Megan Brown, MD

The Health Frontiers in Tijuana (HFiT) clinic is a binational partnership between the University of California, San Diego School of Medicine (San Diego, California); the Universidad Autónoma de Baja California School of Medicine (Tijuana, Mexico); and Desayunador Salesiano Padre Chava, a community grassroots organization in Tijuana, Mexico. Health Frontiers in Tijuana provides accessible quality health care for the underserved in Tijuana's Zona Norte.¹ This article is a narrative meant to share my clinical experience as a dermatology resident who worked with HFiT to establish teledermatology services at this clinic.

Teledermatology in Tijuana

The patient population served by the HFiT clinic includes substance users, sex workers, the homeless, deportees, indigent patients, and recently Haitian immigrants.¹ We established teledermatology services under the faculty leadership of Casey Carlos, MD, who was awarded a SkinCare for Developing Countries grant from the American Academy of Dermatology in April 2015 to address the need for teledermatology support for the clinic.²

Over the last 2 years, we have worked closely with 2 medical students from the University of California, San Diego--Nicole Herrick, BS, and Nicole DeMartinis, BA--to apply for the grant and create a system whereby volunteer residents and faculty consultants at the University of California, San Diego, can provide teledermatology services on a weekly basis to support the HFiT staff as they see patients with dermatologic conditions. Initially, we purchased touch screen tablets to use the Africa Teledermatology Project (africa.telederm.org) web-based program. The clinic was already functioning with electronic medical records with volunteers who carried tablets and scribed for the providers as they saw patients. We felt this method would be a great way to incorporate teledermatology into the clinic, and it functioned moderately well for several weeks but was very labor intensive on our part, as we frequently had to travel to Tijuana to retrain rotating clinic volunteers on how to use the program. Often, the Internet connection was slow, which made pulling up the Africa Teledermatology Project website difficult, and photographs also would take too long to upload in the middle of a busy clinic.

We are now exploring how to use a more simple email format to send the teledermatology consultations while still being compliant with the Health Insurance Portability and Accountability Act. We currently use secure university email accounts. Although we are still working out the details, this email-based method seems to work well. It has been a simple solution to accommodate a slow Internet connection and many rotating volunteers without requiring additional training. The email format also allows the photographs to be saved in draft messages, even if the Internet connection times out.

Once the teledermatology consultation is sent, the medical students and I review them and then get an attending physician's input on our proposed working diagnosis and plan. We work to have this process complete within several days to return the answered consultation to the requesting provider.

Final Thoughts

The HFiT providers have shared a lot of positive verbal feedback about this project. One frequent comment is how helpful it is to have access to a dermatologist for challenging cases. We also have heard many times that this project has inspired medical students and volunteers to expand their knowledge of dermatology. We are continuing to form new collaborative relationships with physicians in Tijuana. We will soon have the ability to train primary care providers at HFiT on performing simple skin biopsies and managing basic dermatologic conditions. Through our support of these providers, we are creating a sustainable partnership that is mutually beneficial to the patients in Tijuana as well as the medical students and residents in the United States. It is highly rewarding to all those involved with this project, and I am excited to see what challenges this next year will bring as we welcome many new patients from Haiti into the HFiT patient population.

The Health Frontiers in Tijuana (HFiT) clinic is a binational partnership between the University of California, San Diego School of Medicine (San Diego, California); the Universidad Autónoma de Baja California School of Medicine (Tijuana, Mexico); and Desayunador Salesiano Padre Chava, a community grassroots organization in Tijuana, Mexico. Health Frontiers in Tijuana provides accessible quality health care for the underserved in Tijuana's Zona Norte.¹ This article is a narrative meant to share my clinical experience as a dermatology resident who worked with HFiT to establish teledermatology services at this clinic.

Teledermatology in Tijuana

The patient population served by the HFiT clinic includes substance users, sex workers, the homeless, deportees, indigent patients, and recently Haitian immigrants.¹ We established teledermatology services under the faculty leadership of Casey Carlos, MD, who was awarded a SkinCare for Developing Countries grant from the American Academy of Dermatology in April 2015 to address the need for teledermatology support for the clinic.²

Over the last 2 years, we have worked closely with 2 medical students from the University of California, San Diego--Nicole Herrick, BS, and Nicole DeMartinis, BA--to apply for the grant and create a system whereby volunteer residents and faculty consultants at the University of California, San Diego, can provide teledermatology services on a weekly basis to support the HFiT staff as they see patients with dermatologic conditions. Initially, we purchased touch screen tablets to use the Africa Teledermatology Project (africa.telederm.org) web-based program. The clinic was already functioning with electronic medical records with volunteers who carried tablets and scribed for the providers as they saw patients. We felt this method would be a great way to incorporate teledermatology into the clinic, and it functioned moderately well for several weeks but was very labor intensive on our part, as we frequently had to travel to Tijuana to retrain rotating clinic volunteers on how to use the program. Often, the Internet connection was slow, which made pulling up the Africa Teledermatology Project website difficult, and photographs also would take too long to upload in the middle of a busy clinic.

We are now exploring how to use a more simple email format to send the teledermatology consultations while still being compliant with the Health Insurance Portability and Accountability Act. We currently use secure university email accounts. Although we are still working out the details, this email-based method seems to work well. It has been a simple solution to accommodate a slow Internet connection and many rotating volunteers without requiring additional training. The email format also allows the photographs to be saved in draft messages, even if the Internet connection times out.

Once the teledermatology consultation is sent, the medical students and I review them and then get an attending physician's input on our proposed working diagnosis and plan. We work to have this process complete within several days to return the answered consultation to the requesting provider.

Final Thoughts

The HFiT providers have shared a lot of positive verbal feedback about this project. One frequent comment is how helpful it is to have access to a dermatologist for challenging cases. We also have heard many times that this project has inspired medical students and volunteers to expand their knowledge of dermatology. We are continuing to form new collaborative relationships with physicians in Tijuana. We will soon have the ability to train primary care providers at HFiT on performing simple skin biopsies and managing basic dermatologic conditions. Through our support of these providers, we are creating a sustainable partnership that is mutually beneficial to the patients in Tijuana as well as the medical students and residents in the United States. It is highly rewarding to all those involved with this project, and I am excited to see what challenges this next year will bring as we welcome many new patients from Haiti into the HFiT patient population.

The Health Frontiers in Tijuana (HFiT) clinic is a binational partnership between the University of California, San Diego School of Medicine (San Diego, California); the Universidad Autónoma de Baja California School of Medicine (Tijuana, Mexico); and Desayunador Salesiano Padre Chava, a community grassroots organization in Tijuana, Mexico. Health Frontiers in Tijuana provides accessible quality health care for the underserved in Tijuana's Zona Norte.¹ This article is a narrative meant to share my clinical experience as a dermatology resident who worked with HFiT to establish teledermatology services at this clinic.

Teledermatology in Tijuana

The patient population served by the HFiT clinic includes substance users, sex workers, the homeless, deportees, indigent patients, and recently Haitian immigrants.¹ We established teledermatology services under the faculty leadership of Casey Carlos, MD, who was awarded a SkinCare for Developing Countries grant from the American Academy of Dermatology in April 2015 to address the need for teledermatology support for the clinic.²

Over the last 2 years, we have worked closely with 2 medical students from the University of California, San Diego--Nicole Herrick, BS, and Nicole DeMartinis, BA--to apply for the grant and create a system whereby volunteer residents and faculty consultants at the University of California, San Diego, can provide teledermatology services on a weekly basis to support the HFiT staff as they see patients with dermatologic conditions. Initially, we purchased touch screen tablets to use the Africa Teledermatology Project (africa.telederm.org) web-based program. The clinic was already functioning with electronic medical records with volunteers who carried tablets and scribed for the providers as they saw patients. We felt this method would be a great way to incorporate teledermatology into the clinic, and it functioned moderately well for several weeks but was very labor intensive on our part, as we frequently had to travel to Tijuana to retrain rotating clinic volunteers on how to use the program. Often, the Internet connection was slow, which made pulling up the Africa Teledermatology Project website difficult, and photographs also would take too long to upload in the middle of a busy clinic.

We are now exploring how to use a more simple email format to send the teledermatology consultations while still being compliant with the Health Insurance Portability and Accountability Act. We currently use secure university email accounts. Although we are still working out the details, this email-based method seems to work well. It has been a simple solution to accommodate a slow Internet connection and many rotating volunteers without requiring additional training. The email format also allows the photographs to be saved in draft messages, even if the Internet connection times out.

Once the teledermatology consultation is sent, the medical students and I review them and then get an attending physician's input on our proposed working diagnosis and plan. We work to have this process complete within several days to return the answered consultation to the requesting provider.

Final Thoughts

The HFiT providers have shared a lot of positive verbal feedback about this project. One frequent comment is how helpful it is to have access to a dermatologist for challenging cases. We also have heard many times that this project has inspired medical students and volunteers to expand their knowledge of dermatology. We are continuing to form new collaborative relationships with physicians in Tijuana. We will soon have the ability to train primary care providers at HFiT on performing simple skin biopsies and managing basic dermatologic conditions. Through our support of these providers, we are creating a sustainable partnership that is mutually beneficial to the patients in Tijuana as well as the medical students and residents in the United States. It is highly rewarding to all those involved with this project, and I am excited to see what challenges this next year will bring as we welcome many new patients from Haiti into the HFiT patient population.

How do we increase patient adherence to therapy? This question fascinates me. As dermatologists, we will see thousands of patients over the course of our careers, most with treatable conditions that will improve with therapy and others with chronic or genetic conditions that will at least be made more tolerable with therapy. Only 50% of patients with a chronic condition are adherent to therapy.¹ Why some patients adhere to treatment and others do not can be difficult to understand. The emotional makeup, culture, family background, socioeconomic status, and motivation of each person is unique, which leads to complexity. This column is not meant to answer a question that is both complex and broad; rather, it is meant to survey and summarize the literature on this topic.  

Education

Health literacy is defined as cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.² Greater health literacy leads to improved compliance and health outcomes.^3,4 When we take the time to educate patients about their condition, it improves health literacy, treatment compliance, and patient safety and satisfaction, factors that ultimately are linked to better health outcomes.^3-8

There are many practical ways of educating patients. Interestingly, one meta-analysis found that no single strategy is more effective than another.⁶ This analysis found that "[c]omprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions."⁶ The Centers for Disease Control and Prevention (CDC) website is an excellent source of information on how to educate patients and increase patient treatment compliance.² The CDC website offers a free tool kit on how to design educational information to your target audience, resources for children, a database of health-related educational images, an electronic textbook on teaching patients with low literacy skills, a summary of evidence-based ideas on how to improve patient adherence to medications used long-term, and more.²

Facilitating Adherence

The World Health Organization (WHO) emphasizes 5 dimensions of patient adherence: health system, socioeconomic, condition-related, therapy-related, and patient-related factors.⁹ Becker and Maiman⁵ summarized it eloquently when they wrote that we must take "clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through 'tailoring' and other approaches." It is a broad ultimatum that will require creativity and persistence on the part of the dermatology community.

Some common patient-related factors associated with nonadherence to treatment are lack of information and skills as they pertain to self-management, difficulty with motivation and self-efficacy, and lack of support for behavioral changes.⁹ It is interesting that low socioeconomic status has not been consistently shown to portend low treatment adherence. It has been shown that children, especially adolescents, and elderly patients tend to be the least adherent.^9-11

Dermatologists Take Action

As dermatologists, the WHO encourages us (physicians) to promote optimism, provide enthusiasm, and encourage maintenance of healthy behaviors.⁹ Comprehensive interventions that have had a positive impact on patient adherence to therapy for diseases such as diabetes mellitus, asthma, and hypertension may serve as motivating examples.⁹ Some specific dermatologic conditions that will benefit from increased patient adherence include acne, vesiculobullous disease, psoriasis, and atopic dermatitis. We can lend support to efforts to reduce the cost of dermatologic medications and be aware of the populations most at risk for low adherence to treatment.^9-12

Final Thoughts

As we work to increase patient adherence to therapy in dermatology, we will help improve health literacy, patient safety, and patient satisfaction. These factors are ultimately linked to better health outcomes. The CDC and WHO websites are excellent sources of information on practical methods for doing so.^2,9

How do we increase patient adherence to therapy? This question fascinates me. As dermatologists, we will see thousands of patients over the course of our careers, most with treatable conditions that will improve with therapy and others with chronic or genetic conditions that will at least be made more tolerable with therapy. Only 50% of patients with a chronic condition are adherent to therapy.¹ Why some patients adhere to treatment and others do not can be difficult to understand. The emotional makeup, culture, family background, socioeconomic status, and motivation of each person is unique, which leads to complexity. This column is not meant to answer a question that is both complex and broad; rather, it is meant to survey and summarize the literature on this topic.  

Education

Health literacy is defined as cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.² Greater health literacy leads to improved compliance and health outcomes.^3,4 When we take the time to educate patients about their condition, it improves health literacy, treatment compliance, and patient safety and satisfaction, factors that ultimately are linked to better health outcomes.^3-8

There are many practical ways of educating patients. Interestingly, one meta-analysis found that no single strategy is more effective than another.⁶ This analysis found that "[c]omprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions."⁶ The Centers for Disease Control and Prevention (CDC) website is an excellent source of information on how to educate patients and increase patient treatment compliance.² The CDC website offers a free tool kit on how to design educational information to your target audience, resources for children, a database of health-related educational images, an electronic textbook on teaching patients with low literacy skills, a summary of evidence-based ideas on how to improve patient adherence to medications used long-term, and more.²

Facilitating Adherence

The World Health Organization (WHO) emphasizes 5 dimensions of patient adherence: health system, socioeconomic, condition-related, therapy-related, and patient-related factors.⁹ Becker and Maiman⁵ summarized it eloquently when they wrote that we must take "clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through 'tailoring' and other approaches." It is a broad ultimatum that will require creativity and persistence on the part of the dermatology community.

Some common patient-related factors associated with nonadherence to treatment are lack of information and skills as they pertain to self-management, difficulty with motivation and self-efficacy, and lack of support for behavioral changes.⁹ It is interesting that low socioeconomic status has not been consistently shown to portend low treatment adherence. It has been shown that children, especially adolescents, and elderly patients tend to be the least adherent.^9-11

Dermatologists Take Action

As dermatologists, the WHO encourages us (physicians) to promote optimism, provide enthusiasm, and encourage maintenance of healthy behaviors.⁹ Comprehensive interventions that have had a positive impact on patient adherence to therapy for diseases such as diabetes mellitus, asthma, and hypertension may serve as motivating examples.⁹ Some specific dermatologic conditions that will benefit from increased patient adherence include acne, vesiculobullous disease, psoriasis, and atopic dermatitis. We can lend support to efforts to reduce the cost of dermatologic medications and be aware of the populations most at risk for low adherence to treatment.^9-12

Final Thoughts

As we work to increase patient adherence to therapy in dermatology, we will help improve health literacy, patient safety, and patient satisfaction. These factors are ultimately linked to better health outcomes. The CDC and WHO websites are excellent sources of information on practical methods for doing so.^2,9

How do we increase patient adherence to therapy? This question fascinates me. As dermatologists, we will see thousands of patients over the course of our careers, most with treatable conditions that will improve with therapy and others with chronic or genetic conditions that will at least be made more tolerable with therapy. Only 50% of patients with a chronic condition are adherent to therapy.¹ Why some patients adhere to treatment and others do not can be difficult to understand. The emotional makeup, culture, family background, socioeconomic status, and motivation of each person is unique, which leads to complexity. This column is not meant to answer a question that is both complex and broad; rather, it is meant to survey and summarize the literature on this topic.  

Education

Health literacy is defined as cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.² Greater health literacy leads to improved compliance and health outcomes.^3,4 When we take the time to educate patients about their condition, it improves health literacy, treatment compliance, and patient safety and satisfaction, factors that ultimately are linked to better health outcomes.^3-8

There are many practical ways of educating patients. Interestingly, one meta-analysis found that no single strategy is more effective than another.⁶ This analysis found that "[c]omprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions."⁶ The Centers for Disease Control and Prevention (CDC) website is an excellent source of information on how to educate patients and increase patient treatment compliance.² The CDC website offers a free tool kit on how to design educational information to your target audience, resources for children, a database of health-related educational images, an electronic textbook on teaching patients with low literacy skills, a summary of evidence-based ideas on how to improve patient adherence to medications used long-term, and more.²

Facilitating Adherence

The World Health Organization (WHO) emphasizes 5 dimensions of patient adherence: health system, socioeconomic, condition-related, therapy-related, and patient-related factors.⁹ Becker and Maiman⁵ summarized it eloquently when they wrote that we must take "clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through 'tailoring' and other approaches." It is a broad ultimatum that will require creativity and persistence on the part of the dermatology community.

Some common patient-related factors associated with nonadherence to treatment are lack of information and skills as they pertain to self-management, difficulty with motivation and self-efficacy, and lack of support for behavioral changes.⁹ It is interesting that low socioeconomic status has not been consistently shown to portend low treatment adherence. It has been shown that children, especially adolescents, and elderly patients tend to be the least adherent.^9-11

Dermatologists Take Action

As dermatologists, the WHO encourages us (physicians) to promote optimism, provide enthusiasm, and encourage maintenance of healthy behaviors.⁹ Comprehensive interventions that have had a positive impact on patient adherence to therapy for diseases such as diabetes mellitus, asthma, and hypertension may serve as motivating examples.⁹ Some specific dermatologic conditions that will benefit from increased patient adherence include acne, vesiculobullous disease, psoriasis, and atopic dermatitis. We can lend support to efforts to reduce the cost of dermatologic medications and be aware of the populations most at risk for low adherence to treatment.^9-12

Final Thoughts

As we work to increase patient adherence to therapy in dermatology, we will help improve health literacy, patient safety, and patient satisfaction. These factors are ultimately linked to better health outcomes. The CDC and WHO websites are excellent sources of information on practical methods for doing so.^2,9

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, laser therapy, and chemical peels. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 2 of this series, laser therapy and chemical peels are discussed.

Lasers

In dermatology, lasers are used to treat dyschromia, resurface scars, remove skin growths, and rejuvenate aging skin.^1,2 Ablative resurfacing lasers such as the CO₂ laser are the most likely to lead to unwanted side effects. There is a risk for herpes simplex virus reactivation, impetigo, persistent erythema, dyschromia, and scarring.^1-3 Some patients who undergo facial ablative resurfacing may develop a visible hypopigmented line of demarcation between treated and untreated skin along the jawline.³ With the development of fractional resurfacing lasers, the risk for dyschromia, persistent erythema, and scarring was lessened.^1-3

Regardless of the type of resurfacing laser used, patients should be given adequate prophylaxis with an antiviral and antibiotic. For skin of color, fractional resurfacing lasers should be set at lower density settings with a higher fluence.^1-3 Sites with fewer adnexal structures (eg, neck, dorsal hands) also should be treated at lower densities.³ When using Q-switched lasers that target pigment, caution should be used to avoid vesicle formation and/or skin crusting, which may lead to scarring or dyschromia.^1-3 Some tattoo inks may paradoxically darken when treated with lasers.³ A test spot is advised, especially prior to treatment of permanent makeup tattoos. A pigmented lesion should never be treated if the diagnosis is unclear (eg, a biopsy to establish the diagnosis may be the best appropriate step for some pigmented lesions). For laser hair removal, the Nd:YAG laser is the safest for skin of color.^2,3

Lasers that target vascular structures may cause unwanted purpura, hypopigmentation, or thermal injury.^1-3 A larger spot size may help decrease the risk for purpura. The skin should be cooled properly and caution should be used to avoid pulse stacking. For intense pulsed light devices, overlap pulses slightly to avoid a zebralike pattern of slivers of untreated skin.^1-3 For all laser procedures, strict sun protection is advised before and after the procedure.

Chemical Peels

Chemical peels are versatile and varied in their composition. They are categorized based on the depth to which the skin is affected by the peel: superficial (stratum corneum), medium (full-thickness epidermis), or deep (mid reticular dermis).⁴ Peels are most commonly used to treat dyschromia, aging, rhytides, actinic damage, and superficial scars.^4,5 The success of a chemical peel depends largely on patient selection and preprocedure preparation. Patients who tend to develop postinflammatory hyperpigmention, have an underlying inflammatory or scarring skin disorder, are on photosensitizing medications, or have continued work- or hobby-related sun exposure are generally poor peel candidates.^4,5 Strict sun protection should be advised both before and after a chemical peel.

While in training, residents are unlikely to perform a medium or deep peel. Superficial peels can be accomplished with trichloroacetic acid 10%, glycolic acid (GA) 30% to 50%, salicylic acid (SA) 20% to 30%, Jessner solution (SA, lactic acid, and resorcinol with ethanol), and tretinoin 1% to 5%.⁴ Glycolic acid and SA are known to be safer for patients with skin of color.^4,5

Care should always be taken to prepare the skin for an even peel. Mild peeling agents such as tretinoin or adapalene may be used to prepare the skin in the weeks before the procedure.⁴ Skin of color may benefit from hydroquinone used before and after a chemical peel.⁵ At the time of the peel, acetone can be used to degrease the skin for a more even, effective peel. If a peel needs to be neutralized (eg, GA), make sure to have the neutralization solution on hand, as leaving the peel solution on for too long can lead to severe epidermolysis, which can be visualized by a graying of the skin and will not be seen with a properly performed superficial peel.⁴ Care should be taken at all times to protect the patient’s eyes. Eye flushes should be readily available. The medial canthus and perinasal folds may be protected with petrolatum. For a superficial peel, some desquamation (less with GA) and erythema may be noted for a few days.

Final Thoughts

For any cosmetic procedure, the patient’s expectations should be discussed. The provider may adeptly guide the patient toward realistic expectations for the procedure. Pretreatment and posttreatment photographs should always be taken to help document treatment progress; it may be helpful to show the patient the photographs at each visit. The expected skin reactions, recovery time, and risks should be fully discussed. Full informed consent should be obtained. Complications from cosmetic procedures will inevitably arise. As residents, we can take the opportunity to learn how to prevent, identify, and manage them.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, laser therapy, and chemical peels. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 2 of this series, laser therapy and chemical peels are discussed.

Lasers

In dermatology, lasers are used to treat dyschromia, resurface scars, remove skin growths, and rejuvenate aging skin.^1,2 Ablative resurfacing lasers such as the CO₂ laser are the most likely to lead to unwanted side effects. There is a risk for herpes simplex virus reactivation, impetigo, persistent erythema, dyschromia, and scarring.^1-3 Some patients who undergo facial ablative resurfacing may develop a visible hypopigmented line of demarcation between treated and untreated skin along the jawline.³ With the development of fractional resurfacing lasers, the risk for dyschromia, persistent erythema, and scarring was lessened.^1-3

Regardless of the type of resurfacing laser used, patients should be given adequate prophylaxis with an antiviral and antibiotic. For skin of color, fractional resurfacing lasers should be set at lower density settings with a higher fluence.^1-3 Sites with fewer adnexal structures (eg, neck, dorsal hands) also should be treated at lower densities.³ When using Q-switched lasers that target pigment, caution should be used to avoid vesicle formation and/or skin crusting, which may lead to scarring or dyschromia.^1-3 Some tattoo inks may paradoxically darken when treated with lasers.³ A test spot is advised, especially prior to treatment of permanent makeup tattoos. A pigmented lesion should never be treated if the diagnosis is unclear (eg, a biopsy to establish the diagnosis may be the best appropriate step for some pigmented lesions). For laser hair removal, the Nd:YAG laser is the safest for skin of color.^2,3

Lasers that target vascular structures may cause unwanted purpura, hypopigmentation, or thermal injury.^1-3 A larger spot size may help decrease the risk for purpura. The skin should be cooled properly and caution should be used to avoid pulse stacking. For intense pulsed light devices, overlap pulses slightly to avoid a zebralike pattern of slivers of untreated skin.^1-3 For all laser procedures, strict sun protection is advised before and after the procedure.

Chemical Peels

Chemical peels are versatile and varied in their composition. They are categorized based on the depth to which the skin is affected by the peel: superficial (stratum corneum), medium (full-thickness epidermis), or deep (mid reticular dermis).⁴ Peels are most commonly used to treat dyschromia, aging, rhytides, actinic damage, and superficial scars.^4,5 The success of a chemical peel depends largely on patient selection and preprocedure preparation. Patients who tend to develop postinflammatory hyperpigmention, have an underlying inflammatory or scarring skin disorder, are on photosensitizing medications, or have continued work- or hobby-related sun exposure are generally poor peel candidates.^4,5 Strict sun protection should be advised both before and after a chemical peel.

While in training, residents are unlikely to perform a medium or deep peel. Superficial peels can be accomplished with trichloroacetic acid 10%, glycolic acid (GA) 30% to 50%, salicylic acid (SA) 20% to 30%, Jessner solution (SA, lactic acid, and resorcinol with ethanol), and tretinoin 1% to 5%.⁴ Glycolic acid and SA are known to be safer for patients with skin of color.^4,5

Care should always be taken to prepare the skin for an even peel. Mild peeling agents such as tretinoin or adapalene may be used to prepare the skin in the weeks before the procedure.⁴ Skin of color may benefit from hydroquinone used before and after a chemical peel.⁵ At the time of the peel, acetone can be used to degrease the skin for a more even, effective peel. If a peel needs to be neutralized (eg, GA), make sure to have the neutralization solution on hand, as leaving the peel solution on for too long can lead to severe epidermolysis, which can be visualized by a graying of the skin and will not be seen with a properly performed superficial peel.⁴ Care should be taken at all times to protect the patient’s eyes. Eye flushes should be readily available. The medial canthus and perinasal folds may be protected with petrolatum. For a superficial peel, some desquamation (less with GA) and erythema may be noted for a few days.

Final Thoughts

For any cosmetic procedure, the patient’s expectations should be discussed. The provider may adeptly guide the patient toward realistic expectations for the procedure. Pretreatment and posttreatment photographs should always be taken to help document treatment progress; it may be helpful to show the patient the photographs at each visit. The expected skin reactions, recovery time, and risks should be fully discussed. Full informed consent should be obtained. Complications from cosmetic procedures will inevitably arise. As residents, we can take the opportunity to learn how to prevent, identify, and manage them.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, laser therapy, and chemical peels. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 2 of this series, laser therapy and chemical peels are discussed.

Lasers

In dermatology, lasers are used to treat dyschromia, resurface scars, remove skin growths, and rejuvenate aging skin.^1,2 Ablative resurfacing lasers such as the CO₂ laser are the most likely to lead to unwanted side effects. There is a risk for herpes simplex virus reactivation, impetigo, persistent erythema, dyschromia, and scarring.^1-3 Some patients who undergo facial ablative resurfacing may develop a visible hypopigmented line of demarcation between treated and untreated skin along the jawline.³ With the development of fractional resurfacing lasers, the risk for dyschromia, persistent erythema, and scarring was lessened.^1-3

Regardless of the type of resurfacing laser used, patients should be given adequate prophylaxis with an antiviral and antibiotic. For skin of color, fractional resurfacing lasers should be set at lower density settings with a higher fluence.^1-3 Sites with fewer adnexal structures (eg, neck, dorsal hands) also should be treated at lower densities.³ When using Q-switched lasers that target pigment, caution should be used to avoid vesicle formation and/or skin crusting, which may lead to scarring or dyschromia.^1-3 Some tattoo inks may paradoxically darken when treated with lasers.³ A test spot is advised, especially prior to treatment of permanent makeup tattoos. A pigmented lesion should never be treated if the diagnosis is unclear (eg, a biopsy to establish the diagnosis may be the best appropriate step for some pigmented lesions). For laser hair removal, the Nd:YAG laser is the safest for skin of color.^2,3

Lasers that target vascular structures may cause unwanted purpura, hypopigmentation, or thermal injury.^1-3 A larger spot size may help decrease the risk for purpura. The skin should be cooled properly and caution should be used to avoid pulse stacking. For intense pulsed light devices, overlap pulses slightly to avoid a zebralike pattern of slivers of untreated skin.^1-3 For all laser procedures, strict sun protection is advised before and after the procedure.

Chemical Peels

Chemical peels are versatile and varied in their composition. They are categorized based on the depth to which the skin is affected by the peel: superficial (stratum corneum), medium (full-thickness epidermis), or deep (mid reticular dermis).⁴ Peels are most commonly used to treat dyschromia, aging, rhytides, actinic damage, and superficial scars.^4,5 The success of a chemical peel depends largely on patient selection and preprocedure preparation. Patients who tend to develop postinflammatory hyperpigmention, have an underlying inflammatory or scarring skin disorder, are on photosensitizing medications, or have continued work- or hobby-related sun exposure are generally poor peel candidates.^4,5 Strict sun protection should be advised both before and after a chemical peel.

While in training, residents are unlikely to perform a medium or deep peel. Superficial peels can be accomplished with trichloroacetic acid 10%, glycolic acid (GA) 30% to 50%, salicylic acid (SA) 20% to 30%, Jessner solution (SA, lactic acid, and resorcinol with ethanol), and tretinoin 1% to 5%.⁴ Glycolic acid and SA are known to be safer for patients with skin of color.^4,5

Care should always be taken to prepare the skin for an even peel. Mild peeling agents such as tretinoin or adapalene may be used to prepare the skin in the weeks before the procedure.⁴ Skin of color may benefit from hydroquinone used before and after a chemical peel.⁵ At the time of the peel, acetone can be used to degrease the skin for a more even, effective peel. If a peel needs to be neutralized (eg, GA), make sure to have the neutralization solution on hand, as leaving the peel solution on for too long can lead to severe epidermolysis, which can be visualized by a graying of the skin and will not be seen with a properly performed superficial peel.⁴ Care should be taken at all times to protect the patient’s eyes. Eye flushes should be readily available. The medial canthus and perinasal folds may be protected with petrolatum. For a superficial peel, some desquamation (less with GA) and erythema may be noted for a few days.

Final Thoughts

For any cosmetic procedure, the patient’s expectations should be discussed. The provider may adeptly guide the patient toward realistic expectations for the procedure. Pretreatment and posttreatment photographs should always be taken to help document treatment progress; it may be helpful to show the patient the photographs at each visit. The expected skin reactions, recovery time, and risks should be fully discussed. Full informed consent should be obtained. Complications from cosmetic procedures will inevitably arise. As residents, we can take the opportunity to learn how to prevent, identify, and manage them.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, chemical peels, and laser therapy. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 1 of this 2-part series, soft-tissue augmentation and botulinum toxin injections are discussed. Chemical peels and laser therapy will be addressed in part 2.

Soft-Tissue Augmentation

Soft-tissue fillers include those that are made from collagen (bovine or human), hyaluronic acid (HA), poly-L-lactic acid, calcium hydroxylapatite, silicone, and polymethylmethacrylate. In general, acute complications of soft-tissue filler injections include erythema, swelling, and bruising.^1-3 Patients who take blood thinners or supplements (eg, vitamin E, ginseng, garlic, ginger) should be asked to discontinue use 1 week prior to the procedure. Patients who take blood thinners also should be counseled to expect some bruising. Prior to injection, the skin should be thoroughly cleansed to avoid introducing skin bacteria into the injection site and to reduce infection risk. Postinjection erythema may be related to mast cell activation, which is temporary and should resolve after a few days.^1-3

If you find yourself injecting the filler too superficially, you may notice that the skin begins to take on a blue-gray hue^1-3 that is known as the Tyndall effect and can be prevented by injecting the filler at the proper level. For example, collagen-based fillers should be placed at the mid dermis, thicker HA fillers should be placed in the deep dermis, and calcium hydroxylapatite should be placed at the junction of the dermis and subcutaneous tissue. Polymethylmethacrylate and poly-L-lactic acid should both be placed subdermally.^1-3

The gravest immediate complications associated with soft-tissue filler injections are occlusion of the central retinal artery and/or skin necrosis.^1-4 Residents should never inject filler to the glabella or to the nose.^1-3 Injections at these sites are sometimes performed but should only be performed by experienced dermatologists. The perioral and tear trough regions also are high-risk injection areas that require a high degree of experience and should only be injected with proper supervision by an experienced dermatologist.^1-3 Residents generally can avoid these complications, though not with a 100% guarantee, by avoiding injections in high-risk areas, aspirating to check for blood, and slowly injecting a small amount of filler into the treatment area.^1-3 A consensus statement on management of injection-induced necrosis advises to apply a nitropaste ointment 2% to the treatment site or administer an oral aspirin if the patient develops severe pain; vision loss; or acute skin discoloration, especially blanching.⁴ For HA-based fillers, at least 200 U of hyaluronidase should be injected. It has been suggested that saline can be injected to flush out calcium hydroxylapatite fillers.³ Warm compresses should be placed on the involved area. Following these interventions, any patient with vision loss or orbital pain should immediately undergo ophthalmologic evaluation.³ The most important intervention occurs in the first 24 hours.^3,4 After 24 hours, careful wound care, oral anticoagulants, and hyperbaric oxygen therapy have been suggested as management options.³

There are 2 major chronic complications of soft-tissue filler injection, including delayed-onset infection, which occurs 2 weeks or more postinjection, and granuloma formation.^1-3 Chronic low-grade infection at the injection site may be indicative of biofilm formation. If an HA filler was used, it should be dissolved with hyaluronidase to help break up the biofilm nidus.³ A course of oral antibiotics also may be indicated.^1-3 Intralesional steroids may be used but only after antibiotics have been administered. A biofilm that develops from more permanent fillers may be more difficult to manage. Atypical mycobacterial infections have been known to develop at injection sites, which should be considered in refractory cases.^1-3,5

Calcium hydroxylapatite, polymethylmethacrylate, and silicone can stimulate chronic immune system activation, which makes them more prone to granuloma formation.^1-3 Once infection is ruled out, granulomas may be treated with intralesional steroids, surgical excision (if the results would be cosmetically acceptable), laser therapy, or potentially local injection of an immunosuppressant (eg, methotrexate, 5-fluorouracil).³

Botulinum Toxin Injections

Patients who are pregnant, lactating, or have neuromuscular disease are not candidates for botulinum toxin injections. There also is a risk that patients taking calcium channel blockers or aminoglycoside antibiotics may experience potentiated effects of the botulinum toxin.⁶

Patients should be informed that a postinjection headache may occur and should be treated with over-the-counter medications.⁶ Complication-free botulinum toxin procedures depend heavily on the physician’s knowledge of facial anatomy.^1,6 The diagrams provided by Hirsch and Stier¹ offer an excellent guide on where to place the injections. Brow droop, eyelid ptosis, and “Spock brow” (eyebrows that are overarched) largely can be avoided by proper injection point placement. A Spock brow may be corrected by injecting the lateral upper forehead with a few units to correct the exaggerated arch.^6,7 For eyelid ptosis, apraclonidine 0.05% drops (1–2 drops 3 times daily) should be used until the ptosis resolves.⁶ Phenylephrine hydrochloride drops may be used should a patient have a documented sensitivity to apraclonidine but should not be used in a patient with acute angle-closure glaucoma or aneurysms.⁶

Final Thoughts

Learning to perform soft-tissue augmentation and botulinum toxin injections can be a satisfying and fun part of dermatology residency. Preventing, identifying, and managing any complications that may occur is an integral part of performing these procedures.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, chemical peels, and laser therapy. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 1 of this 2-part series, soft-tissue augmentation and botulinum toxin injections are discussed. Chemical peels and laser therapy will be addressed in part 2.

Soft-Tissue Augmentation

Soft-tissue fillers include those that are made from collagen (bovine or human), hyaluronic acid (HA), poly-L-lactic acid, calcium hydroxylapatite, silicone, and polymethylmethacrylate. In general, acute complications of soft-tissue filler injections include erythema, swelling, and bruising.^1-3 Patients who take blood thinners or supplements (eg, vitamin E, ginseng, garlic, ginger) should be asked to discontinue use 1 week prior to the procedure. Patients who take blood thinners also should be counseled to expect some bruising. Prior to injection, the skin should be thoroughly cleansed to avoid introducing skin bacteria into the injection site and to reduce infection risk. Postinjection erythema may be related to mast cell activation, which is temporary and should resolve after a few days.^1-3

If you find yourself injecting the filler too superficially, you may notice that the skin begins to take on a blue-gray hue^1-3 that is known as the Tyndall effect and can be prevented by injecting the filler at the proper level. For example, collagen-based fillers should be placed at the mid dermis, thicker HA fillers should be placed in the deep dermis, and calcium hydroxylapatite should be placed at the junction of the dermis and subcutaneous tissue. Polymethylmethacrylate and poly-L-lactic acid should both be placed subdermally.^1-3

The gravest immediate complications associated with soft-tissue filler injections are occlusion of the central retinal artery and/or skin necrosis.^1-4 Residents should never inject filler to the glabella or to the nose.^1-3 Injections at these sites are sometimes performed but should only be performed by experienced dermatologists. The perioral and tear trough regions also are high-risk injection areas that require a high degree of experience and should only be injected with proper supervision by an experienced dermatologist.^1-3 Residents generally can avoid these complications, though not with a 100% guarantee, by avoiding injections in high-risk areas, aspirating to check for blood, and slowly injecting a small amount of filler into the treatment area.^1-3 A consensus statement on management of injection-induced necrosis advises to apply a nitropaste ointment 2% to the treatment site or administer an oral aspirin if the patient develops severe pain; vision loss; or acute skin discoloration, especially blanching.⁴ For HA-based fillers, at least 200 U of hyaluronidase should be injected. It has been suggested that saline can be injected to flush out calcium hydroxylapatite fillers.³ Warm compresses should be placed on the involved area. Following these interventions, any patient with vision loss or orbital pain should immediately undergo ophthalmologic evaluation.³ The most important intervention occurs in the first 24 hours.^3,4 After 24 hours, careful wound care, oral anticoagulants, and hyperbaric oxygen therapy have been suggested as management options.³

There are 2 major chronic complications of soft-tissue filler injection, including delayed-onset infection, which occurs 2 weeks or more postinjection, and granuloma formation.^1-3 Chronic low-grade infection at the injection site may be indicative of biofilm formation. If an HA filler was used, it should be dissolved with hyaluronidase to help break up the biofilm nidus.³ A course of oral antibiotics also may be indicated.^1-3 Intralesional steroids may be used but only after antibiotics have been administered. A biofilm that develops from more permanent fillers may be more difficult to manage. Atypical mycobacterial infections have been known to develop at injection sites, which should be considered in refractory cases.^1-3,5

Calcium hydroxylapatite, polymethylmethacrylate, and silicone can stimulate chronic immune system activation, which makes them more prone to granuloma formation.^1-3 Once infection is ruled out, granulomas may be treated with intralesional steroids, surgical excision (if the results would be cosmetically acceptable), laser therapy, or potentially local injection of an immunosuppressant (eg, methotrexate, 5-fluorouracil).³

Botulinum Toxin Injections

Patients who are pregnant, lactating, or have neuromuscular disease are not candidates for botulinum toxin injections. There also is a risk that patients taking calcium channel blockers or aminoglycoside antibiotics may experience potentiated effects of the botulinum toxin.⁶

Patients should be informed that a postinjection headache may occur and should be treated with over-the-counter medications.⁶ Complication-free botulinum toxin procedures depend heavily on the physician’s knowledge of facial anatomy.^1,6 The diagrams provided by Hirsch and Stier¹ offer an excellent guide on where to place the injections. Brow droop, eyelid ptosis, and “Spock brow” (eyebrows that are overarched) largely can be avoided by proper injection point placement. A Spock brow may be corrected by injecting the lateral upper forehead with a few units to correct the exaggerated arch.^6,7 For eyelid ptosis, apraclonidine 0.05% drops (1–2 drops 3 times daily) should be used until the ptosis resolves.⁶ Phenylephrine hydrochloride drops may be used should a patient have a documented sensitivity to apraclonidine but should not be used in a patient with acute angle-closure glaucoma or aneurysms.⁶

Final Thoughts

Learning to perform soft-tissue augmentation and botulinum toxin injections can be a satisfying and fun part of dermatology residency. Preventing, identifying, and managing any complications that may occur is an integral part of performing these procedures.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, chemical peels, and laser therapy. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 1 of this 2-part series, soft-tissue augmentation and botulinum toxin injections are discussed. Chemical peels and laser therapy will be addressed in part 2.

Soft-Tissue Augmentation

Soft-tissue fillers include those that are made from collagen (bovine or human), hyaluronic acid (HA), poly-L-lactic acid, calcium hydroxylapatite, silicone, and polymethylmethacrylate. In general, acute complications of soft-tissue filler injections include erythema, swelling, and bruising.^1-3 Patients who take blood thinners or supplements (eg, vitamin E, ginseng, garlic, ginger) should be asked to discontinue use 1 week prior to the procedure. Patients who take blood thinners also should be counseled to expect some bruising. Prior to injection, the skin should be thoroughly cleansed to avoid introducing skin bacteria into the injection site and to reduce infection risk. Postinjection erythema may be related to mast cell activation, which is temporary and should resolve after a few days.^1-3

If you find yourself injecting the filler too superficially, you may notice that the skin begins to take on a blue-gray hue^1-3 that is known as the Tyndall effect and can be prevented by injecting the filler at the proper level. For example, collagen-based fillers should be placed at the mid dermis, thicker HA fillers should be placed in the deep dermis, and calcium hydroxylapatite should be placed at the junction of the dermis and subcutaneous tissue. Polymethylmethacrylate and poly-L-lactic acid should both be placed subdermally.^1-3

The gravest immediate complications associated with soft-tissue filler injections are occlusion of the central retinal artery and/or skin necrosis.^1-4 Residents should never inject filler to the glabella or to the nose.^1-3 Injections at these sites are sometimes performed but should only be performed by experienced dermatologists. The perioral and tear trough regions also are high-risk injection areas that require a high degree of experience and should only be injected with proper supervision by an experienced dermatologist.^1-3 Residents generally can avoid these complications, though not with a 100% guarantee, by avoiding injections in high-risk areas, aspirating to check for blood, and slowly injecting a small amount of filler into the treatment area.^1-3 A consensus statement on management of injection-induced necrosis advises to apply a nitropaste ointment 2% to the treatment site or administer an oral aspirin if the patient develops severe pain; vision loss; or acute skin discoloration, especially blanching.⁴ For HA-based fillers, at least 200 U of hyaluronidase should be injected. It has been suggested that saline can be injected to flush out calcium hydroxylapatite fillers.³ Warm compresses should be placed on the involved area. Following these interventions, any patient with vision loss or orbital pain should immediately undergo ophthalmologic evaluation.³ The most important intervention occurs in the first 24 hours.^3,4 After 24 hours, careful wound care, oral anticoagulants, and hyperbaric oxygen therapy have been suggested as management options.³

There are 2 major chronic complications of soft-tissue filler injection, including delayed-onset infection, which occurs 2 weeks or more postinjection, and granuloma formation.^1-3 Chronic low-grade infection at the injection site may be indicative of biofilm formation. If an HA filler was used, it should be dissolved with hyaluronidase to help break up the biofilm nidus.³ A course of oral antibiotics also may be indicated.^1-3 Intralesional steroids may be used but only after antibiotics have been administered. A biofilm that develops from more permanent fillers may be more difficult to manage. Atypical mycobacterial infections have been known to develop at injection sites, which should be considered in refractory cases.^1-3,5

Calcium hydroxylapatite, polymethylmethacrylate, and silicone can stimulate chronic immune system activation, which makes them more prone to granuloma formation.^1-3 Once infection is ruled out, granulomas may be treated with intralesional steroids, surgical excision (if the results would be cosmetically acceptable), laser therapy, or potentially local injection of an immunosuppressant (eg, methotrexate, 5-fluorouracil).³

Botulinum Toxin Injections

Patients who are pregnant, lactating, or have neuromuscular disease are not candidates for botulinum toxin injections. There also is a risk that patients taking calcium channel blockers or aminoglycoside antibiotics may experience potentiated effects of the botulinum toxin.⁶

Patients should be informed that a postinjection headache may occur and should be treated with over-the-counter medications.⁶ Complication-free botulinum toxin procedures depend heavily on the physician’s knowledge of facial anatomy.^1,6 The diagrams provided by Hirsch and Stier¹ offer an excellent guide on where to place the injections. Brow droop, eyelid ptosis, and “Spock brow” (eyebrows that are overarched) largely can be avoided by proper injection point placement. A Spock brow may be corrected by injecting the lateral upper forehead with a few units to correct the exaggerated arch.^6,7 For eyelid ptosis, apraclonidine 0.05% drops (1–2 drops 3 times daily) should be used until the ptosis resolves.⁶ Phenylephrine hydrochloride drops may be used should a patient have a documented sensitivity to apraclonidine but should not be used in a patient with acute angle-closure glaucoma or aneurysms.⁶

Final Thoughts

Learning to perform soft-tissue augmentation and botulinum toxin injections can be a satisfying and fun part of dermatology residency. Preventing, identifying, and managing any complications that may occur is an integral part of performing these procedures.

Books

There are a number of classic textbooks that serve as primary resources for dermatology training^1-4; however, there also are other options if memorizing these books seems a little daunting. The “first aid” books of dermatology are the Derm In-Review binder and Jain’s⁵ Dermatology: Illustrated Study Guide and Comprehensive Board Review. Mariwalla and Leffell’s⁶Primer in Dermatologic Surgery: A Study Companion is helpful for surgical review and is available at a discounted price for members of the American Society for Dermatologic Surgery (https://www.asds.net/store/product.aspx?id=3914&terms=primer%20in%20Dermatologic%20surgery). The American Academy of Dermatology (AAD) provides a list of additional textbooks that dermatology residents may find useful for board review.⁷

Guided Study

The AAD offers board review courses for dermatology residents (cost varies).⁷ The Florida Dermatology and Dermatopathology Board Review Course (http://dermatology.med.ufl.edu/education/florida-dermatology-and-dermatopathology-board-review-course/) is an annual review course held in Tampa (early registration fee, $800 [does not include travel costs]). The Oakstone Institute also offers its Dermatology Board Review Course, which is a self-study program that can be completed online for approximately $1195 (http://www.oakstone.com/dermatology-board-review-course). Be sure to take advantage of free didactics lectures, society meetings with board review courses, and study groups, as these resources can be just as helpful and more budget friendly.

Digital Resources

The Derm In-Review question bank (http://dermatologyinreview.com/Merz) is probably one of the most popular board review resources and is free to US dermatology residents; however, be cautious when using this resource, as a fair number of the answers to questions may actually be outdated or based on older studies. A group study session can help tease out why certain answers are erroneous and provide a forum for discussing what would be a more correct answer. Take advantage of the opportunity to provide feedback on this website, as your comments will improve this resource for future dermatology residents.

Beyond traditional dermatopathology textbooks, there also are some excellent mobile applications (apps) available. The Clearpath app is a user-friendly dermatopathology study tool that is free for download in the iTunes store (https://itunes.apple.com/us/app/clearpath/id540260769?mt=8). However, the app is only compatible with iPads. The Clearpath website also offers virtual study slide sets that are easier to access (http://dermpathlab.com/slide-study-set-program). Your institution’s glass slide sets also are useful for building pattern recognition skills and practicing for the actual board examination. The DermOID website (http://www.derm-oid.com), which is powered by the David Geffen School of Medicine at the University of California, Los Angeles, is another online dermatopathology study database with free registration for access to the site. Another fun way to test your dermatopathology skills is in the exhibition hall at the AAD annual meeting where some vendors may offer daily dermatopathology quizzes and prizes for the residents with the most correct answers. Also, it is worth reviewing the Cutis^® Fast Facts for Board Review (http://www.cutis.com/articles/fast-facts-for-board-review/), as this section offers many outstanding fact sheets that are an easy read and an efficient way to gain board knowledge. Some recent topics include fillers, paraneoplastic skin conditions, and medications in dermatology.

Many residents enjoy using the Anki flashcard app (http://ankisrs.net) for reviewing kodachromes. The AAD website also includes a Boards’ Fodder archive that is worth reviewing (https://www.aad.org/members/residents-fellows/boards-study-tools/boards-fodder/boards-fodder). New board review resources are constantly being posted on the AAD website, so definitely check this out. You may be able to access this resource through your residency program; it is also available for purchase ($425 for AAD members; $850 for nonmembers).

Journals

All the major dermatology journals are helpful in preparing for the board examination. Your resident journal club will likely review many of the most clinically relevant dermatology articles published over the course of your residency. Some other helpful journal resources that are recommended for board review include the Journal of the American Medical Association’s Clinical Challenge, which has many dermatologic cases (http://jama.jamanetwork.com/public/QuizzesAndPolls.aspx), and the New England Journal of Medicine’s Journal Watch (http://www.jwatch.org) and Image Challenge (http://www.nejm.org/image-challenge).

Practice Examinations

The American Board of Dermatology’s In-Training Examination is the most well-known practice examination among dermatology residents.⁸ A link to an additional practice examination usually is provided a few weeks prior to the examination. The Derm In-Review website also offers diagnostic practice examinations with some ability to custom select questions for your studying needs.

Conclusion

There are many board review resources out there. Find the ones that work for you, and be encouraged that your studying and hard work will pay off!

Books

There are a number of classic textbooks that serve as primary resources for dermatology training^1-4; however, there also are other options if memorizing these books seems a little daunting. The “first aid” books of dermatology are the Derm In-Review binder and Jain’s⁵ Dermatology: Illustrated Study Guide and Comprehensive Board Review. Mariwalla and Leffell’s⁶Primer in Dermatologic Surgery: A Study Companion is helpful for surgical review and is available at a discounted price for members of the American Society for Dermatologic Surgery (https://www.asds.net/store/product.aspx?id=3914&terms=primer%20in%20Dermatologic%20surgery). The American Academy of Dermatology (AAD) provides a list of additional textbooks that dermatology residents may find useful for board review.⁷

Guided Study

The AAD offers board review courses for dermatology residents (cost varies).⁷ The Florida Dermatology and Dermatopathology Board Review Course (http://dermatology.med.ufl.edu/education/florida-dermatology-and-dermatopathology-board-review-course/) is an annual review course held in Tampa (early registration fee, $800 [does not include travel costs]). The Oakstone Institute also offers its Dermatology Board Review Course, which is a self-study program that can be completed online for approximately $1195 (http://www.oakstone.com/dermatology-board-review-course). Be sure to take advantage of free didactics lectures, society meetings with board review courses, and study groups, as these resources can be just as helpful and more budget friendly.

Digital Resources

The Derm In-Review question bank (http://dermatologyinreview.com/Merz) is probably one of the most popular board review resources and is free to US dermatology residents; however, be cautious when using this resource, as a fair number of the answers to questions may actually be outdated or based on older studies. A group study session can help tease out why certain answers are erroneous and provide a forum for discussing what would be a more correct answer. Take advantage of the opportunity to provide feedback on this website, as your comments will improve this resource for future dermatology residents.

Beyond traditional dermatopathology textbooks, there also are some excellent mobile applications (apps) available. The Clearpath app is a user-friendly dermatopathology study tool that is free for download in the iTunes store (https://itunes.apple.com/us/app/clearpath/id540260769?mt=8). However, the app is only compatible with iPads. The Clearpath website also offers virtual study slide sets that are easier to access (http://dermpathlab.com/slide-study-set-program). Your institution’s glass slide sets also are useful for building pattern recognition skills and practicing for the actual board examination. The DermOID website (http://www.derm-oid.com), which is powered by the David Geffen School of Medicine at the University of California, Los Angeles, is another online dermatopathology study database with free registration for access to the site. Another fun way to test your dermatopathology skills is in the exhibition hall at the AAD annual meeting where some vendors may offer daily dermatopathology quizzes and prizes for the residents with the most correct answers. Also, it is worth reviewing the Cutis^® Fast Facts for Board Review (http://www.cutis.com/articles/fast-facts-for-board-review/), as this section offers many outstanding fact sheets that are an easy read and an efficient way to gain board knowledge. Some recent topics include fillers, paraneoplastic skin conditions, and medications in dermatology.

Many residents enjoy using the Anki flashcard app (http://ankisrs.net) for reviewing kodachromes. The AAD website also includes a Boards’ Fodder archive that is worth reviewing (https://www.aad.org/members/residents-fellows/boards-study-tools/boards-fodder/boards-fodder). New board review resources are constantly being posted on the AAD website, so definitely check this out. You may be able to access this resource through your residency program; it is also available for purchase ($425 for AAD members; $850 for nonmembers).

Journals

All the major dermatology journals are helpful in preparing for the board examination. Your resident journal club will likely review many of the most clinically relevant dermatology articles published over the course of your residency. Some other helpful journal resources that are recommended for board review include the Journal of the American Medical Association’s Clinical Challenge, which has many dermatologic cases (http://jama.jamanetwork.com/public/QuizzesAndPolls.aspx), and the New England Journal of Medicine’s Journal Watch (http://www.jwatch.org) and Image Challenge (http://www.nejm.org/image-challenge).

Practice Examinations

The American Board of Dermatology’s In-Training Examination is the most well-known practice examination among dermatology residents.⁸ A link to an additional practice examination usually is provided a few weeks prior to the examination. The Derm In-Review website also offers diagnostic practice examinations with some ability to custom select questions for your studying needs.

Conclusion

There are many board review resources out there. Find the ones that work for you, and be encouraged that your studying and hard work will pay off!

Books

There are a number of classic textbooks that serve as primary resources for dermatology training^1-4; however, there also are other options if memorizing these books seems a little daunting. The “first aid” books of dermatology are the Derm In-Review binder and Jain’s⁵ Dermatology: Illustrated Study Guide and Comprehensive Board Review. Mariwalla and Leffell’s⁶Primer in Dermatologic Surgery: A Study Companion is helpful for surgical review and is available at a discounted price for members of the American Society for Dermatologic Surgery (https://www.asds.net/store/product.aspx?id=3914&terms=primer%20in%20Dermatologic%20surgery). The American Academy of Dermatology (AAD) provides a list of additional textbooks that dermatology residents may find useful for board review.⁷

Guided Study

The AAD offers board review courses for dermatology residents (cost varies).⁷ The Florida Dermatology and Dermatopathology Board Review Course (http://dermatology.med.ufl.edu/education/florida-dermatology-and-dermatopathology-board-review-course/) is an annual review course held in Tampa (early registration fee, $800 [does not include travel costs]). The Oakstone Institute also offers its Dermatology Board Review Course, which is a self-study program that can be completed online for approximately $1195 (http://www.oakstone.com/dermatology-board-review-course). Be sure to take advantage of free didactics lectures, society meetings with board review courses, and study groups, as these resources can be just as helpful and more budget friendly.

Digital Resources

The Derm In-Review question bank (http://dermatologyinreview.com/Merz) is probably one of the most popular board review resources and is free to US dermatology residents; however, be cautious when using this resource, as a fair number of the answers to questions may actually be outdated or based on older studies. A group study session can help tease out why certain answers are erroneous and provide a forum for discussing what would be a more correct answer. Take advantage of the opportunity to provide feedback on this website, as your comments will improve this resource for future dermatology residents.

Beyond traditional dermatopathology textbooks, there also are some excellent mobile applications (apps) available. The Clearpath app is a user-friendly dermatopathology study tool that is free for download in the iTunes store (https://itunes.apple.com/us/app/clearpath/id540260769?mt=8). However, the app is only compatible with iPads. The Clearpath website also offers virtual study slide sets that are easier to access (http://dermpathlab.com/slide-study-set-program). Your institution’s glass slide sets also are useful for building pattern recognition skills and practicing for the actual board examination. The DermOID website (http://www.derm-oid.com), which is powered by the David Geffen School of Medicine at the University of California, Los Angeles, is another online dermatopathology study database with free registration for access to the site. Another fun way to test your dermatopathology skills is in the exhibition hall at the AAD annual meeting where some vendors may offer daily dermatopathology quizzes and prizes for the residents with the most correct answers. Also, it is worth reviewing the Cutis^® Fast Facts for Board Review (http://www.cutis.com/articles/fast-facts-for-board-review/), as this section offers many outstanding fact sheets that are an easy read and an efficient way to gain board knowledge. Some recent topics include fillers, paraneoplastic skin conditions, and medications in dermatology.

Many residents enjoy using the Anki flashcard app (http://ankisrs.net) for reviewing kodachromes. The AAD website also includes a Boards’ Fodder archive that is worth reviewing (https://www.aad.org/members/residents-fellows/boards-study-tools/boards-fodder/boards-fodder). New board review resources are constantly being posted on the AAD website, so definitely check this out. You may be able to access this resource through your residency program; it is also available for purchase ($425 for AAD members; $850 for nonmembers).

Journals

All the major dermatology journals are helpful in preparing for the board examination. Your resident journal club will likely review many of the most clinically relevant dermatology articles published over the course of your residency. Some other helpful journal resources that are recommended for board review include the Journal of the American Medical Association’s Clinical Challenge, which has many dermatologic cases (http://jama.jamanetwork.com/public/QuizzesAndPolls.aspx), and the New England Journal of Medicine’s Journal Watch (http://www.jwatch.org) and Image Challenge (http://www.nejm.org/image-challenge).

Practice Examinations

The American Board of Dermatology’s In-Training Examination is the most well-known practice examination among dermatology residents.⁸ A link to an additional practice examination usually is provided a few weeks prior to the examination. The Derm In-Review website also offers diagnostic practice examinations with some ability to custom select questions for your studying needs.

Conclusion

There are many board review resources out there. Find the ones that work for you, and be encouraged that your studying and hard work will pay off!

Several older physicians have emphasized to me the importance of choosing an excellent disability insurance policy during residency. However, choosing the right policy can be a difficult task. The policy definitions are complicated, and there is a lot of fine print. To understand this confusing topic, start with answers to these 3 questions: What is my most valuable asset? When is the best point in my career to purchase disability insurance? What would I do if I were no longer able to perform the material and substantial duties of my occupation as a dermatologist?

A Resident’s Assets

In the world of disability insurance, your most valuable assets are your education and your ability to earn an income in the future.^1,2 A resident’s ability to earn an income in the future reflects a massive investment of time, cost of education, and postponed accruement of wealth due to time spent in training. Any negative impact on your health (eg, back injury, vision loss, hand injury) can jeopardize these assets. Purchasing disability insurance while still in dermatology residency will protect this investment; it also will ensure that you obtain a policy while you are still healthy.^1,2

Choosing a Policy

Disability insurance comes in 2 main forms: individual or group. Individual insurance may be slightly more expensive but may offer better coverage than group insurance. Group insurance often is offered through a large medical association such as the American Academy of Dermatology. Group insurance may be less expensive but often has more limits to coverage. A definite must-have in a disability insurance policy is one that has guaranteed renewal and is noncancellable.^1-3

Interestingly, women are considered a higher risk for disability, and many insurance policies will charge a higher monthly rate for women than men because women are slightly more likely than men to develop a disability, and women are more likely to develop a disability that prevents them from being able to work.⁴ Some insurance companies do offer a unisex policy, which does not discriminate.

When choosing a policy, you want to carefully read the vendor’s definition of disability. The best definition of the term disability is going to be one that includes phrases such as “unable to perform the material and substantial duties of your [own] occupation . . . even if you are gainfully employed in another occupation.”^1-3,5,6 This definition of disability is the least restrictive and would allow you to receive full benefits even if you are able to work in another capacity or occupation.^1-3,5,6 The benefit period of the policy also is something to choose carefully. It is recommended to choose a benefit period that extends to at least 65 years of age.^1-3,5 It is important to remember that the devil is in the details; for example, some disability insurance policies with more restrictive definitions will not pay you benefits if you are working in another capacity (eg, a physician who develops an injury that prohibits working with patients and then chooses to work in another capacity).

Some policies will only pay benefits if you become totally disabled. Shy away from these more restrictive policies; instead, look for a policy that has a liberal definition of what constitutes disability and allows you the option to add in a future purchase option rider. It is important that your policy includes a future purchase option rider, which means that as your income increases you have the option to purchase an increase in your disability coverage.^1-3,5 Look for a policy that allows you to be insured without penalizing you for preexisting conditions; during residency is one of the few times some policy vendors will do it, as they assume residents are generally young and healthy.^1-3,5,7

Final Thoughts

When you choose your policy, read the details carefully. Finally, remember that other physicians in the community are available as resources; they can be a wealth of information on different policies. There are many websites available to read more on this topic. Often, your training institution will offer a disability policy for the duration of your residency. Many residents choose to purchase their postresidency policies while in their third or fourth year of training. Take the time to choose a good policy now; you will be glad you did.

Several older physicians have emphasized to me the importance of choosing an excellent disability insurance policy during residency. However, choosing the right policy can be a difficult task. The policy definitions are complicated, and there is a lot of fine print. To understand this confusing topic, start with answers to these 3 questions: What is my most valuable asset? When is the best point in my career to purchase disability insurance? What would I do if I were no longer able to perform the material and substantial duties of my occupation as a dermatologist?

A Resident’s Assets

In the world of disability insurance, your most valuable assets are your education and your ability to earn an income in the future.^1,2 A resident’s ability to earn an income in the future reflects a massive investment of time, cost of education, and postponed accruement of wealth due to time spent in training. Any negative impact on your health (eg, back injury, vision loss, hand injury) can jeopardize these assets. Purchasing disability insurance while still in dermatology residency will protect this investment; it also will ensure that you obtain a policy while you are still healthy.^1,2

Choosing a Policy

Disability insurance comes in 2 main forms: individual or group. Individual insurance may be slightly more expensive but may offer better coverage than group insurance. Group insurance often is offered through a large medical association such as the American Academy of Dermatology. Group insurance may be less expensive but often has more limits to coverage. A definite must-have in a disability insurance policy is one that has guaranteed renewal and is noncancellable.^1-3

Interestingly, women are considered a higher risk for disability, and many insurance policies will charge a higher monthly rate for women than men because women are slightly more likely than men to develop a disability, and women are more likely to develop a disability that prevents them from being able to work.⁴ Some insurance companies do offer a unisex policy, which does not discriminate.

When choosing a policy, you want to carefully read the vendor’s definition of disability. The best definition of the term disability is going to be one that includes phrases such as “unable to perform the material and substantial duties of your [own] occupation . . . even if you are gainfully employed in another occupation.”^1-3,5,6 This definition of disability is the least restrictive and would allow you to receive full benefits even if you are able to work in another capacity or occupation.^1-3,5,6 The benefit period of the policy also is something to choose carefully. It is recommended to choose a benefit period that extends to at least 65 years of age.^1-3,5 It is important to remember that the devil is in the details; for example, some disability insurance policies with more restrictive definitions will not pay you benefits if you are working in another capacity (eg, a physician who develops an injury that prohibits working with patients and then chooses to work in another capacity).

Some policies will only pay benefits if you become totally disabled. Shy away from these more restrictive policies; instead, look for a policy that has a liberal definition of what constitutes disability and allows you the option to add in a future purchase option rider. It is important that your policy includes a future purchase option rider, which means that as your income increases you have the option to purchase an increase in your disability coverage.^1-3,5 Look for a policy that allows you to be insured without penalizing you for preexisting conditions; during residency is one of the few times some policy vendors will do it, as they assume residents are generally young and healthy.^1-3,5,7

Final Thoughts

When you choose your policy, read the details carefully. Finally, remember that other physicians in the community are available as resources; they can be a wealth of information on different policies. There are many websites available to read more on this topic. Often, your training institution will offer a disability policy for the duration of your residency. Many residents choose to purchase their postresidency policies while in their third or fourth year of training. Take the time to choose a good policy now; you will be glad you did.

Several older physicians have emphasized to me the importance of choosing an excellent disability insurance policy during residency. However, choosing the right policy can be a difficult task. The policy definitions are complicated, and there is a lot of fine print. To understand this confusing topic, start with answers to these 3 questions: What is my most valuable asset? When is the best point in my career to purchase disability insurance? What would I do if I were no longer able to perform the material and substantial duties of my occupation as a dermatologist?

A Resident’s Assets

In the world of disability insurance, your most valuable assets are your education and your ability to earn an income in the future.^1,2 A resident’s ability to earn an income in the future reflects a massive investment of time, cost of education, and postponed accruement of wealth due to time spent in training. Any negative impact on your health (eg, back injury, vision loss, hand injury) can jeopardize these assets. Purchasing disability insurance while still in dermatology residency will protect this investment; it also will ensure that you obtain a policy while you are still healthy.^1,2

Choosing a Policy

Disability insurance comes in 2 main forms: individual or group. Individual insurance may be slightly more expensive but may offer better coverage than group insurance. Group insurance often is offered through a large medical association such as the American Academy of Dermatology. Group insurance may be less expensive but often has more limits to coverage. A definite must-have in a disability insurance policy is one that has guaranteed renewal and is noncancellable.^1-3

Interestingly, women are considered a higher risk for disability, and many insurance policies will charge a higher monthly rate for women than men because women are slightly more likely than men to develop a disability, and women are more likely to develop a disability that prevents them from being able to work.⁴ Some insurance companies do offer a unisex policy, which does not discriminate.

When choosing a policy, you want to carefully read the vendor’s definition of disability. The best definition of the term disability is going to be one that includes phrases such as “unable to perform the material and substantial duties of your [own] occupation . . . even if you are gainfully employed in another occupation.”^1-3,5,6 This definition of disability is the least restrictive and would allow you to receive full benefits even if you are able to work in another capacity or occupation.^1-3,5,6 The benefit period of the policy also is something to choose carefully. It is recommended to choose a benefit period that extends to at least 65 years of age.^1-3,5 It is important to remember that the devil is in the details; for example, some disability insurance policies with more restrictive definitions will not pay you benefits if you are working in another capacity (eg, a physician who develops an injury that prohibits working with patients and then chooses to work in another capacity).

Some policies will only pay benefits if you become totally disabled. Shy away from these more restrictive policies; instead, look for a policy that has a liberal definition of what constitutes disability and allows you the option to add in a future purchase option rider. It is important that your policy includes a future purchase option rider, which means that as your income increases you have the option to purchase an increase in your disability coverage.^1-3,5 Look for a policy that allows you to be insured without penalizing you for preexisting conditions; during residency is one of the few times some policy vendors will do it, as they assume residents are generally young and healthy.^1-3,5,7

Final Thoughts

When you choose your policy, read the details carefully. Finally, remember that other physicians in the community are available as resources; they can be a wealth of information on different policies. There are many websites available to read more on this topic. Often, your training institution will offer a disability policy for the duration of your residency. Many residents choose to purchase their postresidency policies while in their third or fourth year of training. Take the time to choose a good policy now; you will be glad you did.