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Bringing Basic Dermatology Care to the Pediatric Medical Home:
A PPOC/CHICO Learning Community & Integration Program
We have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on,
patients relevant to the content we are planning, developing, presenting, or evaluating.
• Submit on Blackboard or email or by fax to Madeleine Kuhn
• Process Maps, due by 11/11/2016
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Qstream Finish Line!
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Process Map Presenters
Dr. NelkenAndover Pediatrics
Dr. HydeWestwood-Mansfield Pediatric Associates
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Patient Calls for
acne appt or derm referral
Front desk schedules Appt. within a few days
PCP/PNP examine patient
Severe cystic
scarring acne
Start topical or oral medicationF/U in 6-8 weeks
Refer to Derm
Adjust meds if needed
YES
NO
What happens to patient after
referral?
Address Acne at well/sick visits?
CURRENT PROCESSAndover Pediatrics
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Patient Calls for sick/well
visit
Front desk schedules Appt.
PCP/PNP examine patient including
skin exam (starting age 11)
Severe cystic
scarring acne
Talk with patient about acne and
potential treatment options
Offer Rx that day or reschedule for visit dedicated to
acne
Refer to Derm
YES
NOStart topical or oral medication
Follow-up in 6-8 weeks to reassess
Patient improving
Follow-up in 6-8
weeks to reassess
Follow-up in 6-8
weeks to reassess
Adjust meds Patient improving
YES
YES
NO
NO
NEW PROCESS
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Annual well visit 13 and up
Questionnaire given that inquires about acne and
desire to treat
Patient has acne and
wants to treat
Do not discuss Discuss and make treatment plan
Follow up in office in 8
weeks
Are we missing patients who might not be ready but become so during year – Can we give them education and let them know about our ability to treat
effectively?
No Yes
CURRENT PROCESS Westwood –Mansfield Pediatric Associates
Karen Halle, MD; Jen Hyde, MD; Jill Fischer, MD; Erin Kish, MD; Helen
Lyon, MD; Sandra Ventura NP; Meridith Liebman, MD
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Annual well visit 10 and up
All patients receive handout on good skin care and basic acne
treatment
Discuss acne management and make treatment plan. Acknowledge need
for and ability to recommend changes if initial treatment not working
Providers routinely identify and document patients with acne on physical
exam
Patient with acne
Provider educates patient and family about calling
office if acne develops and otc treatments not
working
Make follow up visit in 8 weeks
no
yes
NEW PROCESS
Patient reports interest in treatment
yes
Provider educates patient and family
regarding availability of acne treatment if and when they consider
no
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Process Map Coursework Q & A1. How will you implement your new process? What do office-staff need to
know about it and how will you train them on the new process? We will need to develop a handout to be placed in our well child packets (both online and in office) and make sure that the office staff responsible for these are aware. We will need to train our providers through provider meeting and in office memo that this handout is being provided and that documenting and discussing basics of acne treatment will improve the care of our patients. We will inform front desk staff of the 8 week follow up on initial acne management.
2. Will your new process require any patient/family outreach or education? If so , how will you accomplish the necessary patient/family education? We will need to develop the handout and formulate anticipatory guidance for well visit discussion on acne. We will need to educate providers on such.
3. How will you monitor that the new process is happening correctly over time in your practice? We will check website and packets and will monitor referrals to dermatology for patients we could have likely managed.
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Itchy eruption in classic areas Assess for complicating factors
like contact dermatitis (airborne, saliva) and infection
When treating, remember to treat both the barrier dysfunction and the immune system upregulation
Don't be afraid to use a higher potency topical steroid-when in doubt, schedule frequent follow ups and limit quantities and refills
3 FDA approved OCPs for treatment of acne: Ortho Tri Cyclen (norgestimate/ethinyl estradiol) Estrostep (norethindrone acetate and ethinyl estradiol) Yaz (drosperinone/ethinyl estradiol)
For moderate-severe acne in females who have had their menses for 1 year
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Oral Contraceptives and Acne (Contd.) Pertinent History that Should Be
Elicited Family history of thrombotic
events Smoking history (Migraine with aura)
Thrombotic events are rare in adolescence
Most common side effects: nausea, vomiting, breast tenderness, headache, weight gain, breakthrough bleeding
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Oral Contraceptives and Acne: Important Consideration
Maximization of bone mineral density 50% bone mass accrued between 12-18
years of age 24 month study of postmenarchal girls on
OC did not reveal osteopenia; BMD femoral neck 4.2% compared to 6.3% in control; conclusion was effects of OC unclear
Prescribing of OC based on provider level of comfort
Fertil Steril. 2008 Dec;90(6):2060-7. doi: 10.1016/j.fertnstert.2007.10.070. Epub 2008 Jan 28.
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Salicylic acid + duct tape at all times. Goal is maceration
Pare down before treatments to get to affected keratinocytes
Cryotherapy: 2 cycles of 7 seconds with slow thaw in between
Tretinoin cream for facial flat warts, imiquimod for genital warts
May take months of treatment
Potential benefit of HPV vaccine
Genital warts red flags: Child>4-5, out of diapers with no known non-abuse exposure route)
Symmetric papules on extensor knees, elbows and buttocks
Localized id reaction
Papular Acrodermatitis of Childhood
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Gianotti-Crosti
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Gianotti-Crosti
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Gianotti-Crosti
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Gianotti-Crosti
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Papular Urticaria
Tx: topical steroids, antihistamines, evaluation of home for infestations
Can wax and wane for weeks to months
Id response to arthropod bites
Misnomer: Lesions last > 24 hours
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Papular Urticaria
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Papular Urticaria
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Diaper Dermatitis
• Irritant contact dermatitis• Potential for secondary bacterial and fungal infections• Typically need a multiple-prong:
– Barrier Cream– Antifungal given risk of candidiasis– Lower potency topical steroids (Hydrocortisone 2.5% or
Desonide)– Antibacterial if concern for infection
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Barrier Creams
• Thicker = Better.• If you see the rash without wiping, it isn’t thick enough• Wet diapers pat dry and apply more gobs of cream• Soiled diapers wipe off soiled portions and apply more gobs of
cream • Vaseline, Desitin, Triple Paste, A&D.
– Basically anything that is thick and non-irritating is ok.
• Psoriasis – Typically will improve once out of diapers.– Should improve with basic treatments (barrier, topical barriers)
• Langerhans cell histiocytosis (LCH)– Petechial/non-blanching, favors inguinal creases– Similar lesions on scalp, post-auricular– Can have visceral lesions, including osteolytic lesions and
diabetes insipidus– WONT RESPOND TO TOPICAL DIAPER TREATMENTS