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REGIONAL DERMATOLOGY
OF DURHAM

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REGIONAL DERMATOLOGY
OF DURHAM

Elizabeth H. Hamilton, MD, PhD
Amy Stein, MD
Julie Dodge, PA-C

Lindsey Dudley, PA-C

4321 Medical Park Dr., #102
Durham, NC 27704
Telephone: (919) 220-7546 (SKIN)
www.dermatologydurham.com

Collaboration Key to Unraveling
Skin and Medication Mysteries

At Regional Dermatology of Durham, collaboration bolsters an often detective-like approach to skin conditions. “The beauty of a group practice,” says Dr. Amy Stein, “is that we all have different lenses and different experiences.” Dr. Stein is particularly pleased to welcome the newest addition to their team, Lindsey Dudley, PA-C, who brings an internal medicine background to patient care.”

Amy Stein, MD

This bigger picture view has been particularly helpful during 2020, with the pandemic and associated stress compounding patients’ skin and other health conditions. 

Health&Healing: Along with new challenges, do newer drugs help change the trajectory of some of these conditions? Or do they sometimes add new issues?

JULIE DODGE, PA-C: There’s no question that recent advances in medications—especially the new biologics—have been very positive; but, not surprisingly, they also pose problems—both in terms of access and cost. However, most commonly problems arise with patients on multiple medications.

Ju;ie Dodge, PA-C

For example, a patient came in recently with a new rash, and we found that he was on 20-some medications—most of them new since the last time we’d seen him. And my reaction was: “Oh my goodness, what’s been happening?”

It turns out that he had been put on all these medications for a recent heart condition and other issues, and most recently for gout. When I saw him, we looked at the timeline and realized that one particular medication—Allopurinol for gout—had been prescribed about the time when the rash began. He had this red, maculopapular rash, head to toe—pathognomonic for a drug rash. And, ironically, his gout was still a problem. So, we had him speak with his primary care physician to adjust his medications to find an alternative—to address both the gout and the rash.

H&H: In your specialty, do you see more effects of drug reactions, such as these rashes?

DR. STEIN: Definitely, because a lot of times not only are patients prescribed various different things, they go to different providers for them. And if people are being treating for multiple different things or even one thing and it’s not getting better, it’s important to step back and ask: “Do we have the right diagnosis? Are there interactions between different medications? Are there alternatives to adding medications?” And we say this many times: “less is more.”

Lindsey Dudley, PA-C

LINDSEY DUDLEY, PA-C: In addition to people taking lots of prescription meds, we see patients who come in with two or three pages of what they’ve gotten over the counter. And we don’t know how those react with other things. So, much of our job on a daily basis is playing detective and figuring out what is causing what. And, it’s also worth mentioning cost—if you’re taking 20 medications and 20 over-the-counter supplements, that’s a real burden.

Meet New Team Member
Lindsey Dudley, PA-C

Lindsey Dudley joins Regional Dermatology after a three-year stint in internal medicine and primary care since receiving her Master of Physician Assistant degree in 2016. It’s a homecoming of sorts, as she interned with Regional Dermatology in 2013, and found its collaborative culture a major draw to return.

“I talk to all of the providers every day,” she says, “about the cases and questions I have.” And both PA-C Julie Dodge and Dr. Stein reciprocate with how much they appreciate Ms. Dudley’s internal medicine experience. “That’s been very helpful,” says Dr. Stein, “as she brings a different perspective to the practice—one that broadens our understanding and approach to patient care.” More than that, they like one another, she says, adding, “we even text each other after work!”

H&H: Do you find that certain medications particularly problematic in terms of causing side effects?

LINDSEY DUDLEY, PA-C: There’s always risk with any medication. Even some biologics can cause rashes; for example, one new, great biologic for atopic dermatitis can occasionally cause psoriatic-like rashes in some people.

Because of the concern about drug interactions, it’s best when we can limit the number of prescription medications that patients take and focus on preventive measures. One of the most important lessons I learned in primary care is the value of prevention—and you can translate that to any specialty. It’s true that patients with atopic dermatitis, psoriasis, and other inflammatory conditions often need pharmaceutical treatment, but there are also lifestyle changes that can be very helpful in managing their diseases.

JULIE DODGE, PA-C: That’s an important point. For example, there was a study Lindsey and I reviewed recently that showed when children used regular daily moisturizer for eczema, the use of steroids was greatly reduced. They reduced the use of a prescription steroid on their skin by just moisturizing.

H&H: Why are the new biologics more efficient or effective than previous options?

DR. STEIN: Biologics are amazing; they’re game changers, because they’re targeted—affecting a specific immune response rather than the patient’s whole immune system. And with each new generation, they tend to be even more selective, with specific targeting, so they may have fewer side effects.

Initially with COVID-19, there was a great deal of concern about whether patients should stay on these meds for fear that their immune systems would be compromised, thereby increasing risk of getting COVID-19 and having a worse outcome. But there has been no evidence of that. These medications are not immunosuppressors, they’re immunomodulators. And, because conditions like psoriasis increase inflammation in the body, and we know that inflammation is associated with arthritis and cardiovascular disease, these biologics are actually cardio-protective. So, for people who are doing well, we keep them on their biologic meds. Obviously, you need to wear your mask, social distance, and wash your hands—but you can continue these medications safely.

JULIE DODGE, PA-C: And while psoriasis is the most common condition treated with biologic medications, in our office we also use them in the treatment of atopic dermatitis, eczema, and hidradenitis suppurativa (a skin condition where lumps most often occur under the skin in areas where skin rubs together). And there’s morbidity associated with hidradenitis and psoriasis when they’re not under good control.

H&H: How do you pick which medicine to use?

DR. STEIN: With psoriasis, we look at how much of their body surface the psoriasis affects, whether they have joint pain or not. Some biologics target joint pain better than others, so that helps make the decision. Their underlying medical conditions always play a role, as well as how often they may be willing to inject.

JULIE DODGE, PA-C: And—we have to say—insurance plays a role. Ultimately, the patient’s insurance company will determine what’s covered or not. A lot of times we have to do an about-face because insurance declines it.

I will say that the pharmaceutical companies have been really great about trying to get patients access to their medicines. It’s often assumed that the pharmaceutical companies are the “bad guy” in some ways, but in fact they can be very helpful.

H&H: Have the patients and conditions you’re seeing changed in terms of COVID-19?

DR. STEIN: Without question. Stress is a big factor, and we’re all dealing with increased stress on many levels. So, we’re seeing more acne, rosacea flares, psoriasis flares, dermatitis—all conditions that are usually flared by stress.

And sadly, we’re seeing a lot more tears because of difficult times that our patients have experienced. People have gone through a lot over the last seven months and to be able to see them in person where we can look at their face during their skin exam, it brings back the humanity.