what i saw in dermatology clinic today - September 2016

I mentioned in my reflecting on the first four months of dermatology residency that residency has been much more difficult than expected. One reason for that is the enormous amount of material I need to know for clinic and for my board exam.

I thought I’d give you guys (y'all - I'm typing this from Atlanta) an inside look at what a typical day looks like for me as a first year dermatology resident at my program. To be honest, every day is somewhat different, so I may do one of these posts every couple of months to give you a growing glimpse into my really awesome job.

What I saw in dermatology resident clinic today including hair loss, lichen planopilaris, frontal fibrosing alopecia, hyperpigmentation, dark spots, seborrheic dermatitis, basal cell carcicnoma, actinic keratosis, corticosteroid injections, topical corticosteroids, cellcept, mycophenolate mofetil, erythema nodosum, chronic granulomatous mastitis, discloid lupus, vitiligo


Each morning we have a one hour lecture before clinic. The lecture is either given by a co-resident (I have a talk of infestations coming up in a few weeks), a faculty member, or both.

We have a reading schedule, and each week the morning lectures correlate with that week's reading material. The lectures vary each day between basic sciences, clinical dermatology, dermatopathology, clinical-pathological correlation, and grand rounds.

On this particular day, we had a weekly textbook review, where one of the residents summarizes that week's Bolognia readings. We reviewed 2 chapters

  1. Principles of tumor biology and pathogenesis of basal cell carcinomas and squamous cell carcinomas
  2. The epidemiology, pathogenesis, clinical presentation, and treatment of actinic keratosis, basal cell carcinomas, and squamous cell carcinomas.


845 – 910 am: MORNING COMMUTE

After lecture, our residency program splits up between our three hospital sites. Currently, it takes me about 10 minutes to walk to lecture from my apartment and 20 minutes to walk to my clinic from lecture. Walkability is by far one of my favorite things in New York City. Occasionally lecture will end early and I'll have time to pick up my dry cleaning or drop by home before clinic starts.


I couldn’t remember every patient I saw but I tried my best! I typically see between 6-8 patients in a half-day (12-16 in a full day) depending on how complicated the patients are, how many are follow-ups versus new patients, how many patients my coresidents see that day, and how many scheduled patients show up to clinic.


915 am – 1230 pm: MORNING CLINIC

We have hair clinic on Monday mornings, so I saw a few of those patients to start the day.

1. My first patient was a patient with hair loss – specifically lichen planopilaris,  frontal fibrosing alopecia subtype. This patient has had pretty extensive hair loss so her treatment regimen consists of daily medications by mouth, daily application of medicated solutions to the scalp, and monthly corticosteroid injections into the affected scalp performed in the office.

Frontal fibrosing alopecia is a type of "scarring" hair loss, which basically means permanent hair loss. The goal of treatment is to stop the progression of disease and prevent further hair loss. At her appointment, she had no symptoms of burning or itching and there was no redness surrounding her hair follicles; these are signs that the treatment is working.

She also had a history of a rash condition termed lichen planus, but this was stable and we didn’t address it fully during the visit.


2. My second patient had two forms of hair loss - frontal fibrosing alopecia (a permanent, scarring alopecia) and androgen hair loss (aka female pattern hair loss - a common, nonscarring, somewhat reversible form of hair loss). I can't remember if she was taking pills by mouth, but she was using medicated topicals at home and receiving monthly corticosteroid injections into the affected areas. She had experienced some hair regrowth in the nonscarred areas and she was very happy about it.


3. My third patient was a patient with seborrheic dermatitis (dandruff) of the face and dark spots on the face. This is pretty "bread and butter" dermatology.


4. My fourth patient was a patient I’d seen in clinic 2 weeks before. She’d had a rash that appeared to be a resolving herpes zoster (shingles) rash (reactivation of the “chicken pox” virus), but today she presented with a new rash consistent with herpes simplex virus (a common viral infection, often sexually transmitted). I provided her with medication by mouth for her herpes outbreak, counseled her on the unpredictable course of the disease, and ways to decrease chances of spreading to other people. She also had tinea pedis (a common, benign fungal infection)


1230 – 130 pm: LUNCH

Clinic usually runs until about 1245. Some days it runs until 1 pm, and on the worst day it runs until afternoon clinic starts. If I finish eating in time, I like to do a few of the administration things I have pending in my inbox so that I can leave work a little earlier in the evening.


130 – 500 pm: AFTERNOON CLINIC

1. My first patient of the afternoon was a young female I’d seen in clinic once before. We follow her for her scleroderma – which is a systemic disease that can affect the skin, kidneys, lungs, and GI tract. This patient is affected by skin tightening, acid reflux, and Raynaud’s disease. She’s on an immunosuppressant called mycophenolate mofetil which requires close lab monitoring. I ordered labs on her with the plan to send the prescription to the pharmacy if her lab work returns normal. She also receives IVIG infusions, so I scheduled her next infusion before the clinical encounter ended.


2. My next patient has systemic lupus erythematous. He was previously stable on a medication called plaquenil, but on this day he was having a flare in his skin symptoms. I gave him a topical to apply to the area and scheduled close follow-up to make sure he improves with the change in medication.


3. My next patient has discoid lupus erythematous and vitiligo. She is on two strong medications called thalidomide and plaquenil. She’d previously been stable for many months, so we were in the process of decreasing her by mouth medication. Unfortunately, she started to experience a mild flare. We decided to keep the by mouth medication as is and add topical medication to be applied to the skin in order to control the flare. I ordered required lab work for her with the plan to send her prescription to the pharmacy if the lab work remained stable. She also had a new growth on her breast that was consistent with a resolving inflamed cyst. We prescribed cold compresses and scheduled close follow-up with her to make sure the inflammation resolved.


4. My next patient was also my very first patient of dermatology residency. He has vitiligo and a chronic actinic lichenified dermatitis. He has a severe, full body rash that worsens with sun exposure. The skin is very thick and easily cracks in some areas and in other areas, it is very thin and becomes easily infected. He has been hospitalized multiple times for infections. When I met him, he was experiencing a flare, so I have seen him every 2-4 weeks since starting residency. We recently got insurance approval to start thallidomide for his condition (after a lot of insurance paperwork), so today’s visit was just to make sure he wasn’t experiencing any serious side effects. I again ordered blood work, with the plan to increase the dose if his lab work was within normal limits.


5. My next patient was also a follow-up. She’d been referred to our clinic two weeks prior by rheumatology for erythema nodosum (painful nodules of the lower legs) and chronic granulomatous mastitis. Chronic granulomatous mastitis is an autoimmune disease that presents with repeat inflammation of the breast. The inflammation can mimic breast carcinoma or an abscess of the breast. These patients often receive multiple minimally invasive procedures – such as incision and drainage – to treat their condition, but the best treatment is anti-inflammatory medications by mouth. Because the disease presents as a mass on the breast with tenderness and discharge, every patient has a core needle breast biopsy before starting treatment. The biopsy is to rule out breast cancer and cultures are sent to rule out bacterial and fungal infections before starting the patient on an immunosuppressive medication. She was here for follow-up after her core needle biopsy (performed by breast surgery). Her erythema nodosum had almost complexly cleared but she was still experiencing significant pain in the breast.


6. My last patient on the day was a total body skin exam. The patient was an elderly, pale skinned male with a current melanoma of the eye. He’d also had previous non-melanoma skin cancers, previous pre-cancers, and previous atypical moles. I examined each of his moles with my dermatoscope – a special instrument that allows me to see beneath the top layer of skin. We biopsied one lesion that was concerning on dermoscopy. It came back benign and he was so relieved!


This is the time of day that I catch up on all the labs I ordered the day before and my biopsies results as they come in. If a patient has a medication pending their lab work, I send it in over the electronic medical record. This is also the time that I have to deal with insurance problems. It’s common for insurance companies to deny medications I prescribe, and so it’s a routine part of my job to advocate for my patients. Doing insurance paperwork is by far my least favorite part of my job, but if it doesn’t get done, the patient won’t get their prescribed medications and their visit with me would have been a waste of time. In routine practice, there is usually someone to help with these issues, but in residency it mostly falls on us.

Okay – there you go! I hope that gives you guys a good idea of what I'm doing when I'm MIA on snapchat - and why my blogging frequency has decreased so drastically over the past few months.

If I do another one of these in the future, what things would you like me to go into more detail about?

Is there anything you’d like me to expand on in a separate blog post?

Are there other specialties you’d like to get a “day in the life” look into?

Your wish is my command.


With love,

Elyse Love, MD