January News & DERMfoot 2017 Update!

January 2017

NEWSLETTER

Stay up-to-date with podiatric dermatology
from the DERMfoot bi-monthly newsletter.

DERMfoot's acclaimed faculty includes podiatrists, dermatologists, plastic surgeons and infectious disease specialists who are experts in the field of dermatology. We also invite guest speakers in the areas of practice management, medico-legal cases, and billing and coding of skin and nails that will affect our future in today's healthcare environment.

We are the Skin and Nail Disease Experts!
Dermatology Update 2017
By Annette Joyce, DPM

Podiatrists are often overlooked as experts in dermatology. Our students start with extensive surgical residency training and we believe our practice lives revolve around hospital rounds and emergency room visits. This is not always the case. Commonly, podiatrists see 100 patients a week- many of these patients with skin and nail concerns- brought to the attention of a foot and ankle expert. If you add up these numbers, we see over 1,000,000 toenails in 20 years of podiatry service. Our profession has roots deep in skin and nail concerns providing comfort and expertise to patients with corns, callouses, and ingrown nails for over a century of medicine. One of the reasons I was drawn to this profession as a female physician was skin and nails. Working in a podiatry office that focuses on nail disorders or a nursing home facility, allows an acceptable work life balance. There are few skin and nail emergencies and most nights I even get home to my family for dinner.

The recent introduction of a dermatoscope to my practice has brought great joy and sometimes frustration while learning a new world that lives in the nail and skin. By simply illuminating tissue with polarized or unpolarized light, you can reassure a patient that a pigmented band in the nail is most likely benign. Alternatively, you may choose a nail matrix biopsy “just to be sure” that there is no risk of melanoma. By taking a nail culture for dermatopathology, the patient appreciates you are diagnosing the disease- not just prescribing a drug empirically. There is value in this clinical knowledge.

Over the past 3 years, I have had the privilege of working with DERMfoot. This world class seminar of skin and nail experts provides a new direction for cutting edge patient care. There is a knowledge gap in other podiatric seminars where surgery and biomechanics predominate. In 2017, skin is finally “in”. This year’s Annual Scientific Seminar DERMfoot in Historic, Annapolis Maryland promises not to disappoint. Infectious disease leaders such as Warren Joseph and “Doc” Dockery will illuminate our profession with the latest in lower extremity skin like we’ve never seen it before. Tracks on fungal infections, inflammation, and regenerative medicine will teach us the latest tools for treating challenging derm cases. Dr. Ash Marghoob will teach his world renowned dermoscopy course on pigmented lesions. Avoiding audits on routine foot care and new meaningful use rules will be essential to practice survival in the next decade.

PICA will provide a 10% Risk Management discounts to those who attend their essential lecture, “MACRA, MIPS, APM OH MY”! with David Freedman.

Our Master Surgery and Aesthetics Cadaver lab is like no other on the planet. DERMfoot remains the only hands on cosmetic filler lab in this profession at an affordable price of only $149! Not sure how or when to biopsy? You will learn from the masters of dermatological surgery- Drs Ribotsky, Dockery and Markinson. Not to be missed.

As everyone enters the New Year, please make an effort to learn something new. Remember skin is the key to diagnosing both simple and complex foot and ankle pathology. Hundreds of surgeons remark each year that DERMfoot has changed the way they think about patient care and medical education. You will too!

Join us at www.dermfoot.com. Early bird registration discount ends February 14, 2107. Don't delay!

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Focus on the Nail and Skin
Bradley W. Bakotic, DPM, DO

I’ve come to learn through the years that, just as the healthcare community had historically neglected the surgical needs of the feet, modern medicine has at times banalized the biomechanical nuances of foot health, healthcare professionals have also over-simplified, and in some instances totally overlooked the appropriate management of lower extremity skin disease. It’s been my experience that there are “traditional” conditions of the foot, which are addressed by podiatric medical professionals, to wit, verrucae, tylomata, nail unit dystrophy, etc., but more mainstream dermatological conditions are often dismissed.

Though the integument is but one organ, the acral surfaces boast structural and physiologic properties that are largely unique as compared to alternate sites. Volar surfaces have a markedly thickened epidermis relative to other anatomic locations. In addition, they disclose a thick and compact stratum corneum, an extremely deep and dense reticular dermis, and an entirely different compliment of adnexal structures. These distinguishing features play a significant role in the bizarre presentations exhibited by various diseases when arising on the skin of the volar surfaces, and its predilection for dermatitides and forms of neoplasia that are unlike alternate anatomic sites. These properties also play a role in the need for customized therapeutic approaches when managing such disease processes.

Inflammatory dermatological conditions
The wide range of inflammatory, or non-neoplastic, skin diseases that affect the volar surfaces are often insufficiently studied and under-appreciated. In the United States, students of podiatric medicine are often led to believe that dermatitis involving the skin of the foot is by default tinea pedis. Many physicians maintain this mindset for day after day, and year after year, without ever coming to the realization that up to 2/3s of the clinically suspected tinea pedis is in actuality something else. Acral eczematous dermatitis, allergic contact dermatitis, dyshidrotic eczema, id reaction, pitted keratolysis, psoriasis, and lichen planus, can all have features that resemble tinea pedis. In the webspaces, tinea may be indistinguishable from Candida intertrigo, erythrasma, and spongiotic dermatitis (eczematous and allergic contact dermatitis).

All four of the traditional spongiotic dermatitides may be found on acral surfaces (eczematous/nummular dermatitis, allergic contact dermatitis, dyshidrotic eczema, Id reaction). Acral Eczematous Dermatitis may begin with erythema and vesicle formation, but by presentation, much more chronic findings are usually seen, with lichenification and fissure formation. Acral eczema is far more likely to affect the weight bearing surfaces, and a classic patter is that of a horseshoe around the periphery of the heel. This condition worsens during the winter and may be recalcitrant to non-aggressive therapy. Dyshidrotic eczema has features in common with acral eczematous dermatitis though it tends to affect the digits and forefeet, and exhibits a far more cyclic course. Allergic contact dermatitis is a delayed type hypersensitivity reaction. In most instances, this eruption correlates well with the pattern of allergen exposure; however, because of the use of barriers such as socks, and the influence of pressure and sweating patterns, affected sites may not appear to correlate with a particular allergen. Identification and removal of the allergen is the key patient management. Patch testing may be invaluable in this context. Id reaction occurs as the result of a tinea pedis infection. Reactants liberated by leukocytes at the site of the superficial fungal infection are picked up by the lymphatics and deposited in the skin at an alternate location, resulting in an inflammatory response. This condition is cured upon the eradication of the primary infection.

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Physicians Are Sharing Their DERMfoot Experiences!

"I wanted to make a comment regarding the recent DermFoot Conference in October of 2016. It was probably the most insightful one day conference I have ever attended. The lectures were cutting edge, short and numerous and that they held my interest without wandering were a testament to the medical professionals organizing the content and event. It was probably the most personal event I have been a part of that I can remember.. The hands on component introduces new techniques I simply was not aware of and I can only suggest that if you get an opportunity to take this one day course it is affordable and well worth your invested and valuable time."

Robert Spalding DPM
Signal Mountain, TN