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

Evaluating Symptoms:
“Look First, Ask Questions Second”

Patients frequently come to Regional Dermatology of Durham knowing intuitively that something is wrong that is manifesting on their skin. Over the years, Dr. Elizabeth Hamilton, Dr. Amy Stein, and Certified Physician Assistant Julie Dodge have learned to “look first and ask questions second.” Their skills are sharpened daily through experience and good detective work.

Elizabeth Hamilton, MD, PhD

Health&Healing: Why do you say “look first, and ask questions second”?

DR. HAMILTON: A dermatologist is more likely to ask the patient to ‘show me your symptoms’ rather than to describe them, because diagnosis in dermatology is based on the appearance and on patterns. Sometimes the process is very simple. You look at a rash, and you recognize it; you don’t have to ask further questions and go down this long path. Dermatology is quite the opposite of internal medicine, for example, where the patient describes his symptoms in detail and then the physician orders lab work. In dermatology, the physical exam is of first importance. What we see drives the intensity and level of questioning, which is knowledge-based. If you don’t have an understanding of what you’re seeing, then you have no idea what questions to ask.

DR. STEIN: That’s why the visit with a patient always begins as a visual experience. Patients fairly often want to describe, in some detail, what their skin problem is like, when our focus is greatly on the desire and need to look at their problem. But describing the problem is not nearly as helpful as viewing the problem. And, in this regard, pictures of skin problems as they manifest are often very helpful now that people have smart phones. If a patient can show us a photo with the comment ‘It started out like this,’ that can be extremely useful.

Amy Stein, MD

H&H: Do you typically follow a set routine when examining a patient?

JULIE DODGE: Sometimes things just have to unfold. I may be doing a routine skin check, examining a patient’s body for skin cancers, and they might say, “You know, I have this mole that’s itchy.” Most often this mole is normal but in a bad spot or may show signs of irritation.

At some point you get an especially challenging case where something looks completely normal—it doesn’t have any pigment, the borders are regular, the color is even throughout, but the patient is complaining that it’s itchy. You wonder if it’s itchy because it’s under the waistband, or is it something else? You have it biopsied and it returns as a melanoma. I always listen to what patients have to say because they know their own bodies better than anyone else ever can. We tell our patients to do a thorough skin check themselves once a month. Even if they find no physical changes, there may be an area that is symptomatic—it’s itchy and irritated. It’s also a sign the body is trying to tell you something.

DR. HAMILTON: The symptoms themselves tend to guide the process. Patients often come in with unexplained pain. It can be in one location, perhaps a shoulder, or on the forehead; there’s nothing there—their skin is unblemished; the pain can wax and wane over weeks and months or it may be constant. I usually think this may be impending shingles.

Shingles is a painful, blistering skin rash, most commonly appearing as a band or stripe on one side of the body. There is no definitive guide to know exactly at what point to treat shingles when no rash is present, or whether oral antivirals will abort the breakout—but it is worth it. Fortunately, the medication for shingles is safe; so I am inclined to have patients take it sooner rather than later.

I recall a patient who had an itch, and no obvious changes of the skin other than discoloration from scratching. There are some hotspots for neuropathic itch, such as on your anterior elbow. More commonly it is related to arthritis in the neck. And then there’s the most common issue, between the shoulder blades, which is a nerve itch. The skin looks totally normal. But this patient has a really unusual pattern of episodic itching. We came to understand that whenever this patient slept in a certain position, it caused the spot to itch. So it was a nerve itch. In our line of work we need to be detectives.

Julie Dodge, PA-C

H&H: Can “common” skin issues at times become a bit of a mystery?

DR. STEIN: Yes, there are symptoms we see more commonly—yet aren’t always the result of the same problem. For instance, a recent patient had a very itchy scalp, with redness and scaling. Usually this is ordinary dandruff, or seborrheic dermatitis. I gave her medicine but she returned a bit later, saying that her scalp still itched. The medicines weren’t helping. I biopsied the scalp, knowing that there is a very rare condition called dermatomyositis, an auto-immune condition, like lupus. But at that point, there were no associated symptoms. Her biopsy came back positive, and then shortly thereafter, she actually had other connective tissue disease findings that confirmed this condition. She didn’t progress to muscle weakness until much later, but she did have pulmonary disease, which can go along with dermatomyositis. While this is a rare condition, it does illustrate how common symptoms might stem from uncommon causes.

DR. HAMILTON: Another example of that “uncommon” reason for a common symptom was a patient of mine—a young woman—who for years had a really recalcitrant, horribly itchy scalp and she wouldn’t take her medications in a prescribed manner. She came in and her scalp was beet red and more than just a little itchy and scaly. After talking with her mother we figured out that this patient would take a wad of shampoo, and dump it on one spot on her scalp, and was not very good about shampooing it out. Now her mom mixes her shampoo with water, diluting it. That simple act has basically cured her itchy scalp problem. And it helped me as well: that episode made me realize that this same type of problem might exist with a lot of itchy scalps.

DR. STEIN: Sometimes the diagnosis only becomes clear in hindsight because the symptoms are so uncommon. But they can produce huge manifestations if not treated. A common symptom people come in with is a plain itchy, red, scaly patch, like eczema. I had a patient who had a patch like this on her breast, and had been treated for it by her physician, but it wasn’t responding. I saw her a few months after this scaly patch first appeared. She’d already used antifungal medicine, so I gave her a topical steroid, telling her to come back if it didn’t get better.

And it didn’t improve, so we biopsied the patch and it came back as something very uncommon—Paget’s disease. And with that finding you have to assume the diagnosis of breast cancer.

But a mammogram came back negative. However, her physician followed up with special tests and found that this woman did have very early stage breast cancer. Surgery was done, followed by treatment, and she’s perfectly okay now—left only with her scar. It’s a helpful reminder that mammograms are not always sensitive in picking up early stage breast cancer.

DR. HAMILTON: And it’s a reminder that symptoms can fool you. In some cases, we may think we know precisely the nature of the problem based on first observations, and then—as we dig deeper—we realize that our early conclusion is wrong in some way. You learn from these experiences. That’s what keeps it all fun and interesting.

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