eight treatments a month apart or more.


Tattoo Removal(continued)

• Treatment depends on size and color of the tattoo.

• A concern includes carcinogenic effects of pigment by-products in lymph nodes.


Tattoo Removal is Not Perfect



Tattoo Removal(continued)

• Tattoo removal often involves more pain, money and time for removal than the original placement.


Is a tattoo for you?

• The “no returns” policy: Is this really an artiste?

• Universal precautions mean they are “universal.”

• Single-use materials matter• Remind clients this is a

commitment longer than some marriages.


Is a tattoo for you? (continued)

• Life and career changes and quite a bit of change.

• Don’t hide the moles• Gee, I wonder if I scar? Or am I

allergic?



She met him first day…

• She met “Ruslan” online. The first day they met, had his name tattooed.

• Another, which reads “all for love,” above her eyebrow


Latest News for Biologics

• Phase II: Parallel, randomized, placebo-controlled trial with blinded 16-week and open label 36 week periods of adalimumab 40 mg EOW subQ for hidradenitis suppurativa.

• Dosing switched to once per week in second period


Hidradenitis Suppurativa

• Chronic scarring, painful cysts, foul odor

• Current conclusion is that adalimumab dosed once per week alleviates moderate to severe HS.



Biologic Research

• Pyoderma gangrenosum• Granulomatous diseases (i.e.

sarcoidosis)• Paradoxically, sarcoidosis is a

warning with biologics.• Vitiligo• Scleroderma


FDA Label Change to Finasteride 1 mg/5 mg

• Propecia® 1 mg for hair loss and Proscar® 5 mg for prostate hypertrophy has serious label changes as of mid-2012.

• Simply, it is not understood whether use of product leads to permanent sexual side effects.

– Source-http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm299754.htm, accessed 3.10.13.


• Issues currently are under investigation and complicated.

• However, while there is no direct causal proof established, it requires thorough patient/provider discussion.


FDA Label Change to Finasteride 1 mg/5 mg

(continued)


Psoriasis: More Serious Than First Understood

• Psoriatic arthritis (PsA) is found to occur in 42% of psoriasis patient.

• PsA affects distal joints.• Painful and debilitating• Methotrexate, anti-TNF-alpha or

combination is standard of care.



(continued)

• Cardiovascular disease increased with psoriasis due to chronic inflammation.

• There is a marked increase of coronary artery calcification and ischemic heart disease among the psoriasis population.


• Metabolic syndrome, a combination of obesity, dyslipidemia, glucose intolerance and elevated blood pressure, correlate highly with the psoriasis population.

• Several studies provide evidence that psoriasis and obesity are linked.



(continued)


Psoriasis and Gluten

• Significant evidence points to a small set of psoriasis patients who improve greatly with a gluten-free diet.

• Test for antigliadin IgA. High levels may be a marker.


The Perils of the Modern Age

• Increasingly common heat-induced patches that develop into permanent hyperpigmentation.

• Sources include heated car seats and recliners, heated popcorn bags, lap top computers, cell phones and space heaters.


Erythema Ab Igne

• Other names for this condition include: Toasted skin syndrome, ephelis ignealis, heat-induced dermal melanosis and livedo reticularis e calore.



Treatment of Erythema Ab Igne

• Remove from heat source, and practice awareness.

• Crushed ice behind cloth towel helps reduce swelling.

• Aloe vera with lidocaine 5% OTC as with sunburn


Prevention and Awareness


First-line Acne Treatment

• Due to significant resistance, AAD no longer recommends oral tetracycline and oral erythromycin for acne treatment.

• Topical erythromycin and clindamycin also show marked resistance and should be avoided.



Jumpstart Acne with Photopneumatic Therapy (Ppx)

• Photopneumatic therapy emits light and suction over skin.

• Reduces P. acnes bacteria and brings sebaceous glands to surface

• Performed weekly for one month in addition to topical and oral antibiotics


Ppx Treatment

• Ppx therapy is best used with traditional regimens, the first month and flare maintenance.

• Lower energy settings for darker skin tones

• Redness, hair loss at site are side effects.


Ppx Devices are FDA Approved


• Anesthesia or analgesia is not required.

• Spray cooling used after 5 to 7 pulses.

• Excellent option for unresponsive acne prior to oral isotretinoin initiation


The Challenge of Prepubescent Acne

• Typically on nose and forehead

• Younger population without indication on product labeling

• Topical products best• Non-compliance is

high.


Early Acne Pearl

• Consider the advice of a pediatric endocrinologist if hirsutism, body odor, genital maturation present as the androgen excess may be the result of a deeper process.


Acne Increases Suicidal Ideation

Gupta MA et al. Br J Dermatol. 1998;139:846-50.

This is the original classic study.

General Medical Patients

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63 Fitzgerald Health Education Associates, Inc.


The Isotretinoin Challenge: Will we practice on the evidence?

• 2/4/08 (San Antonio)- In the largest study of its kind, more than 9.6 million patient visits “failed to demonstrate an association between isotretinoin use and increased depression or suicide.”

• American Academy of Dermatology 66th Annual Meeting


The Psychological Impact of Scars in Children

• Solid documentation exists that the emotional and mental issues resultant from visible scars significantly impede the ability to form healthy peer relationships, and impact the ability to progress in academics, social outings and other coming-of-age processes.


The New England Journal of Medicine Study 2005

• Nearly all patients achieve initial clearing of acne.

• 40% observe complete remission following one course of isotretinoin.

• 40% develop less severe acne.• 20% relapse to warrant an

additional course of isotretinoin.



Self-fulfilling Side-effects

• Isotretinoin-related depression, in one study, was found as “an idiosyncratic side-effect.” Often anxiety of potential side effects can bring on acne and depression, creating more anxiety.


Isotretinoin

• iPledge to continue writing isotretinoin to approximately 600 pt a year, and two family members.

• The FDA first approved isotretinoin in September, 1982.

• Severe acne patients with suicidal tendencies deserve isotretinoin as soon as possible.


“I will not prescribe isotretinoin as it may cause depression.”



Oral isotretinoin is standard of care for nodular-cystic acne.

• Indications include1) Inflammatory cysts and pustules with

scarring2) Unresponsive to conventional therapy

3) Severe psychological distress


Severe Acne May Increase Risk for Attempted Suicide


Isotretinoin is a vitamin A derivative.

• Brand names include Amnesteem®, Roaccutane®, Sotret®, and Claravis®

• It is not for everyone.• The iPledge program protects

patient and provider.• Side effects are remarkably

predictable and consistent.72 Fitzgerald Health Education Associates, Inc.


Isotretinoin Dosing

• Dosing is generally 0.5 to 1.0 mg/kg per day for 16 to 20 weeks, reaching a cumulative dose of 120 mg/kg.


The iPledge Program

• Blood work prior to prescribing for liver and lipid abnormality

• Two negative pregnancy tests and monthly thereafter

• Two forms of birth control• iPledge online• Prescribe for 30 days, no refills


The iPledge Program (continued)

• Product dispensed and obtained within 7 days of qualification

• Patient and parent educated with verbal discussion and written contract of warnings and hazards

• Look for Dr. Danby’s handout on-line as supplement.



Isotretinoin Research

• 16 of 102 patients (15.7%) required a retrial of isotretinoin.

• Female patients were at a higher risk of needing retrials.

• No suicidal thoughts reported.• No documented, defined cases of

clinical depression


Key Findings in Research

• Additional trials do not appear to cumulatively increase side effects.

• Patients may not be improving because medication not absorbed

• Trials continue to show mood improvement, proving acne is the depressant, not the medication.


Isotretinoin and Memory

• Hippocampus sensitive to retinoic acid– Active agent in isotretinoin

• Study reveals improvement of learning and memory with dosing.

• Retinoic acid brings increased levels of hippocampus to optimal levels.



Isotretinoin Litigation


Final Thoughts on Isotretinoin

• Efficacy and safety• The evidence of research• Vitamin A is a natural component

of our body; yet teratogenic.• Mood improvement often observed• Be wary still: Bipolar,

noncompliant, IBS and the flippant80 Fitzgerald Health Education Associates, Inc.

The Skinny on Acne and Diet

• Foods that increase insulin levels magnify male hormone effect

• Dairy products boost insulin, and are high in hormones made by pregnant cows that produce milk.

• Avoid dairy and sugar to lessen oil stimulus production.



The Evidence of Diet in Acne

• No question that diet plays a role in rosacea.– Research on going with acne

• Glycemic load assesses potential of food to increase blood glucose.

• Glycemic index is measure of carbohydrate quality. (i.e. the source)


Foods High in Both

• Coca-Cola®

• Sweet corn• Ice cream• Mac and cheese• Corn chips• Popcorn• Doughnuts

• Gatorade ®

• White bread• Cornflakes• White rice• Kudos ® bar• Pretzels• Baked potato


Acne in Skin of Color

• 29% incidence in black patients• 50% incidence in adult black women• Post-inflammatory

hyperpigmentation most common complaint

• PIHP can be quickly caused by benzoyl peroxide and tretinoin use!



Acne Vulgaris Comparison


Acne in Skin of Color

• The Kligman formula for HP is tretinoin 0.1%, hydroquinone 5% and dexamethasone 0.1% in a hydrophilic ointment QHS.


Acne in Skin of Color (continued)

• Minocycline is not first-line due to darkening patches.

• Clindamycin gel and topical dapsone are effective.

• Hydroquinone gold standard for hyperpigmentation at 4%-10%

• Watch for the “hydro-halo”



Treatment Options Paradigm

OralAntibioticsIsotretinoin

Hormone therapyCorticosteroids

TopicalRetinoids

Benzoyl peroxide (BPO)Topical antibiotics

Azelaic acidSalicylic acidCombinations

OtherLaser therapyDermal fillers

Surgery88 Fitzgerald Health Education Associates, Inc.

Why do some relapse?

• Early relapse may occur if patients have ingested oral isotretinoin on an empty stomach, thus leading to a lesser cumulative drug exposure despite the daily dose administered.

– Source- Del Rosso, JQ. 2012. Face to Face with Oral Isotretinoin: Why Some Patients Need Repeated Courses. Clin Aesthet Dermatol. 2012 November; 5(11): 17–24.


Self-fulfilling Side-effects

• Isotretinoin-related depression, in one study, was found as “an idiosyncratic side-effect.” Often anxiety of potential side effects can bring on acne and depression, creating more anxiety.



How important is skin?


The Faces of Meth


Rosacea



Current Understanding of Rosacea

• Inflammatory disorder made worse by multiple contributing factors

• Affects women 8:1 over men• Begins significantly at age 40• Requires life-style changes to

achieve best control


Is it acne or rosacea?

• First, don’t use the term “acne-rosacea.”

• The two conditions are clinically and bio-chemically distinct.

• Rare to have both at once


The Term “Generally”

• Rosacea generally in older patients of central face with erythema, ocular and rhinophymic inflammation, with marked flushing and telangiectasis.

• Acne generally in younger patients of face, trunk, with cysts, scarring and comedones. Erythema is observed perifollicular.



Crucial Differences Between Acne and Rosacea

• Both conditions are essentially the dysregulation of the immune system, but the difference lies in the trigger mechanism. Acne is powered by androgen stimulation of sebocytes that leads to follicular hyperproliferation and keratinization…


Crucial Differences between Acne and Rosacea

(continued)• …and rosacea is heavily influenced

by ethnic background, gender and skin type, and can be markedly improved by lifestyle changes, as the top two triggers include stress and sunshine. A bacterial pathogenesis for rosacea has never been established.


CDC Facts

• Half of antibiotics written are unnecessary. – Approximately 50 million prescriptions

• Antibiotic resistance- “One of the world’s most pressing public health threats.”



CDC Recommendations for Antibiotic Use

• Only when the diagnosis is confirmed and likely to be of benefit to the patient

• Use agent that specifically targets the likely pathogen

• Use appropriate dose and durations


First-line Treatment for Rosacea

• Azelaic acid or metronidazole• Sodium sulfacetamide-sulfur• Anti-inflammatory doses or

doxycycline or minocycline• Lifestyle modification


The Pathology Report



Demodex Mites: In Your Face


• Lives on humans alone, attracted to sebum

• Means “fat boring worm”

• Entire life cycle and feces production on human face

• Generally adults

Demodex Mites (continued)

• More than 8x likely to be where rosacea is present

• Early reports show resistance to treatment.

• Possible help with tea tree oil application


Demodex Mites, Up Close



Phymatous Rosacea

• Fibrous growth from persistent inflammation over time.– Traditionally called

“rhinophyma”

• Simple surgical solution available.


Phymatous Rosacea in Celebrities


Phymatous Rosacea Up Close


• Surgically skilled dermatologists and plastic surgeons can dramatically improve in one sitting.


Before and After Examples of Phymatous Rosacea Ablation


Management Checklist For Rosacea

• Lifestyle modification• Topical therapies• Oral therapies• Procedural options• Combinations of all


Rosacea Triggers Survey

• Sun exposure 81%• Emotional stress 79%• Hot weather 75%• Wind 57%• Exercise 56%• Alcohol 52%

• Hot baths 51%• Cold weather 46%• Spicy foods 45%• Coffee 36%• Acidic foods 13%• Marinated meats,

10%



Lifestyle Modification

• Sun avoidance/protection• Stress control• Coffee, chocolate, caffeine and wine• Hypoallergenic, noncomedogenic• The use of green tinted makeup• Throw out cosmetic brushes!• Stop smoking


Lifestyle Modification


You’ll find rosacea in Margaritaville.



Delusions of Parasitosis

• Sensation of crawling, stinging and biting are very real.

• Elaborate presentation of evidence• Microscopic exam often reveals

fibers, seeds, plant material and occasionally, real parts of insects not known to inhabit skin.


Delusions of Parasitosis, (continued)

• Skin is often fissured or disfigured in places only where the patient can reach.

• Family members are emotional.


Delusions of Parasitosis, (continued)



Forme Fruste Argument

• Excoriative behaviors appear to result in new neuronal pathways.

• Does a tic disorder or repetitive action become genuinely dysesthetic (burning, crawling, stinging, itching) because of dopaminergic activity?


Low Dose Pimozide Treatment

• First, treat lesions and eliminate if possible.

• Consider IL suspension triamcinolone injections

• H1 and H2 blockers with antibiotics

• Pimozide 1 mg 1 PO Qday x one month is a dopamine antagonist

• Document risks• Risks for not treating

scarring, infection, depression, impairment


Treatment Paradigm

• Listen, be sympathetic but firm• Client is often opposed to consider

any other factors of their condition.• Referral is nearly impossible unless

family members are included.• Treatment is long-term.



Advances in Skin Cancer Treatment

• Non-invasive superficial radiotherapy (SRT) for non-melanoma skin cancers

• No shots, scalpel, sutures or scar, and very safe, because superficially targeted


One Tanning Session Multiplies Skin Cancer Risk

• Single UV tanning session increases risk of SCC by 67% and BCC by 29%.– Source- Indoor tanning and non-

melanoma skin cancer: Systematic review and meta-analysis. BMJ , Oct: 2012; 245-355.


End of Presentation Thank you for your time and attention.

Victor Czerkasij MA, MSN, FNP-C www.fhea.com e-mail: [email protected]



References

• Carrascosa JM., Rocamora V., Fernandez-Torres RM., et al. 2012. Obesity and psoriasis: Inflammatory nature of obesity and psoriasis, and therapeutic implications. Academy of Dermatology, Nov23:457-507.

• Skelsey M. 2012. Vitamin D: Getting the message right. The Skin Cancer Foundation Journal. Vol.30;44-45.


References(continued)

• Wolpowitz D., Gilchrest B. 2006. The vitamin D questions: How much and from where? J Am Ac Derm, 54:310-317.

• Cook-Boolden, FE. The study of skin of color in dermatology. Journal of Drugs in Dermatology. 2012 Apr;11(4):448-450.

• Ernst, J. Current issues in treating patients with skin of color. The Dermatologist. 2012 Oct;29-32.


• Armstrong AW., Harskamp CT. 2012. The association between psoriasis and obesity: Systemic review and meta-analysis of observational studies. Nutr Diabetes, Dec 3;2e54.

• Blagosklonny, MV. 2012. Prospective treatment of age-related diseases by slowing down aging. American Jour of Path. Oct;181(4):1142-6.




• Schwartz JR., Messenger AG., et al. 2012. A comprehensive pathophysiology of seborrheic. Acta Derm Venereol. Aug 6.

• McGrath BM. Identify this skin lesion: Senile hemanigioma. Can Fam Physician. 2011 Jun;57(6):682,686.



• NA CR, Wang S., et al. 2012. Elderly adults and skin disorders: Common problems for nondermatologists. South Med Journal, Nov:105(11)600-6.

• Sezgin B., Findikcioglu K., Kaya B., Sibar S., Yavuzer R. 2012. A study of women’s perception of facial features as they age. Aesthet Surg Journal Mar 20.



References (continued)

• Reichenberg JS., Magid M., Jesser CA. 2013. Patients labeled with delusions of parasitosis compose a heterogeneous group: A retrospective study from a referral center. J Amer Acad of Derm, Jan;68(1):41-46.



Resources (continued)

• www.aad.org American Academy of Dermatology, accessed 03.10.13.

• www.asds.net American Society for Dermatologic Surgery, accessed 03.10.13.

• www.plasticsurgery.org American Society of Plastic and Reconstructive Surgeons, accessed 03.10.13.



• Amin K., Fraga GR. 2012. Cutaneous biopsies for melanocytic neoplasms. Am J Dermatopathol. 2012 Mar 14. 12-19.

• Ghinea N., et al. 2012. Taking responsibility for off-label prescribing. Intern Med J. Mar;42(3):247-51.


• Burgos AM., Villa AV., Noguera-Julian A., Fortuny C., González-Enseñat MA. 2012. Fever and skin lesions: Understanding emergencies in pediatrics. Pediatr Infect Dis J. Jan 14(1):6-12.

• Naini FB. 2012. Studies of beauty and “ideal” proportions. Arch Facial Plast Surg. Mar;14(2):148-9.




• Springer IN., Wiltfang J., et al. 2012.Self-perception of beauty versus judgment by others. J Cranio-maxillofac Surg. Mar 13:133-139.

• Rush M., Bagel J. 2011. The role of a gluten-free diet in psoriasis. Psoriasis Forum, 17:4;254-258.



• American Society for Aesthetic Plastic Surgery, available at www.surgery.orgaccessed 03.10.13.

• www.skincarephysicians.com/agingskinnet, accessed 03.10.13.

Fitzgerald Health Education Associates, Inc.134


• American Cancer Society. 2010 Cancer Facts and Figures. www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-026238.pdf, accessed 03.10.13.




• Robinson JK. Sun Exposure, Sun Protection, and Vitamin D. JAMA 2009; 294:1541-43.

• Linos E., Swetter S., Cockburn MG., Colditz GA., Clarke CA. Increasing burden of melanoma in the United States. J Invest Derm. 8 January 2009.423.




• King, R., et al. 2011. Melanoma: A review of identification and subtypes. Arch Pathol Lab Med, Mar;135(3): 337-41.

• Yamada C., Moriyama K., Takahashi E. 2012. Comprehensive indicators of lifestyle-related health status. Prev Med. 2012 Mar 17.

• Berg A. Screening for skin cancer. US Preventive Services Task Force, 2010.


• Couteau O., Alami-El Boury S., Coiffard LJ. 2011. Sunscreen products: What do they protect us from? Int J Pharm. Aug 30;415(1-2):181-4.

• Mimeault M., Batra SK. 2012. Novel biomarkers and therapeutic targets for optimizing management of melanomas. World J Clin Oncol. Mar 10;3(3):32-42.




• Committee for Guidelines of Care for Chemical Peeling. J Dermatol. 2012 Apr;39(4):321-325.

• Alam M., Omura NE., Dover JS., et al. Glycolic acid peels compared to microdermabrasion: A right-left controlled trial of efficacy and patient satisfaction. Dermatol Surg. 2008;28:475-479.



• Wong, K., Forsyth, A., et al. 2012. Mohs micrographic surgery: A comprehensive review of techniques. Clin Exp Dermatol. Mar 15.(3):33-42

• Keri, JE., et al. The role of diet in acne and rosacea. J Clin Aesthetic Derm2008;1(3):22-26.



• Johnson SM. Self-reported treatment of rosacea patients treated with doxycycline, 40 mg capsules. Jour Drugs Dermatol. 2011;10(12):1376-1381.

• Sharad J. Combination of microneedling and glycolic acid peels for the treatment of acne scars in dark skin. Jour Cos Derm, 2011.





• Rafailovich, T. The effects of UV emission from CFL exposure on human dermal fibroblasts and keratinocytes in-vitro. 2012, June. Journal of Photochemistry and Photobiology.

• A.B. Kimball, F. Kerdel, D. Adams, et al. 2012. Adalimumab for the treatment of moderate to severe hidradenitis suppurativa: A Parallel Randomized Trial. Annals of Internal Medicine. 12(157);846-855.



• LeBlanc P., Hollinger K., et al. 2012.Tattoo Ink–Related Infections —Awareness, Diagnosis, Reporting, and Prevention. New Engl Jour Med 9.13.12 (367), 985-987.

• Cohen J., Berlin A. 2013. Improving outcomes and compliance for acne patients. The Dermatologist. January (22-23).



• Fried, R. Neurotic excoriations be a form fruste or Tourette’s syndrome? The Dermatologist. 2012. October; 38-39.


© 2007 fitzgerald health education associates, inc© 2007 fitzgerald health education associates,...

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