Seeing, Listening, Diagnosis: The Art & Science of Dermatology

Dr. Briley: “Microscopic evaluation of skin samples is often a critical part of diagnostic testing.”

SOUTHERN DERMATOLOGY &
SKIN CANCER CENTER

For more information about skin conditions and their treatment, contact:

SOUTHERN DERMATOLOGY and SKIN CANCER CENTER
An Affiliate of Anne Arundel Dermatology


Gregory J. Wilmoth, MD
Eric D. Challgren, MD
Margaret B. Boyse, MD
Laura D. Briley, MD
Tracey Cloninger, PA-C
Stephanie S. Pascale, MSN, FNP-C

4201 Lake Boone Trail, Suite 200
Raleigh, NC 27607
Telephone: (919) 782-2152

THE SKIN RENEWAL CENTER AT SOUTHERN DERMATOLOGY
4201 Lake Boone Trail, Suite 207
Raleigh, NC 27607
Telephone: (919) 863-0073

“Dermatology is a highly visual specialty that truly does blend art and science,” observes Dr. Laura Briley of Southern Dermatology & Skin Cancer Center in Raleigh. “The art part is the visual training—the ability to ‘read’ the skin—and to decipher the bumps, rashes, and blisters. To this we add the science of what’s called differential diagnosis—a systematic process of testing and evaluation to accurately identify the problem and its cause.

“Although there are some rashes/skin conditions that can only be one thing,” explains Dr. Briley, “a great many symptoms may point to multiple issues and sources. And this is where differential diagnosis is key. When we look at a problem such as atopic dermatitis—a condition which, by the end of residency, we’ve seen thousands of times—you can almost hear the clicking noise in our heads, as we tick off the possibilities: It could be this . . . or it could be this . . . or this.

“A half-dozen or more possibilities present themselves very quickly to the trained dermatologist. And then, based on many factors, we rank-order the possibilities and continue the diagnostic process. Psoriasis offers a good illustration. While sometimes symptoms are so characteristic, there’s nothing else it could be. However, people can have different forms of it where it’s difficult to distinguish between psoriasis and very common rashes.”

The Art of Listening

While a dermatologist’s visual skills are critically important to the diagnostic process, Dr. Briley emphasizes the value of listening as well. “To the cues we see when examining a patient we must add the information the patient provides,” she points out. “What is the patient’s history and family history? Are there many questionable spots or just one? What other risk factors contribute to this particular patient’s condition?

“There are some rashes we look at and that’s the only thing it could be,” she says. “So, often I don’t actually need to hear the whole story, but there’s something therapeutic in people telling their whole story. It’s not fun having a rash; they want to tell you they’ve been through. I’ve known patients for 10 or 15 years who might come in with a rash and will tell you that they’ve just lost a loved one. That emotional pain might be contributing to the rash; listening to what they’re going through is part of the healing process. And hearing their stories is one of the great honors of being a doctor.”

The Art of Treatment

“The ‘art’ of dermatology begins with teasing out an accurate diagnosis,” observes Dr. Briley. “And there’s quite a bit of artistry as well in our treatment approaches, as there are different, and equally successful approaches, for example, to treating similar skin conditions. Step one is accurately identifying the problem.

“In teasing out that diagnosis, among the many things we pay attention to is texture. Psoriasis, for example, can have a different type of scaling than, say, a fungal infection. Or you can tell just by feeling and looking if it is a rash that’s evolving in the second layer of skin or in the top layer of skin—which changes your diagnosis.”

Rashes, notes Dr. Briley, “take on all kinds of different shapes, textures, and patterns. For example, there’s a rash—called Pityriasis rosea—that makes a pattern of what look like tiny psoriasis spots in the shape of a Christmas tree. But it’s actually a viral reaction that is very transient, lasting six to twelve weeks and then going away.”

Reaching that precise diagnosis is important, she emphasizes, “because it has everything to do with effective treatment. One great example of misleading symptoms is a round rash. A lot of people assume that a ring-shaped rash is ringworm. Sometimes it is; but there is another rash called granuloma annulare, whichis a benign skin condition characterized by small, raised bumps that form a ring with a normal or sunken center. This ring-shaped rash is in the second layer of skin and doesn’t have the flaking that ringworm would have.

“Both conditions produce circular rashes that look the same,” she notes, “but you treat them differently. So, it’s not uncommon to have patients come in complaining that although they’ve been treating their ‘ringworm’ for three weeks with an antifungal, it’s not going away. And I then explain why it’s not going away: antifungal treatment is not the treatment for granuloma annulare.”

The Science: A New World of Medication

“You can’t talk about the science of dermatology without noting the tremendous advances in medications in recent years,” observes Dr. Briley. “These new drugs have simply revolutionized the treatment for inflammatory skin conditions, such as psoriasis, eczema, and hives. Biologic medications, for example, target overactive immune cells in the body by working on the long pathways that create too much inflammation, thus calming the inflammation. And, importantly, they seem to have fewer long-term side effects than some of the medications we used to use.

“There are unique classes of these biologic medications, depending on what pathway they suppress, and we can target the medication to the specific patient in a way that was not possible with the older meds.”

Psoriasis illustrates the remarkable benefits of these biologic drugs, notes Dr. Briley. “As a genetic disease, psoriasis is often a lifelong condition that can be activated by a number of triggers that cause the immune system to make antibodies that attack the skin and cause inflammation. Even though these flares can come and go, this is a condition that requires long-term treatment.

“And it is the need for long-term treatment that is a particular challenge and why newer medications are so valuable. Older treatments like methotrexate came with serious side effects from cumulative dosing, such as liver damage. Starting a younger person on such a drug felt like a non-starter. Because when you’re talking about a psoriasis patient who might be 20 years old, you have to take into account that you’re probably going to have them on a medication for at least the next 40 or even 60 years. So, ten years ago, minimal symptom relief was about all a psoriasis patient could hope for.

“Today, however,” notes Dr. Briley, “patients taking new medications are often 100 percent clear of psoriatic lesions. Previous treatments claimed success with only 50 to 75 percent clearance, making this a huge leap forward in treatment.”

Another striking example of the transformative power of newer biologic medication, says Dr. Briley, “is chronic, idiopathic hives—where there’s no known cause. For people who’ve had hives for greater than six weeks, most have produced antibodies that are triggering the hives, so the condition persists—and it’s a miserable condition.

“These patients used to have to live on Benadryl just to get through the day. Now there is a new medication called Xolair, which is given by a monthly injection, and it’s amazing. I have patients who have itched for 10 years or more, and this just fixes it. These patients, who would come into my office sobbing from constant discomfort, are now able to get their lives back.”

A newer generation of transformative medications—JAK inhibitors—offers similar life-changing benefits for some patients, notes Dr. Briley. “These drugs have been especially effective in treating a condition called Alopecia areata—which is an autoimmune disease that attacks your body’s hair follicles, causing patchy hair loss. “Prior to the development of JAK inhibitor medications, we’ve not had anything other than big time immunosuppressants to treat this condition, which is problematic, because you don’t want to put people on medication that could affect kidneys or liver to treat a hair problem. But alopecia areata is a stressful, scary condition—with bald spots popping up overnight. So having these new medications to treat it is a wonderful step forward.”

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