November 2, 2005

An affluent lady came into my office today from a little town elsewhere.

Several years ago I treated her for little lumps on her elbows known as granuloma annulare. On one elbow I compressed and elevated the lesions and froze them solid with liquid nitrogen. The ones on the other elbow I injected with a corticosteroid by the brand name of Kenalog. Both elbows responded equally well and she has been free of these since then.

I showed slides of her elbows at the American College of Cryosurgery meeting in New Orleans that year.

Today she complained of profuse nose bleeding from the right nostril. Upon examination the nasal septum had the typical hole in it that is seen in cocaine sniffers. A vein lay almost bare on the proximal rim of the septal perforation. I injected the septal mucosa with lidocaine and cauterized the varicose portion of the vein with electrocautery. She left in a happy mood.

Five patients came in with skin cancers, four with basal cell carcinomas (local skin cancers) and one with multiple squamous cell carcinomas. All of these patients came in early enough that cryosurgical destruction of these tumors should be successful without fear of recurrences.

This month is starting off smoother and less stressful than last month in which five patients came in with melanomas, the severe and dangerous type of skin cancer. The thickest of the five was 0.4 mm thick, and so nothing more than local surgery and followup should be necessary on these five.

The girls at the office gave me happy birthday gifts for my 82nd birthday which included dinner theater tickets at ACU Homecoming Theater performance and a gift certificate to be used at the Red Lobster.

It's been a good day and beautiful clear fall weather in Abilene, Texas.

November 03, 2005

Going over the schedule is like going to the bazaar; there is an assemblage.

A high time pilot from Florida needs a class II Flight Physical. I have been doing these for the FAA since 1969. He has been in for removal of multiple skin cancers and sure enough today he has a basal cell carcinoma on his mid forehead and a squamous cell carcinoma on the dorsum of his right hand. I saucered these out under cryoanesthesia with a razor sharp curette and then treated both for adequate margins with cryosurgery. This method in my hands gives a cure rate comparable to Mohs microsurgery at a fraction of the cost.

A farmer who farms next door to my little farm on the South Fork of the Brazos River in Jones County needed a post operative check on a Basal cell carcinoma behind an ear. We visited like neighbors do.

A fellow member of the Sons of The American Revolution, who has suffered in the past with atopic dermatitis needed to be seen for a new problem, tinea cruris. We visited about our wives health and I gave him what he needed.

A new patient, an outdoor person, had hyperkeratotic actinic keratoses on the rims of his ears. He was familiar with cryosurgery and wanted these removed cryosurgically.

An 87 year of age male complained of severe itching from a confined cluster of irritated lesions of seborrheic keratoses. All he needed was cryosurgical removal of these lesions.

The new red tape of the iPledge program raised its ugly head next. An African-American in need of Accutane was referred from Dyess Air Force Base by Dr. Rodriguez. I thanked God when I learned she had had a tubal ligation.

Three members of a family from Africa had various needs. The head of the house wanted a variety of benign lesions removed. I accommodated him on several elective needs because of his lack of medical facilities at home.

The spouse had been in ten days previously for a mildly inflamed epidermoid cyst on her back, measuring an inch and a half in diameter. I thought it was too inflamed to surgically excise at the time and gave her a choice of incisional drainage with its pitfalls or of trying to quieten it down and excise it later. She chose the latter. I gave her a prescription for Amoxicillin and injected as much Kenalog into the cyst as I could without causing it to leak. I scheduled her for 45 minutes today for surgery, but found no residual cyst to remove and only the vaguest discoloration of the skin where the cyst had been. After more than fifty years in medicine it is more of an intuition thing to recognize when and when not to try this almost miraculous treatment.

After I saw this family of three, I had a coffee break and then saw a Hispanic male for a three month postoperative visit following removal of a crateriform invasive squamous cell carcinoma of the inner third of the right lower eyelid. I chose to excise this somewhat advanced cancer with minimal surgical margins and to then extend the safety margins rather widely with cryosurgery and to then let the wound heal by secondary intention. Today he has full function of the lower eye lid with absolutely no retraction and a scar that has to be searched for to find. The healing power of God's nature is marvelous.

The office day ended with three patients with sun damage and basal cell carcinomas. The last patient had been a little apprehensive in the past because of a cousin-in-law who had metastatic squamous cell carcinoma after undergoing Mohs micrographic surgery elsewhere. I had treated her about a year ago for a basal carcinoma and today she shows no signs of apprehension and was a most pleasant lady to end the day with.

11/04/2005

Friday Highlights:

My highlight of the week goes to a patient from Dallas who came in for his annual skin check up. When I saw him last year he was an overweight poorly controlled diabetic. At that time I did some skin surgery on him and warned him that the healing may be slow due to his poorly controlled diabetes. I advised him to lose about thirty pounds and see if his diabetes would be easier to control. When I walked into to the examining room this visit, the first thing he did was to look at me with a big smile and say, "I took your advise and lost thirty pounds. My blood sugar never goes over 112 and I don't have to take pills for my diabetes." How great!

A new patient from San Angelo came complaining of scalp itching and scaling that over the counter dandruff shampoos failed to help. On examination she had typical psoriasis plaques with well demarcated edges and covered with glistening white clean looking scales.

Another patient not so fortunate as to have a limited area of psoriasis cleared after six weeks of 0.5 cc. injections of a 1:1250 dilution of influenza vaccine given subcutaneously twice weekly. This treatment is a great deal safer than the new medications that are directed at the immune system for treatment pf severe psoriasis and most often tames the immune system surprisingly well.

A lady with a painful finger tip and an associated elevated fingernail gave a history of taking Lamisil for two months for a diagnosis of finger nail fungus and had had no response from treatment. It took me almost thirty minutes to par and trim down the tender mess to the point where a subungual wart was definitely visible. The diagnosis has to be correct before the treatment can be expected to work.

Two melanoma patients and a dysplastic nevus syndrome patient complicated the day and has started November off much the same way as October started.

This was a day for physicians and when we can we schedule patients who know each other as closely together as possible. The reassurance gained from running into friends and fellow physicians at the doctor's office is an excellent public relations tool.

The low point of the week was grafito painted on the back door of my office building which the janitor painted over within a few minutes of its discovery.

This weekend we will celebrate my birthday with children and grandchildren coming from as far away as Edmond. Okla., and Anchor Point Alaska.

Monday

11/07/2005

Monday is unpredictable due to urgent things that happen to patients over the weekend. They are always a heavy load.

Sometimes it takes only one patient to tire me out and sometimes after twenty patients who are fun to treat, I feel fresh and raring to go.

Attrition of a dermatology practice in Abilene, Texas, is a little less than twenty per cent per year due to deaths and the transitory nature of the area population. To maintain a level practice requires a varying number of new patients per day, usually four or five. For a young growing practice a greater number of new patients is needed. The insecurity of the younger practice requires contracts with many managed care organizations which pay poorly. To meet the demands and volume of patients needed for these low pay services requires running patients in and out almost as if they are cattle. There are few to no openings for emergencies and for conditions that are urgent to be seen soon if good results are to be obtained. This is especially true for diseases such as herpes zooster which respond best to treatment if seen within two days of onset.

Other patients who find themselves in these practices get short changed simply because the doctor has so much pressure on his time that he does not give good service.

Today a surgery patient had a recurrent basal carcinoma who had been to a dermatologist who is a Mohs' surgeon and had failed to adequately remove it from his forearm on two separate operations. Examination revealed a red (erythematous) nodule in the center of an old scar with palpable tumor extending to a width of one inch. The tumor bleed easily. It was located below the elbow where the skin had stretched since the previous surgery, making it amendable to using compression and elevation with cryosurgery.

A primary goal in treating skin cancers with cryosurgery is to freeze the tissue as rapidly as possible and to thaw it as slowly as possible. Compression and elevation of a tumor during cryosurgery allows the lesion to be frozen more rapidly and to thaw more slowly than otherwise could be done. This is because the depth of freeze is reduced by approximately half when omnidirectional spray is directed at the tumor. Also the compression reduces the volume of the tumor and further lessens the depth of freeze. Additionally elevation and compression impedes the blood flow, further shortening the freeze time and prolonging the thaw time.

During the past twenty six years, I have treated several thousand basal carcinomas of the skin using compression and elevation of the tumor during cryosurgery and to my knowledge none has recurred. Due to location some tumors can not be elevated and compressed.

Eight patients were skin cancer patients, including one with a melanoma and several patients had rashes. One young lady had Pityriasis rosea (Christmas Tree Disease) with the usual history of sniffles about two weeks before she noticed the herald patch on her abdomen. I mention this patient because pityriasis rosea is seen mostly in the spring. Another had contact dermatitis from the metal hooks on her clothing.

Tuesday, November 08, 2005

The phone rang off the wall today tying up two and sometimes three employees. One is out with a virus infection and at times this left only one to help me.

A farmer scheduled for a postoperative visit following the removal of two basal cell carcinomas also presented with a hay mite rash mostly on his forearms where he lifted the hay for feeding his livestock.

An elderly couple had multiple mosquito bites, but were most reluctant to believe they had mosquitoes in the house and denied being outside. In the part of town in which they live, the mosquitoes are now thick.

Eight skin cancers on six patients were seen today and one was a post excisional biopsy melanoma on a ladies leg. She had stated the mole had been there all her life. The thickness of the melanoma was 0.6 mm. She will require wide excision of the lesion.

Marquis Who's Who telephoned telling me they were listing me in the upcoming issues of Who's Who in America and Who's Who in The World. I have been listed in seven of their publications and am currently listed in six, including Who's Who in Healthcare and Medicine, a listing I have not missed since they began its publication a few years ago.

Two patients had keratoacanthomas. A keratoacanthoma at onset is a fast growing elevated red bump with a central crater-like appearance. The cause of this tumor is unknown and it is a tumor of uncertain behavior. Recently these have been more prevalent in my practice than at anytime that I can remember.

Wednesday

11/09/2005

A long time patient with bullous pempigoid who has been controlled on tetracycline and low doses of prednisone complained of an increase in rapidity of developing actinic keratoses (precancer sunspots of red scaling skin lesions that can be felt with the fingertip) after being placed on Remicade for his rheumatoid arthritis. Bullous pempigoid is a blistering disease in which large flaccid (soft) blisters develop with a typical distribution over the girdle areas. The disease is difficult to control without flare ups and is not curable. These blisters do not usually become infected but may. I thought the rheumatologist was rather courageous to give him Remicade which is one of the new medications that has infections and lethal infections in the black box warning.

Nine patients with eleven skin cancers and six patients with benign skin lesions made the surgery schedule today.

Thursday, November 10, 2005

Today is the day before a major holiday and as is often the situation people want their surgery done when they do not have to go back to work the next day.

All the patients were surgery patients and since tomorrow is Veterans Day, I encouraged the patients who are veterans to tell their war stories while I operated.

A fly boy gave his account of Christmas Day in 1944. He was piloting his B-24 on a bombing mission in Southern Italy. Over one of the targets, the anti-aircraft flak was heavy with red and green flak instead of the usual black. He said, "We couldn't help but smile while being shot at and wondered how they (the Germans) did that. We wished we'd had red and green bombs to drop on them, but we didn't."

A career Air Force Officer told of WW II, Korea, and Vietnam. He was the commanding officer for two Air Bases before retirement. Without diminishing from those who were in Korea and Vietnam, he reflected his greatest admiration for those who served in WWII. Maybe it was because WWII was a war that was fought to be won. He flew 25 missions in B-24's at low altitude, had one forced landing in France that was due to loss of fuel from a direct hit, and had great respect for the crew he had. His comment on Korea was that the fight was boys on bicycles armed with bazookas going up against enemy tanks. I think this was a great observation, because the summer between my freshman and sophomore years in medical school I spent working at Kelly Field in San Antonio to make old airplanes taken from the Air Force bone yards airworthy for use in Korea.

Another patient had been a supply officer who was in charge of the vital mission of supplying diesel and gasoline to the vehicles used in the Battle of the Bulge. He was the oldest patient I saw today, age 94.

Friday November 11, 2005

An acne patient with autism is being treated by an Austin physician for his autism with the antiviral medication Valtrex. As far as I can determine he has shown improvement in his autism and it has not interfered with his acne treatment.

A beautiful lady had generalized hair loss after being placed on two medicines that are known to cause hair loss. Neither medicine seemed necessary so I took her off both and we will wait and see.

A diabetic patient referred by her endocrinologist lost her husband three months ago and her hometown physician had placed her on Elavil that elevated the doses on some of her other medicines. She developed acute urticaria which should subside after leaving off the Elavil. CYP-450 utilizing medications and their interactions are a big problem in the practice of dermatology and not appreciated by many practitioners.

This week's Friday Highlight goes to the most happy patient I had this week. Five weeks ago I treated a large angioma on the lower lip that she had irritated by biting it and it also was embarrassing to her. I published an article in the Southern Medical Journal in 1981 on how to treat these cryosurgically. There was no trace of surgery having been done and her lip was back to its normal appearance.

I removed five skin cancers today, including one melanoma from the leg of a thirty year of age lady.

Tuesday November 15,2005

Today is a spill over day from all the paper work due to be done yesterday that was not done because I rushed off to the hospital. My daughter-in-law had a lump of breast cancer removed. The sentinel lymph node was negative for cancer, so we were relieved.

One patient with finger nail dystrophy was responding to treatment with Elon cream and Biotin 5 mg daily. The use of Biotin for this I learned from Walter B. Shelley, MD several years ago.

A male with sun damage (actinic keratoses) to several places on his face had responded after using 5-fluorouracil for twenty one days. This is the routine that the late Dr Dillaha, who did the original research for this use, recommended. This treatment when done following Dr Dillaha's protocol is superior to all the other chemical treatments that I have tried for an actinic keratosis lesion.

One patient had a large 2.2 cm keratoacanthoma on his left ear. His previous dermatologist had treated a basal cell carcinoma on his mid forehead using Aldara cream following recommended directions. He came to me about a year afterward. The carcinoma thusly treated appeared to have submerged under the skin spreading for a considerable distance from the center of the original lesion. I sent him to Dr Taylor in Dallas for Mohs surgery. He returned with a skin graft measuring twelve by thirteen centimeters that covered just about all of his forehead.

Another patient was in for minor skin problems whose father had died suddenly from a heart attack while using Aldara cream on a small basal carcinoma located on the inner canthus of the eye where absorption of a topical medication is often significant.

Wednesday November 16, 2005

This morning we had the first freeze of the season and a beautiful day after wind gusts to forty and fifty miles per hour yesterday.

A typical contact dermatitis from shoes was present on the top of the feet of one patient. The rash started shortly after he bought a pair of black shoes with foam rubber padding under the tongues of the shoes. The shoes were made in China. Hopefully taking him out of these shoes along with topical triamcinolone acetonide cream will suffice. If not, he will need to be patch tested for shoe allergy.

A patient with melasma came in with fairly good results ascertained by history. She was using a topical medication a nurse practitioner had given her. The medicine was samples of Tazorac cream 0.1 % applied nightly. This is an off label use for this drug, and it carries a pregnancy warning that the patient had not been warned about.

Patients are not wanting surgery between now and Thanksgiving. I only had skin cancer surgery on a few patients today and none on the face.

Thursday November 17, 2005

An Oriental patient came in three days ago with hand dermatitis. She is a beautician and does finger nails. I patch tested her for contact dermatitis and today she has positive findings for nickel allergy, formaldehyde allergy, and for quaternium allergy.

She comes in contact with these three in her work. She does not understand English and her husband was helpful, but it took a long time to go over what they needed to know because of the communication barrier.

Since she was my first patient I ran behind schedule for the rest of the day. Staying on schedule has top priority in my office so when things do break down the patients are most understanding and remain appreciative of the times that they did get in and out on time.

One patient had had diffuse sun damage to his face and needed a chemical peel with 5-fluorouracil when he last visited. He followed instructions taking photographs every other day and brought them in today. One place on his forehead had had the appearance of a sebaceous hyperplasia (a build up and thickening of an oil gland duct) at his last visit, but the pictures showed a beefy red discoloration and rawness of the lesion by the sixteenth day that remained through day twenty eight. The remainder of the face cleared beautifully well. I removed the basal cell carcinoma that I first had thought was only a sebaceous hyperplasia.

A new patient referred by the doctor in a small town had suffered from a chronic paronychial inflammation. He had been treated with Clindamycin and was free of acute infection. I did a nerve block and injected the residual granulomatous tissue with two mg of triamcinolone acetonide diluted with normal saline.

The last patient seen suffered from a drug rash. She was on eight medications that are CYP-450 utilizers and a few medicines of which little is known about their metabolism. These patients are too common and are complex problems in evaluation and management. In my opinion this is one of the greatest problems in the field of medicine at the present time. One of her medicines could be discontinued safely. Also it was safe to reduce the dose on one of her blood pressure medicines. She is to return in two weeks for re-evaluation. I promised to work her into my schedule if she gets worse in the mean time.

Friday November18, 2005

A long tiresome day with most patients from goodly distances such as Forth Worth. I felt obligated to do for them what needed to be done so that they would not have to make the trips so often. Maybe that is why patients come so far to be treated, because they can not get that much done in one visit at home.

Monday November 28, 2005

A hectic return after the holidays. The postman brought the mail in one of their postal baskets, about the size of a laundry basket.

There is a backlog of skin cancers, keratoacanthomas, nevi that are dysplastic, a spindle cell tumor of the skin, and skin rashes.

Most of the skin rashes this time of year are due to medications, and the most common seen the past two months have been acute vasculitis rashes on the legs and due to cardiovascular medications. Invariably these patients are on several medications. DNA Drug Reaction Testing locally has been unsatisfactory, with the local lab sending the tests out of town. The scope of the tests are too limited to be of practical value. Presently I am looking into Genelex Corporation Labs in Seattle, Washington.

One patient with onychomycosis (toe nail fungus) is having a response to a 2% solution of 5-fluorouracil one drop applied twice daily. The paronychial skin and proximal subungual area become erythematous much as does the skin with abnormal keratinocytes in actinic keratosis. Eventually new nail replaces the diseased nail. This is an off label use of this product that has not been heretofore reported.

Tuesday November 29, 2005

Because of the Holidays last week, this Tuesday is more of a catch up day than Tuesdays usually are. On Tuesday there is always a spill over on paper work and phone calls from Monday due to the increased load on Monday from over the weekend, including Saturday's mail. Hopefully catch up on these items will be made before the week is over.

Today my daughter in-law had her left axillary lymph nodes removed because of breast cancer found two weeks ago in the second sentinel lymph node. I spent most of the middle of the day at the hospital and she is doing well.

One patient came in with Herpes zooster less than two days duration. I painted the early rash with 3% dialdehyde and prescribed the usual antiviral medication that is available in liquid form because of a swallowing problem. Some advocate that dialdehyde should not be used because of the possibility of inducing an allergic reaction to it. I have had one contact allergy from this in eight hundred and that did not transfer to formaldehyde sensitivity as some claim. It does kill the herpes virus superficially if properly applied and does lessen the incidence of post herpetic neuralgia if used within the first two days of the illness. Because of this these patients are given emergency status when they first call in for appointments.

Wednesday November 30, 2005

When tissue reports come in first by fax, I telephone the patients and give them the report. This averages about eight reports a day and is time consuming, but being in the double digits all this week. It is appreciated by the patients and is nearly always the diagnosis that they were told to expect. There was a back log of these calls to be made after the holidays and what a relief it is to be caught up on them.

A new patient who is a brick mason at age 51 came in today with a blistering rash of two months duration. It is on the upper extremities and shoulder girdle area. The blisters are typical flaccid bullae of bullous pemphigoid. I sent a biopsy to Ameripath in Dallas and started him on prednisone and tetracycline.

The run on skin cancers, dysplastic nevi, postoperative melanomas and keratoacanthomas continued today. Medication rashes were mixed in with these patients.

The temperature dropped to 22 degrees F night before last and I probably saw the last insect bite of the season on Monday of this week.

December 1,2005

November ended without any rain for the Abilene area. This is the eighth time in recorded history that a month has gone by without any rain. However the lack of rain does not seem to be slowing down business or the economy.

All of the patients today were surgery patients except for two. There continues to be a run on keratoacanthomas, removing two today.

One lady in her eighties came in with a drug reaction to Bactrim (a sulfa drug) that was of the most severe type, being the scalded skin syndrome called toxic epidermal necrosis. Her skin looked as though it had been scalded with boiling water. Its onset was after she had been on Bactrim for two days for a kidney infection. Her internist wisely stopped the Bactrim immediately upon being informed of the reaction by the patient and sent her for consultation. She appears to be stabilized, but even so her prognosis is guarded.

Friday December 2, 2005

The lady with the scalded syndrome seen yesterday is holding her own and possibly improved. Her prognosis is more favorable.

The patient of the week honor goes to an eight year of age boy who had a wart in the palm of his hand. He has the emotional maturity of age ten or higher. He understood reasoning and let me freeze the wart sufficiently that he did not feel the needle of a local anesthetic with lidocaine. Then I proceeded to freeze the wart and an area around it of several millimeters. The 3-m Company had research done showing that the DNA of the wart virus could be found in the skin cells for several mm around the peripheral edge of a wart. While the tissue was frozen, I curetted out the wart and the superficial skin for the required distance to eliminate cells containing this DNA material. I followed this with an acid salt to help identify any residual infected tissue and re-curetted any suspicious remnants. This works excellently, eliminating the usual twenty per cent or so recurrence rate. I know of no reports in the medical literature of this exact procedure for treating warts. It is a lot of work and precise record keeping to compile records needed for publishing any treatment procedure. I have been there on other research already and know what it takes to publish and eventually be listed in Marquis Who's Who in Healthcare and Medicine and in their Who's Who in the World.

Again all the patients today were surgical save two. The run on melanomas and keratoacanthomas did not slack today and there are always multiple basal cell carcinomas and squamous cell carcinomas.

One lady came with a malignant spindle cell carcinoma of the skin of the anterior chest. These need aggressive treatment.

Monday December 5, 2005

The dermatopathologist from Ameripath called to state that Clay Cockerell, MD had reviewed the slides on the lady with the spindle cell carcinoma and that special stains have been done. They are not certain if the tumor is a spindle cell carcinoma or a clear cell melanoma. She is scheduled for wide excision and is to be treated surgically as if it is melanoma.

The lady with the scalded skin syndrome is much improved today, and she should be grateful to her internist for catching this problem early.

One of my international patients came in from Russia. I saw him a few months ago after he had spent time in Oman. At that time he complained that he was bitten by an insect. The bite itched and he scratched it. When he came to me he had multiple red spots on his lower extremities that were primarily macular (flat) and no visible scales.

Today when he came back, his rash had spread and had become generalized in a typical guttate psoriasis distribution with some lesions with the glistening white scales and the sharply demarcated margins of psoriasis. When I saw him the previous time I missed the diagnosis because I looked for a Canary since he had been in Oman. Now the diagnosis is a common sparrow, a rash that is seen over and over again.

Tuesday December 06,2005

Today's patient of interest came in for his one year postoperative followup on a rare and aggressive skin cancer known as Merkel Cell Carcinoma. He almost certainly saved his life by coming in within three weeks of when this small red nodule first appeared on his right cheek. I excised it with wide excision comparable to that taken for a melanoma. This was followed with radiation treatments.

A man was referred with a medication rash that is from Zocor, a cholesterol lowering medication. This group of drugs is the second most common cause of drug rashes next to the cardiovascular group of medications.

A long time friend came for actinic keratoses and skin cancers. His primary care physician had him on so much medication that he was a walking zombi. What a sad state of affairs!

A melano was referred for a solid tumor deep in his eyebrow region. It will be interesting to learn what the dermatopathologist finds.

Wednesday, December 7, 2005

Today's date being sixty four years since Pearl Harbor deserves a comma between Wednesday and December. That Sunday sixty four years ago was mild in Abilene compared to today which has been in the upper teens and lower twenties all day. The Abilene Reporter News carried only a short article by Lisa Hoffman on Pearl Harbor and even that was relegated to the fourth page. History fades away and our learning is forgotten.

Out of town patients usually come the third hour of the morning due to travel time. The first seven patients were locals and came as scheduled. After that it was a schedule shuffle with cancellation of patients from elsewhere being replaced by patients anxious to be seen sooner than previously scheduled.

The first patient was a long time physician patient and routine in nature.

The next was for a postoperative check on a basal carcinoma and for removal of newly developed actinic keratoses. What he really wanted was to ask me questions about his post carotid artery surgery that he had had since I last saw him. The lower portion of his postoperative wound was crusted over and tender. The surgeon that did the operation was two hundred miles away and also out of the country so the patient was somewhat anxious. I asked him how his carotid problem came to be diagnosed and his presenting symptoms were repeated one to two minute episodes of temporary blindness in the eye on the affected side.

I referred him to the appropriate department of Covenant Hospital in Lubbock, which is closer than he had been going and which has an excellent staff for his type problems.

The patient who first told me about the off label use of 5% 5-fluorouracil for treating solitary onychomycosis had a purpura type rash from Enbrel that he has been taking the past three years for severe rheumatoid arthritis. Enbrel is a dangerous drug with black box warnings. He is to return in two days to his internist who is prescribing this medication.

Two more patients were seen with medication rashes and the remainder of patients were for skin cancers and keratoacanthomas.

One sweet lady and long time friend and patient brought a gift of Russel Stover French Mint Chocolates for me and my wife. These are refreshingly good and the good taste lingers for awhile afterward.

Thursday December 08, 2005

The temperature was a record low of 10 with a wind chill factor below zero. It stayed that way most of the morning and warmed up very little this afternoon. I could not help but remember that night in January, 1942, at Elmendorf Field in Anchorage, Alaska, when I was inspecting General Butler's Lockhead Lodestar. The turnbuckle for adjusting the cable tension to the right aileron had been disconnected and wired back together with a single strand of brass wire. The sabotage would have let the pilot (the General in this case) observe free and full movement of the controls on control check before take-off, but would break after being airborne. I suppose I saved his life.

All appointments showed up for their appointments in spite of the weather and I worked hard all day. The patient who required the most time was a physician's wife who is on dialysis and has severe generalized pruritus. Zonalon cream helps some, but cryosurgical removal of multiple dry seborrheic keratoses has helped her the most. Again on this visit she had many new irritated ones from scratching them.

The first patient seen had a squamous cell carcinoma of the margin of the right lower eyelid. I removed it cryosurgically and he will have full function of the eyelid without postoperative retraction of the eyelid and eyelid margin. The cost to do this is a fraction of the cost he would encounter having it done by the eye surgeon in Austin, Texas, to whom some of the ophthamologists here refer their patients, and the results will be better.

A new patient with a keratoacanthoma kept my run on seeing more than the usual number of keratoacanthomas.

One acne patient was changed from Retin-A cream to Tazorac Gel 0.1% and from past experience I expect him to further improve.

Sunday December 10, 2005

Last Friday I was unable to log in probably due to heavy traffic on blogstream.

The first patient was my physical chemistry professor in college, who rescheduled due to the cold weather. At his age I expected this. The second patient always comes early, and his postoperative squamous cell carcinoma of the lower eyelid margin of a year ago reveals excellent cryosurgical results for eyelid margin cancer.

Two new patients had acne of the lower jaw and chin that flared premenstrually. They will do good on hormonal therapy.

The run on keratoacanthomas continued. There have been three skin conditions showing unusual increases in frequency the last one to two years. One of these is keratoacanthomas, which usually are fast growing at first and often are tender. They look like warty volcanoes with a crater at the top. I am wondering if there is something common in these patients such as a recent medication on the market. For example psoriasis is often precipitated and/or aggravated by beta blockers used for high blood pressure.

Another increase has been with melanomas and dysplastic nevi that borderline on being melanomas for which surgical excision is indicated.

The biggest increase in skin conditions is by far the iatrogenic group of skin diseases and conditions. Iatrogenic means the origin of the problem is caused by a physician. A day never goes by anymore that I do not see one or more patients with an iatrogenic disorder. I have not heard mentioned the old adage of do your patient no harm among physicians for many years. At the University of Texas Medical Branch in Galveston in the late 1940's and early 1950's this axiom was hammered into the medical students almost daily.

The patient of the week is one of those with an iatrogenic vasculitis of the lower extremities. A vasculitis is an inflammation of the small vessels and in this case caused by the drug Enbrel, the only drug the patient was taking. The blood work-up was normal and the problem is caused by the medication that the pysician gave. This is the first patient that I have seen with vasculitis caused by Enbrel. Purpura is listed among the side effects of Enbrel, but Enbrel being a relatively new medicine has not yet been listed among those causing vasculitis.

Monday December 12, 2005

One of the most medically intriguing patients that I have seen in a long time was referred to me by her Dyess Air Force Base Physician for evaluation in reference to a diagnosis of lupus erythermatosis that she had been saddled with for the past three years.

She brought in a stack of past medical records several inches thick that contained some of the most complete and thoroughly written work ups that I have ever examined. The most sophisticated, high tech, and current tests had been done. I would guess that thousands and thousands of dollars had been spent. The diagnosis remained indefinite; her two antinuclear antibody tests being an example in that they were elevated to a borderline inconclusive level and the pattern was inconclusive.

Her base physician had the guts to question the diagnosis after some of the biggest dogs in medicine had seen her, diagnosed her, and unsuccessfully treated her for lupus erythematosis. He requested a new dermatology consultation, and I was honored to be the one to whom he referred her.

After reviewing the records, I sent my nurse in to ask the patient a few specific questions while I was seeing another patient. She came back with the exact answers that I expected.

The patient had been placed on atenolol for high blood pressure one to two months before her "lupus" started. She had not been on any other medication at the time of onset of her rash and the atenolol was the only medication she had taken continuously for the past three years. The rash showed evidence of photosensitivity on sun exposed skin, but more importantly the distribution was widespread as typically seen in medication rashes.

I showed the patient recorded examples of medication induced lupus erythematosis caused by atenolol and of the associated photosensitivity and generalized nature of it.

My hat goes off to the Dyess physician who decided to take a new and fresh look at this patient. She was labeled with an incorrect diagnosis that has followed her for three years. If she were a civilian rather than military, she would not be insurable. And even so, if she needs insurance in the future, her past history may impair her chances.

It is sad to say that I see patient after patient who is not insurable because a false diagnosis has made its way into their medical records.

Three postoperative melanomas were checked and one keratoacanthoma, keeping the run on these conditions going.

A patient with an epidermoid cyst of the temple that I had done three years ago came back with a relapse. Looking at my notes the sac of the cyst had been excised intact, but I had not been able to identify the oil gland duct. I had tried to minimize the scar by not taking skin where the duct might be or might not be. These can recur from from incomplete excision of either the sac or of the duct.

Another patient required patch testing with TRUE Test Patches for a suspected contact dermatitis for a common sensitizing ingredient in shampoos and cosmetics.

A young man was concerned about lumps in his neck that were found to be enlarged lymph nodes due to two gum line caries of molar teeth, bilaterally.

The other patients had problems previously noted in this diary.

Tuesday December 13, 2005

On the third patient seen this morning, I excised a nevus that may be an early melanoma or melanoma in situ. Four of the first six patients were either for basal cell carcinomas or squamous cell carcinomas.

An elderly patient was referred for a basal cell carcinoma, that I am certain is an irritated and infected benign seborrheic keratosis on the dorsum of her hand. I sent the tissue to be checked.

Another referred patient had factitious dermatitis that is a skin condition where the patient scratches and digs out what appears to them to be little worms or parasites. I placed her on 1 milligram of Orap nightly and the chances are good that she will respond. Orap is a cytochrome P-450 3A utilizer and is dangerous to use with certain other commonly used medications. A current electrocardiogram is obtained.

Surgery was done on an elderly man for chondrodermatitis nodularis helicis. This is a condition in which the cartilage of the ear gradually hardens as the patient grows older. On the upper edge of the ear the cartilage forms a spicule that is almost bony in nature. This is usually a unilateral condition involving the ear on the side on which the patient sleeps. These are basically pressure sores where the skin and underlying cartilage become inflamed, tender, and swollen over the hardened spicule of cartilage. Sometimes a patient can sleep on the other side and the lesion will get well without intervention. Some of these will respond by having a patient use a stockinette doughnut placed around the ear for sleeping and held on with a hair net. Others may respond to freezing the cartilage sufficiently to soften it. Most end up needing surgery where the cartilage is trimmed away sufficiently that the skin is no longer stretched tightly and thinly over the cartilaginous spicule.

About mid morning Dr. Sinclair phoned from Dermpath in Dallas in reference to a solid tumor beneath the skin of the eyebrow that I had sent her for examination. She thought it was a metastatic tumor either from the prostate or from the lungs and asked for more information on the patient. The patient was referred from another physician who indeed had referred him to an urologist last October. At that time his PSA was 11.6 and the patient had been scheduled for a sonagram of the prostate, but he had canceled. This information helped Dr. Sinclair know which special stains to use first in order to expedite the diagnosis

Thursday December 15, 2005

Yesterday blogstream failed to load. There were 12 tissue reports back from the dermatopatholigist. One was a keratoacanthoma, one was transient acantholytic dermatosis (Grover's disease), six squamous cell carcinomas, and seven were basal carcinomas. For the second day in a row there was a patient with chondrodermatitis nodularis helicis, but what was unusual was that the patient was in mid life and young for this problem. The history revealed that he kept pressure on the point on the ear with a welding helmet that he wore all day. When I trimmed back the spicule of cartilage from his ear, the cartilage was softer than most patients that have this problem. This was actually a self employment job injury.

The lady who had the patch tests put on last Monday had a reaction to nickel and not to the cosmetic ingredient that I had anticipated.

An acne patient in her thirties and who has had a tubal ligation has completely cleared on Flutamide 125 mg daily. Her liver function tests are normal. A trial on 125 mg every other day for the next month will be tried.

The distal interphalangeal joint on the index finger of a patient was injected with corticosteroid due to a painful myxoma between the joint and the fingernail. When this is done,it is always interesting to see the white corticosteroid solution leak out of the joint into the myxoid cyst.

A diabetic patient who had acute vasculitis from his Glucophage came to be rechecked. The vasculiltis subsided slowly over a two week period of time after discontinuing his Glucophage. With careful attention to his diet, he had kept his diabetes under excellent control without the Glucophage.

Friday December 16, 2005

Today is a cold wet, drizzly day, just above freezing. The low point of the week was an electrical black out on Monday. We were out of lights, out of telephones except for my wireless which number is guarded, no copy machine, no fax, and no computer for two hours. The business office had enough window light that filing continued and that was about it.

Oh! For the good ole' days!

The first patient was a young man suffering from Tine Versicolor. Actually you don't suffer from Tinea Versicolor except his was showing on the upper neck and a problem to him cosmetically. This is a superficial fungus infection that responds to medicine and appears to be worse in the summer time because of the uneven tanning that results from pigment damage at the site of infection. The fungus is light weight and falls off of the head onto the shoulders and upper trunk. After killing the fungus, it takes several weeks or months for the skin to recover and appear normal in color.

An adult female patient with cystic acne along the jaw line and chin had been to several dermatologist.

This week's high point came when I was able to help the patient with the atenolol induced lupus erythematosis.

The first patient was a young man who came for tinea versicolor, a superficial fungus infection usually of the upper trunk. His rash was high enough on his neck that he was suffering emotionally. This fungus does not live at body temperature and only grows on the skin surface and is easy to treat and kill, but the skin is slow to recover normal appearance.

A lady in her upper twenties came with an acne problem and had been to all of the dermatologists in the area except me. The acne was cystic, confined mostly to the chin and lower jaws, and flared the week before menstruation. The only thing that she had been given that helped was a birth control medication suitable for treating this type acne. By adding spirinolactone and Differin cream to her present care routine, she should do well within three months.

Just as I was finishing up, Dr. Casey came in unannounced to ask me about medicine interactions. He had a patient to whom another physician had given Neurontin in the maximum recommended dose and she experienced a sudden death withing ten days. Several sudden deaths have been reported while taking this medicine. The Neurontin is a Cytochrome 3A utilizer and has an interaction with a whole bunch of medicines some of which she was taking.

Tuesday December 20, 2005

I have a cabinet maker who has a contact dermatitis that has been a problem for him. The standard panel of patch tests in the T.R.U.E. Test strips failed to reveal the cause. I made patches using samples of fine saw dust mixed in Vaseline and hope I may find which wood, glue, stain, or varnish that is bothering him.

December has been somewhat of a diagnostic dilemma month. The solid tumor taken from the subcutaneous tissue of a man's left eyebrow has yet to be identified. Derm Path in Dallas did special stains thinking it may be metastatic cancer from the prostate, but these failed to identify the cancer as coming from there. Now they are thinking metastatic lung cancer or carcinoid from the gastrointestinal tract. Dr. Clay Cockerell, a World Class Pathologist, said he had never seen anything like it in his career. I think he would remember since he went all the way through public school here in Abilene, never making less than an A grade. He also studied under Bernie Ackerman, MD, for years and years. These are two of the best dermatopatholigist in the world. Now they are sending the tissue for a consult. I checked the man for possible male breast cancer and found nothing. The results of a chest X-ray taken probably will be back tomorrow.

A fairly common diagnostic mistake came from a referral by a physician from another town. The patient was sent for athlete's foot not responding to treatment. This was in a fifteen year of age boy and the rash started at the top of the interspace between the first and second toes. Tinea pedis (athlete's foot) is usually not seen in children and almost always starts toward the plantar surface of the interspace between the fourth and fifth toes. This patient had clear skin in this area. He was wearing shoes made in China and wore a black and a gray pair of these shoes. A shoe contact dermatitis usually is more predominant on the thinner skin on the dorsum of the foot or toes as was this rash and foreign made shoes are almost always the culprit. The American made shoes are usually made with the same materials that the shoe companies use to make shoes for the military. The military requires their shoes to be made with hypoallergenic materials to reduce this problem in the military. The older the shoe and the it has become wet the more the ingredients of the materials come to the surface where the skin contacts them.

Wednesday December 21, 2005

One of the pediatricians referred an eight year of age patient for molluscum contagiosum. This is a viral infection with a pox virus and the skin has umbilicated papules with a white top and an erythematous base. If the lesion is opened the white top will be found to contain a white lump of material called a molluscum body. Removal of this lump cures the infection in that papule. However there are usually too many lesions for a patient to tolerate the pain opening all of the lesions would cause. On this particular patient, he was emotionally mature enough to let me pick up each lesion with curved thumb forceps, hold the lesion up and let me freeze it solid. This method allows freezing from the top and all side, reducing the depth of freeze and sparing the skin around the lesion.The less the depth of freeze, the faster and easier it is to reach the freeze temperature required to destroy the pox lesion.

Most patients under age nine fail to understand that the freeze pain is not a burn and become too frightened to be treated with liquid nitrogen.

A foreign body was removed from the posterior aspect of the proximal phalangeal joint (PIP joint)of the index finger of a man who had been suffering with it for a year. He had been to his family at the time of injury who did electrocautery to the wound. The patient claims this did not help. Then he went to a hand surgeon several months later with the painful swollen finger and was told he would need to see an orthopedist for a bad joint. When I showed the patient the foreign body that popped out after making the incision, he was one happy man.

Friday December 23, 2005

The office was closed today. Yesterday was post operative examinations and mostly students since it was the first day of Christmas break for the public schools.

One post op check was for a basal cell carcinoma of the scalp on a 25 year of age civil engineer major from Texas A&M. I recently read a retrospective study where the history of sun exposure was taken on skin cancer patients. The findings suggested that basal cell carcinomas tend to result from childhood sun exposure whereas squamous cell carcinomas tend to arise from adulthood sun exposure. This patient claims that he always wore a hot and he has a thick head of hair. I would guess that his excess sun exposure occurred in infancy.

The path report on the re-excision of the tissue taken from the lady with the spindle cell tumor of the chest came back with only the scar of biopsy operation showing. Spindle cell carcinoma and atypical spindle cell tumor were the diagnoses made by the two different pathologist that examined the original biopsy. She will be followed
closely.

One psoriasis patient has been on Enbrel for a year now and has not really responded to the medication. Enbrel was chosen because of his arthritis associated with his psoriasis. The Enbrel also has failed to help his arthritis. He states that his arthritis and increase in severity of his psoriasis started following an anthrax vaccination he received in the military.

December 26-27, 2005

closed

Wednesday December 28, 2005

The final path report came over the fax on the patient with the solid tumor of the left eyebrow that was submitted to Derm Paths in Dallas on December 6. After doing special stains and obtaining consultation with a pathologist who has a special interest in carcinoid tumors, this is the final diagnosis. Carcinoid tumors of the skin are usually metastatic cancer from either the lungs or the gastrointestinal tract. This patient had a negative chest X-ray, so I sent him back to the referring physician to do a gastrointestinal work-up on him.

The first patient today was a physician whose group has 4,000 square feet of space in the Professional Building on North 19th Street. The building is between 50 and 55 years old and in excellent condition. I learned that Hendrick Medical Center gained ownership in the recent past and now plans to tear it down and make a parking lot out of it. Needless to say this patient is under stress, because of time constraints on moving and finding a suitable location that can provide 4,000 square feet or more of floor space near the Medical Center, that his practice requires.

Another medication rash from iodine in a scan dye showed up early without an appointment and in a great deal of discomfort.

The last patient of the day was a 13 year of age boy who came in with the complaint of athlete's foot. He had bought a black pair of Addidis shoes made in China just before the rash began. He had failed to respond to two different over the counter antifungals that he used the past three weeks. The rash was on top of his foot and to some extent on the inner mid aspects of the soles where the arch supports exerted pressure. I placed him on triamcinolone acetonide cream 0.1% three times daily and took him out of his foreign made shoes. He should do well, but if not he will be patch tested with a shoe patch test kit. This is the second shoe dermatitis in the past two weeks and both in children. Often in medicine things show up in threes. We'll wait and see.

Thursday December 29, 2005

A 76 year of age man who has been a patient for over thirty five years and who had the David Reese band that played at one of the big hotels in Las Vegas from 1956 to 1959 came in to have a "mole" checked. He is now retired and spends daily time at the State School in Abilene where he plays the guitar and sings hymns and western songs to the patients there. His finger tips are callused from picking his guitar.

A 68 year of age female presented with acute edema and eczema of the lips from lip stick. She had used the same brand and color of lipstick a few years ago and had the same reaction then. She said she liked the color and that is why she tried it again.

One patient had four depigmented circular lesions on her abdomen with raised erythematous edges suggestive of ring worm. Antifungals prescribed by the Dyess Air Force Base physician had failed to help and he sent her for biopsy.

Another lady had need for genetic testing concerning medications that utilize the cytochrome P-450 pathways.

Friday December 30, 2005

The year 2005 comes to a close with FDA Medwatch having published new side affects on over 100 prescription medications. These are newly reported significant problems that were not reported by the pharmaceutical companies when these medications were submitted to the FDA for approval. Some have been on the market many years, but most are relatively new on the market, and a whole bunch of them are the ones we see advertised on the TV.

A retired road worker from the Texas Highway Department was treated cryosurgically for a basal carcinoma. Roofers and pavement workers are exposed to tar, sun, and wind, all of which when combined predispose to the development of basal cell carcinomas. Over a period of several years I had a patient who had worked for a tar factory in Southern California. During that time I took off more than sixty newly occurring basal carcinomas before I gave up on keeping count. He has had another twenty or thirty since then. This is one reason I never liked using coal tar in the treatment of psoriasis.

An acne patient had an appointment to refill her Accutane before the i-Pledge Program was scheduled to go into effect on January 1. About last week the FDA postponed requiring the i-Pledge Program until March 1, 2006. This will save me considerable time because by then she will be through with her Accutane and I don't have anyone else that is going to run into that date before being through. Many of the dermatologists with whom I have talked are refusing to prescribe Accutane. The i-Pledge requirements will be time consuming and demeaning at best.

Tuesday January 3, 2006

In a college town like Abilene, people are thrown together from all parts of the world on the first week of school and on the first week after Christmas Holidays. All manner of contagious diseases become widespread during those times.

As soon as the office opened today, three patients called and canceled due to acute illness.

Those who were seen were either had acute skin problems or had been scheduled for necessary surgery.

Among the acute patients was a man who was suffering from dermatitis herpetiformis, a blistering disease due to gluten sensitivity. He is a lover of beer which contains gluten, but I believe was in sufficient discomfort that he really wants to and will go on a gluten free diet. This includes reading all labels, no wheat, barely, rye, or oat products, but does allow corn and rice products.

A 79 year of age retired physician patient was suffering from apparent Cozaar (a blood pressure medicine) overdose symptoms. His cardiologist was prescribing the highest recommended dosage for a young patient. The elderly patient often does not tolerated the usual dose and needs Cytochrome P-450 3A4 and 2C9 studies made to determine if they are slow metabolizers. He is to taper his dosage and to have the needed lab work done. The cytochrome enzymes in the liver break down the Cozaar into water soluble metabolites so that liver is able to get rid of them. Otherwise an overdose build up.

Thursday January 5,2006

Yesterday I did not post, but as a graduate of UTMB in Galveston I watched the Longhorns win the National Championship.

The old medical adage of things come in three's, held as I saw the third patient, a 15 year of age female, come in with a shoe dermatitis. She had been treated by two physicians for athlete's foot (tinea pedis), one used topical antifungals and the other prescribed griseofulvicin by mouth. Neither helped. As is typical of shoe dermatitis, the rash started on top of the foot where the skin is thinner and not between the fourth and fifth toes that is typical for tinea pedis.

One man whom I treated cryosurgically for squamous cell carcinoma manifested a common finding in cryosurgery that to my knowledge has never been reported. He had a well differentiated squamous cell carcinoma on the superior edge of a scar where a dermatologist (now retired) had removed a skin cancer previously. It appeared to be just far enough from the scar to be a separate and new cancer. However upon freezing it to a low enough temperature that it took slightly over 90 seconds for the ice ball to thaw back to the edges of the visible cancer, and then observing it after complete thawing two cracks appeared in the skin. One of the skin cracks traveled into the edge of the old scar. The cracking of the skin in basal cell cancer tissue and in squamous cell cancer tissue after freezing is not described in any of the cryosurgical literature of which I am aware. I find it to be a useful phenomenon to watch for especially when the borders are somewhat uncertain. In this patient it enabled me to know that I needed to extend my margin of freeze further beyond grossly visible margins of cancer than usually needed.

Today a patient with a pyogenic granuloma came after it had recurred after surgical excision of it elsewhere. A pyogenic granuloma is a red round elevated lump that comes on with rapid growth and bleeds easily. It is a tumor of granulation tissue and has markedly increased vascularity with vessel endothelial cells being prominent in it. A hard solid freeze using two freeze thaw cycles has worked better for me in treating these than has other surgical procedures that are commonly used.

Friday January 6, 2006

Short weeks are the heaviest on the days open for that week. Today was all surgery except for one patient with acute urticaria probably from egg nog and one patient with acute contact dermatitis.

The surgery included an ingrown toenail and two recurrent basal carcinomas. Usually I only see one or two recurrent basal cell carcinomas out of my practice each year and I hope these are the two for this year. Both were on patients who failed to come in on their scheduled post operative visits. Often on the post operative visits an actinic keratosis will begin to show up on the edges of a basal cell carcinoma post op site and can be removed with a few seconds of freezing. Most of these few recurrent cancers are long enough afterward that they are most likely due to cancer arising in these peripherally appearing actinic keratoses.

Monday January 9, 2006

The biggest event of the day was an hour long operation doing a wide surgical excision of a 2X3 cm. melanoma from the scalp of an elderly man. On biopsy the thickest and most active part of the tumor had 3 mitotic cells in the high powered field on the vertical section. This is the first melanoma tissue report that I have received from Derm Paths in Dallas reporting this new way of evaluating prognosis. It is hoped to be more accurate and on this patient this method of evaluating the prognosis predicts a little better than an 85% chance that he is cured by surgery alone. I have referred him to the oncologist to be followed. His scans are negative. Whichever way this goes,he needs to hang his hat on the precepts of God.

Tuesday January 10, 2006

Today is a crisp day, beautiful to behold, and the schedule was likewise,with all appointments showing and being seen on time.

One middle aged lady referred by TriCare (Dyess Air Force Base) had been treated there without success and the skin biopsy on her that I did has the appearance of a gyrate erythema.The report is compatible with the clinical picture. I referred her to Willeford Hall in San Antonio for a workup because sometimes this skin problem is seen in patients with internal malignancies.

One man whose younger daughter was diagnosed a few days ago with multiple myeloma was sure that he had a skin lesion on his forehead. Careful evaluation with excellent lighting and magnifying glasses failed to reveal any abnormalities of the skin. Either he was unduly alarmed by his daughter's illness or he needed someone whom he trusted to talk with.

Wednesday January 11,2006

All patients showed up on schedule today and an average assortment of common conditions were seen. There were the usual basal and squamous cell carcinomas, acne patients, epidermoid cysts, precancers, and postoperative examinations. The usual medication rashes were missing.

Thursday January 12, 2006

This is a day of more variety than yesterday.

One male patient had his patch tests read and had reactions to Neomycin, Quaternium-15, and mercapto mix. He had been applying Neo-Sporin ointment to his rash. This ointment contains Neomycin, which is a common sensitizer. The ointment is applied to the rash and gives the patient a sense of relief, but the Neomycin causes a delayed reaction that may be delayed one to three days. When the flare of the reaction occurs, more Neo-Sporin is applied to relieve the skin and the rash is again catapulted toward a delayed flare. The only source of the Quaterium-15 is apparently from contact with his spouse's make-up that she wears. He had rash around his waist from the elastic in his underwear, and this is probably from the mercapto mix allergy.

One lady had rheumatoid nodules on her fingers. Rheumatoid arthritis usually involves the proximal interphalangeal joints, that are the first joints distal to the knuckles. She had a rheumatoid nodule along side these joints on her left index finger and right middle finger.

An eleven year of age girl had the distribution of adult atopic dermatitis on the upper extremities and gave a history of her last episode of atopic dermatitis (flexural excema) at age five years.

An elderly man had a wide spread erythematous rash from a beta blocker he is taking for blood pressure. His blood pressure was 80/50 and he claimed that he has always had low blood pressure. I was unable to ascertain any history that indicated that the beta blocker was given for any reason other than for high blood pressure.
About a third of the patients (by carefully taken history) that I see for rashes from medicines for high blood pressure had their first prescription written on the basis of one blood pressure reading. From there the prescription is continued indefinitely when in fact these patients have normal blood pressure readings after discontinuation of the medication. I plan to taper this patient off of his beta blocker and monitor his blood pressure closely. If indeed he has hypertension, I will refer him back to his attending physician.

Friday January 13, 2006

Some days the appointment schedule has a lot of octageneraians. This was one of those days. It is interesting that female patients outnumber male patients in most doctor's offices, but in my office in the age eighty plus group of patients sometimes the males outnumber the females by several multiples. Most are skin cancers and that explains the difference. There are more women living in this age group than there are men. In the southwest skin cancer belt, there are more men who need a dermatologist.

An eleven year of age boy had a history of scalp problems. Examination under a Wood's lamp revealed the bright orange fluoresence seen in tinea capitis.

An 85 year age man lost his house, fences, and barns in the Carbon Fire that burned 45,000 acres a few days ago. His livestock moved away from his coastal burmuda that carried the fire and were not harmed.

Monday January 16, 2006

This Monday was more in keeping with the average dermatology practice as compiled by the National Deseases and Therapeutic Index. They list acne as the most common reason for seeing a dermatologist, and today I saw more acne patients than any other single diagnosis. Usually surgery patients make up the bulk of the day's work.

One patient was referred from Dyess Air Force Base for severe generalized psoriasis. She developed a sudden flare-up a little over two weeks ago when she became sick with a strept infection involving her throat and tonsils. She was on one of the new immune modulators, Enbrel, at the time of the flare-up and had a injection immediately before the coming down with the acute throat infection. The sore throat was treated with a Z-Pak and the infection responded. This is the second patient with psoriasis whom I have seen have an acute flare-up of their psoriasis while taking Enbrel for it.

The usefulness of Enbrel is yet to be determined.

Tuesday Januaary 17, 2006

Today I cryosurgically treated several skin cancers. All were on loose enough skin to utilize compression and elevation of the tumor during the cryosurgical procedure. I use specially made curved thumb forceps for this. The elevation and compression protects underlying nerves and also allows freezing from the sides as well as the top of the tumor, reducing the depth that the freeze temperature needs to travel. This and the decreased blood flow allows a faster freeze of the cancer cells as well as allowing a more prolonged thaw time. A fast freeze and a slow thaw has been shown to destroy the cancer cells best. In the treatment of basal and squamous cell carcinomas, I have done close to 10,000 skin cancers using liquid nitrogen spray while compressing and elevating the cancerous lesion. To my knowledge none have ever recurred. There are places where this technique can not be used because the skin is too tight to grasp in the forceps. I have had recurrences of tumors in these areas and treated two such recurrences earlier this month.

Wednesday January 18, 2006

A pilot who married the daughter of one of my high school classmates came in for his annual Flight Physical. He took a 20 year retirement from the Air Force 31 years ago and has flown a King Air for the same company these 31 years. At age 72, his insurance company will no longer insure him for the King Air unless he has a co-pilot. The company can save a bundle by hiring charter pilots, so he retired this month.

Several patients with basal and squamous cell carcinomas were treated today all of which I could elevate and compress while spray freezing the cancers.

One man had a severe papular erythematous generalized medication rash from Cipro that he took for an upper respiratory tract infection.

A high school teacher had a scabies rash that was generalized, on the scrotal area and absent between the fingers. When absent between the fingers these rashes are due to animal scabies rather than human scabies. He and his wife have had a rash for the past three weeks, both breaking out at about the same time. They have an in house cat and a young dog one year old and a four year old dog. Dogs older than two years are normally immune to the mite. He and his wife are to be treated at the same time and the cat and younger dog is to be checked by a DVM.

Thursday January19, 2006

A new male patient came in for an irritated seborrheic keratosis, who had the same surname as mine. He did not know his family history, but he is the only patient out of thousands that on examination I found to have the exact same hair texture as I do. If I closed my eyes I could not tell if I had his hair between my fingers or mine. So much for surnames and what's in a name.

An adult presented with flexural eczema (atopic dermatitis). Usually these present with hand dermatitis when adults.

A 24 year of age patient complained of a bald spot that was growing larger and on examination was found to have alopecia areata. I gave him a prescription for Elevil cream 1% to use twice daily and will recheck him to determine if that is sufficient to restore his hair growth.

A lady was suffering from a pruritic (itchy) bilateral neck rash that was beginning to spread to the lower face. She wore long hair, the ends of which touched at the sites of the worst areas of rash. Usually when hair products cause contact dermatitis the rash occurs where the ends of the hair touch the skin. On the scalp the hair stands up and away from the skin and the vertex of the scalp is exempt.

My near neighbor complained of skin rash that was associated with incompatible medications, the mixture of which has caused a goodly number of deaths in the United States; deaths resulting from heart rhythm problems when these two medications are mixed. The pharmacist somehow failed to catch or review her list of medications and apparently her internist failed to read his chart of medications that she was taking. These problems are far too common. I can remember two patients within the recent past who had this happen to them and they both were revived only to have permanent brain damage. Too many patients slip through the crack of checks and balances that are in place at this time.

Friday January 20, 2006

The first patient was a lady whom I've been treating for plantar warts using bicholoacetic acid topically. She is finally well and is appreciative because she was able to be on her feet for the entire duration of treatment.

About the middle of the morning an elderly lady came in for a postoperative examination of her nose where a basal cell carcinoma had been removed. She lost her husband on January 2, 2006. He had severely suffered from Parkinsonism several weeks before and so in some ways it was a relief to her. However they had been married 57 years and the adjustment is great, especially in the evenings. Her husband was a remarkable man in that he never stopped working, even in his final days. He was a primary flight instructor during WWII and he and his brother owned an airport on the west edge of town for about ten years following WWII. In 1946 I bought a surplus BT-13 and kept it at his airport. He and his brother were both A & E mechanics. At the time, the the FAA required the tail wheel section of the BT-13 to be reinforced with a heavy aluminum bar. I was able to install it and this man signed it off for me. Also they honored my military service by never charging me for keeping my airplane. He was my friend for sixty years and my patient for over 51 years.

Another WWII pilot and War hero who is now 84 years of age came to have a postoperative examination on his ear where a basal carcinoma was removed last month. He is going blind, has had a mild stroke, and is on medicines that adversely interact with one another. He is so afraid of having a more severe stroke that I found it was useless to try to explain to him that some of his problems were due to dosage problems of interacting medications.

Monday January 23, 2006

The newspaper this morning had a brief article in which someone was giving reasons why today (this date) is the worst day of the year.

Everything was going smoother than belief through the first ten patients, when I got a short putt to disaster. The 39 year of age grandson of a physician, had had two brain operations for seizures and was on a ton of medications that interact with one another. He was seen for a complaint of acne. Two of his medications are known for causing acne after long term use, and neither could be withdrawn safely. Any treatment was limited due to the many medications he was taking and interactions limiting what was safe for me to give to him. Finally we compromised on giving him topical Benzaclin in hopes of keeping him somewhat comfortable with his acne.

The give-me putt to disaster came when I saw the last patient, who issued an ultimatum to the nurse that if I did not prescribe Accutane for her acne that she would go to another darmatologist. She claimed that her present medicines were not working. I asked when she took her last Doxycycline. Her answer was two weeks ago. She swore that she had taken it faithfully and had not skipped taking any doses. On checking her prescription, it ran out 3 months ago and had no refills authorized. Examination of her acne revealed it to be grade I or less, having only one inflammatory palpable lesion of a small size on the right cheek and some mild residual postinflammatory pigmentation. Certainly Accutane is not indicated in this patient. She is a non compliant patient to boot, having not taken her previous medicine as prescribed. Giving Accutane to a non compliant patient is a no, no, let alone to one that doesn't need it.

Some days are like this, even in the practice of dermatology.

Tuesday January 24, 2006

The first patient returned to have a medication rash rechecked that was due to his blood pressure medication. He has tapered off of his medication, his blood pressure today was 100/60, and his rash has completely subsided. He is to return in two weeks to determine if this is his usual blood pressure, which by history he claims it to be. This is a patient who is mentally alert and states that he has always had low blood pressure, has never had any cardiovascular event, and has always had a regular pulse. He fits into the one third of patients I have taken off of blood pressure medications in my practice because of medication rashes who turn out to have normal blood pressure and who never needed the medication in the first place.

A lady barely past middle age complained of a red place on her nose, a complication of microdermabrasion done elsewhere. She chastised herself for having it done because her daughter also had complications from microdermabrasion.

Almost every day I treat someone for a squamous cell carcinoma in situ. Today I had such patient and only mention it to explain what is meant by in situ. A basement membrane separates the epidermis from the dermis. The epidermis is a solid layer of cells. The dermis has nerves, blood vessels, and skin glands such as oil glands and sweat glands. In situ means that the cancer is above or superficial to the basement membrane and has not broken through it or invaded it.

Wednesday January 25, 2006

Today all patients were skin surgery patients. One had an epidermoid cyst and the others had skin cancers. There was a mixture of basal cell cacinomas, squamous cell carcinomas, and one squamous cell carcinoma in situ.

Basal cell carcinomas arise in the basal cell above the basement membrane. The squamous cell carcinomas arise out of the squamous cell (sometimes called prickle cell) of the epidermis. Basal cell carcinomas normally do not metastasis (scatter) by spreading through the blood stream or the lymphatic system. The well differentiated squamous cell carcinomas usually arise out of sun damage and seldom metastasis unless left untreated until an inch or so in diameter. Even then the per cent of metastatis is in the single digit figures. Most that metastasis are either poorly or only moderately well differentiated. A squamous cell carcinoma of the lip caused by smoking may fall into this category and calls for more radical treatment that the others.

Thursday January, 2006

Today started with a Flight Physical for a new patient. One medication he is taking had to be cleared through the Regional Flight Surgeon in Fort Worth.

After Christmas there is always an increase in winter dermatitis (asteatotic dermatitis or dry skin dermatitis). A lady presented with asteatotic eczema on her legs. She had received an electric blanket for Christmas. Electric blankets are excellent skin drying gadgets.
Due to the increase in energy costs, electric blankets were apparently popular gifts for Christmas. This month I have seen a number of patients suffering with winter dermatitis precipitated by electric blankets.

One patient had her patch tests removed and is allergic to quaternium-15 and formaldehyde. These two allergies commonly occur together.

A man seen for irritated seborrheic keratoses on his forehead was fearful that I might want to cut them off. He was quick to tell me that he is on coumadin and his doctor was having trouble adjusting the dose. His wife was afraid that he might bleed to death if I did anything. I ran his list of medications through the software program for drug interactions that is available from Genelex. Due to medication interactions his coumadin dose was approximately double what it should have been.

A lady complained of rash. It is a medication rash. On running her medications through Genelex's medication interaction software, she proved to have five medication interactions among the eight that she is taking. Some medication rashes have a threshold and by that I mean they are dose related. This is not true for all medications. When a new medicine is added and it significantly raises the dose on three other medicines, there is no immediate way to identify the offending allergen. These are complicated situations and the prescribing physician is seldom receptive of the fact that the medicine that he or she prescribed is the cause. It is easy to lose a referring source if the problem is not handled discretely.

Friday January 27, 2006

The patients were all surgery patients today.

One was an epidermoid cyst. These were called sebacious cysts and then called intradermal cysts before becoming designated as epidermoid cysts. With the improvement in microscopes and tissue study techniques, the pathology causing these cysts appears to begin in the epidermis. On excision of these cysts, the recurrence rate is definitely reduced by excising the skin over the cyst that contains the pore to the affected oil gland. I learned this when these were still being referred to as sebacious cysts and in recent years the name change confirms this observation.

Many of these cysts do respond to triamcinolone acetonide injections. The forty milligram per cubic centimeter concentration is used without dilution. Depending upon the size of the cyst, it must retain ten to twenty mg. of the triamcinolone without leaking it out through the oil gland duct or through a leak through the wall of the cyst. The secretory cells usually atrophy by three weeks or less and the cyst disappears.

One long time patient who came today is a look alike for Bob Hope. Not only is he a spittin' image, his voice, his expressions, and his skin color are all his look alike. I am sure of the observation because as a WWII pilot for the African Middle East Theatre Provincial Headquarters Flight I had the privilege of piloting one of the two C-47's, that flew Bob Hope and his troop from Cairo, Egypt, to Asmara, Eri Trea.

Monday January 30, 2006

Monday is a difficult day for the scheduling of appointments. Acute conditions develop over the week end and other patient's cancel because their plans suddenly change. Usually the one or two cancellations early on Monday are filled with the patients with the acute conditions and the two balance out more or less evenly. When they don't, Monday can be a hectic day. Today is such a day, in that there were five more patients with acute conditions than there were those who call to cancel.

The first patient had a severely acute contact dermatitis that began on Saturday night. He is going to need patch testing as soon as he can be quietened down, since this has been a recurrent rash from time to time.

A farmer's wife also suffered with an acute contact dermatitis on the flexor surfaces of her forearms. She had spent three days cutting brush and vines and carrying them bundled on her forearms. She will respond to treatment for plant contact dermatitis.

One man came from elsewhere. He had a generalized eczematous pruritic rash of a less rapid onset. His medication list included ten medicines, six of which were interacting with one another, He was receiving more than a double dose on two of the medicines because of the interactions. Most patients in their eighties need a lower dose than normal on most of the medicines taken. He was on the normal doses for healthy young adults on all of these ten medications.
When a patient of this nature comes in, I get the feeling of wanting to turn my back, walk out of the room, and throw up my hands. I ran his list of medicines through the software program from GeneLex Labs, and gave him a copy to give to his home town physician. His physician is a good friend and has referred many patients to me for many years. Hopefully he will reduce the doses on the medicines that show to be overdosed and everything will work out for the better. If he is not a normal metabolizer, this may not work out for the better. Ideally these patients should have their doctor have the lab do a CYP-450 profile on them. The problem here is that it costs about $800 and insurance may not pay for it.

I had a follow up on the patient with Gardner's disease, and he is being controlled with Derma Smoothe FS Eczema Oil, which is a corticosteroid in peanut oil. He had failed to respond to a stronger corticosteroid cream, and apparently the use of moisture on the skin before applying the peanut oil product which occludes makes the difference. So far this has been the only product that I have found that actually helps Gardner's disease.

Tuesday January 31, 2006

Today I saw one post operative patient who had his first melanoma removed two years ago and a second one last year. The run on melanomas last year has let up and during the month of January I had only one patient on which I excised a melanoma. The great number of patients with dysplastic nevi continue to show up almost daily and sometimes several in a day. Overall the patients have been coming earlier, and even with the increased number of melanomas seen last year, none were so far along as to not expect a cure. Usually a few come so late each year that there is no hope for a cure. I have not gone through this sad experience with anyone since 2003.

All the patients were for surgery today except for one with granuloma annulare and one for a Flight Physical.

Wednesday February 1, 2006

A young lady from DAFB was referred for rash that was tentatively diagnosed there as urticaria. Examination revealed her to be suffering from asteatotic eczema. This is an eczema that results from skin that is so dry that it breaks down into an eczematous rash. It is usually more severe on the extremities and tends to be worse in the dry winter time. Often there is a family history of atopic dermatitis and/or asthma or of respiratory allergies. This patient had positive findings on all these matters.

A middle aged man presented with a red solid lump in his left eyebrow. It had much the appearance of metastatic breast cancer that is sometimes seen in the scalp of women with advanced breast cancer. I excised the lump and sent it to Derm Path in Dallas to be checked.

Hair loss was the chief complaint of a lady who was having menopausal hot flashes. She also complained of redness and itching on her forearms where she was applying a topical progesterone product for her hot flashes. On inquiry it was learned that her hair loss began soon after she began applying the progesterone cream. Progesterone may be the cause the hair loss. She prefers the hot flashes to the hair loss. We will wait and see.

A rash that I had not seen in 25 or 30 years was present on a German exchange student. She had had a sore throat with swollen glands in her neck. The most renown ear nose throat doctor in the area prescribed Amoxicillin for the acute illness. Soon after Amoxicillin came onto the market it was learned that it would induce the rash of mononucleosis when prescribed for acute infectious mononucleosis. This patient has the lab findings of acute infectious mononucleosis and does not have an allergy to Amoxicillin. Rather it is the typical macular rash that borders on being a papulosquamous rash and may occur in acute infectious mononucleosis. In my experience it always occurs when amoxicillin is given to these patients.

Thursday February 2, 2006

I had an interesting finding on an adult male patient first thing this morning. He complained of an itching rash. Over his trunk and upper extremities, he had a few scattered mildly appearing papules that had been scratched and that were pruritic (itching). The interdigital spaces were free from lesions. His history revealed that he had been itching for about two weeks and that he had a grand daughter and daughter who also had rashes of about the same duration and were itching. When queried, he said they both had multiple itching papules between the fingers, indicating a human mite (human scabies) as the causative reason for the rash. The usual rule of thumb that if the interdigital spaces are free from rash it is due to animal scabies and not human scabies failed to prove true in this patient. For everything in medicine there seems to be exceptions.

Friday February 3,2006

Today was an all surgery day, one being a plastic surgery flap on the nose for revision of a scar made from cryosurgery for a basal cell carcinoma. I do not like to do primary flaps for skin surgery cancer because the tissue is distorted in the event of a recurrence. I like to do the surgery first without distortion of the tissues, letting the wound heal from the edges inward. Then I like to wait long enough to be certain of the success of the cancer surgery before considering reconstruction of the wound site if needed. Most of these surprisingly end up so that the scar is not significant and the patient refuses any revision surgery. This was a middle aged male who needed revision for the best results. Some are in professions where it is better to go ahead with the plastic procedure from the start. Another disadvantage in this other than distortion of the tissues is that a larger margin is required primarily and the plastic surgery scar is greater than if it is done secondarily at a later date.

In today's mail, I received my invitation from Marquis Who's Who in

Monday February 06, 2006

Two patients with postoperative melanoma appointments are doing well. One is less than a year post op and the other one was surgically removed without further treatment in 1990.

A 96 year of age lady with a post operative examination for cryosurgical removal of a squamous cell carcinoma on her scalp is doing well. Some cryosurgeons have recommended to do not do cryosurgery on the scalp for scalp cancers. In my experience I have had less healing problems with cryosurgery than with cold blade knife surgery on basal and squamous cell carcinomas of the scalp. The anatomy of the skin differs and understanding that the scalp is more vascular and that the basal cell layer and squamous cell layer is deeper is important. These factors must be taken into consideration by anyone doing scalp cryosurgery, They slow the speed of freeze as well as increase the speed of thaw. A larger aperture for the liquid nitrogen spray is helpful, and compression of the scalp tissue circling the cancer using an open neoprene cone is beneficial.

A lady complained of a red itching rash along the folds of the axillae. This is a common location for contact dermatitis from clothing. The apex of the axillae where the blouse does not touch the skin is free from rash. The perspiration from the axillae gets on the clothing and then where the wet clothing touches the front and back folds of the skin of the armpits, the rash occurs.

Tuesday February 07, 2006

A Dyess Air Force Base pilot came for his FAA physical for his civilian pilot license. These young healthy pilots are always a pleasure to help. The picture of the Air Force they present is entirely different from the old Army Air Corps of WWII in which I served sixty to sixty three years ago.

The first dermatology patient had a contact dermatitis of the knee. I had patch tested him before and found that he is allergic to paraphenylene diamine. He was given a material data sheet on this chemical, but like so many patients had not studied it as much as he needs to do. His rash on this visit is due to the paraphenylene diamine in the black rubber knee pads that he is wearing when laying carpet (his occupation).

An obese patient who requires periodic visits for stasis dermatitis presented with a myxoid cyst of the left thumb. These cysts communicate with the distal interphalangeal joint as a rule and are distal to the joint. Because the origin of trouble is in the joint and due to the cyst communicating with the joint, surgery commonly fails. Most of these will respond to corticosteriod injections in the joint. This requires a 25 gauge needle or smaller and the joint is found easily by injecting it at the end of the largest transverse wrinkle that runs across the top side of the joint.

Having not mentioned stasis dermatitis previously, it is a chronic eczematous dermatitis that occurs between the knees and the ankle. It is associated with swelling in the legs and is often associated with varicose veins. Often obesity is a factor. Stasis in the Greek means standing still. This refers to the lymphatic or vein valves being incompetent and the fluid does not efficiently move up the leg. Some contend that stasis dermatitis is not altogether due to the stasis. This patient for example weighs over 350 pounds, his skin is stretched in the areas of the stasis dermatitis from his obesity. He is unable to cope with his weight disorder and his attending physician has not been able to help him. The extreme overweight medical problelm is outside the field of dermatology. Even so I have been able to keep his dermatitis under control because he is a compliant patient in every other way.

Wednesday February 08, 2006

A sixteen year of age male patient passed his first FAA physical for a student pilot's license. This is the youngest age at which the FAA allows a pilot to solo and obtain a pilot's license.

Two patients came for post operative examination for basal cell carcinomas cryosurgically removed from the lower eyelids. Both had excellent cosmetic results without retraction of the lower eyelids and no visible scarring except detectable with magnification in bright surgical lamp light. It is difficult to surgically excise carcinoma as large as these were and in this location without retraction of the lower eye lid and also without resultant eversion of the lower eyelid. Ectropion is a most bothersome condition of the eyelid.

One lady returned three weeks after two tender, painful, and unsightly rhumatoid nodules were injected with a corticosteroid. These were on the proximal interphalangeal joints of the third and fourth fingers of the right hand. She was extremely grateful for the excellent results and disappearance of both of them.

Thursday February 09, 2006

The 96 year of age gentleman that had a medication rash from a medicine for hypertension early last month came in acting and looking twenty years younger. His rash is gone, he feels better than he has in a long long time and he has life about him with sparkle in his eyes. Before he was dull of life and miserable in general in addition to having a severe rash that kept him from sleeping. He finished tapering off of his blood pressure medication on 01/24/2006. His blood pressure is 98/60. He will not need to have his medication replaced since it was not needed in the first place.

The other patients were surgical, one from out of state who needed a lot of work done for sun damage and multiple skin cancers. The biggest dermatology coding consulting firm in the country encourages dermatologists to limit what they do to medicare patients pretty much to one lesion at a time. Actually the recommendation is not to do multiple lesions at one time. Many dermatologists are following this advice and collect a full fee for each lesion that way. When a second lesion is removed at the same visit, medicare reduces the fee by one half or more than one half for biopsies. This patient is a victim of such care, and at one at a time rate of biopsy and one at a time rate of removal of his skin cancers he would never become free of cancer.

Friday February, 2006

A long standing patient's post operative examination for cryosurgical removal of a basal carcinoma that had occurred at the mucocutaneous junction of the inner aspect of the left nare was negative. Had this been removed with cold knife surgery, a reconstruction procedure on his nose would have been required. The cryosurgical scar and minimal thinning of the septum is not noticeable without retraction of the left ala. He is most grateful.

A young lady had an epidermoid cyst 2 centimeters in diameter in her groin area injected with triamcinolone acetonide last week and examination reveals no residual trace of it.

A new patient, middle aged, complained of brittle finger nails. Walter B Shelley, MD, when he was practicing gave these patients 3,000 mcgm of Biotin daily. Hopefully this will help.

Another new patient from a distant elsewhere presented with dermatitis herpetiformis (DH). In the event that she needs to go on Dapsone, she will need to go to the lab for Glucose 6-phosphate dehydrogenase to make sure there is not a deficiency of this enzyme. In the mean time she is going on a gluten free diet and topical corticorsteriods. To help, this diet has to be strict and not even an envelope licked.

A 9 year of age girl had a pruritic erythematous rash beneath where the metal button on her blue jeans had been. Her mother, who also is allergic to nickel, had already made the correct diagnosis and replaced the metal button with a plastic button. All that was needed was a prescription for triamcinolone acetonide cream 0.1

Monday February 13, 2006

I received an e-mail announcement from Marquis Who's Who that I have been selected for inclusion in Who's Who in Heallthcare and Medicine the 6th edition for the years 2007-2008. This will make all six editions over twelve years in which I have been included, the first being in 1996.

The first patient was the high school golf coach for one of my grand daughters. I played golf with him the four years that my grand daughter played college golf. Her golf paid for her college degree.

Another patient recently lost his wife from small cell cancer of the breast, diagnosed in 1999. Just last year she was dismissed from the oncologist as being cured. She had a hard death. Her esophagus had been burned from radiation. She had severe dysphagia and had trouble eating.

A young Air Force Captain was referred for a mole on her breast. It appears to be a melanoma. I excised it and sent it to Derm Paths in Dallas. If it is an early melanoma, a more radical excision will be necessary.

The last patient was a retired dentist who had negative findings on his two year post operative melanoma examination.

Tuesday February 14, 2006

I schedule flight physicals for the first appointment and today was the patient's first flight physical since his last one that I did 33 years ago when he was a young man. He flew 135 hours before hanging it up, and now he is thrilled to learn to use new navigational aids. The excitement of learning things new is a tonic for his soul.

A lady came for a hyperthrophic and erythematous actinic keratosis on her left arm. On Thanksgiving Day she broke out with shingles (herpes zooster) and waited until Monday to call her internist because of the holiday. Many patients do not realize that herpes zooster comes under the specialty of dermatology. Herpes Zooster needs to be treated with anti viral medication within the first two days to be most effective. The post herpetic pain results from viral damage to the myelin sheath that insulates the nerve. The myelin does not regenerate and the nerve becomes like a wire with damaged insulation.

One patient had a contact dermatitis from Benadryl cream that she had been using on her neck. The Benadryl cream relieves the skin upon each application. The delayed reaction occurs a couple of days after application and a deteriorating cycle follows. A minor small area of irritation turns into a full blown rash requiring medical help.

An older lady who looked to be much younger than her age and who had not had aesthetic procedures presented with a history of recurrent fever blisters on her lower lip. I have had the best results treating these patient with 2,000 mg of Valtrex at the first hint of recurrence, followed by 2,000 mg in twelve hours if not symptom free by then. The Valtrex tablets need to kept on hand so that there is absolutely no delay in the initiation of the treatment.

The last patient complained of sores in his scalp. He had spent most of last year in the hospital with lung problems. Yesterday a patient presented with similar scalp findings who had no history of hospitalizations. The latter patient had been using tar shampoo for a long time. Tar shampoo commonly precipitates scalp folliculitis. Changing shampoos and prescribing clindamycin lotion for his scalp should be all that is needed for him. The folliculitis in the patient today appears about the same as in the patient yesterday. However he was sent for a nose culture because he is most likely suffering from Methicillin Resistant Staph Aureus (MRSA) folliculitis. For the past year or so there has been a surge in MRSA infections associated with the hospitals here, and any person hospitalized past six days may be at risk.

Wednesday February 15, 2006

My patient from Florida who is a pilot returned. He has diffuse mil actinic keratoses lesions across his forehead. He will respond to 1% Fluoroplex cream applied twice daily to this area of skin. Dr Dillaha who was head of the dermatology department at the medical school in Little Rock did the pioneer work on the use of 5-fluorourical in treating actinic keratoses. Back then we had to compound the 5-FU in propylene glycol. He found that on the face a 1% solution worked best and on the hands a 5% solution worked best. Through the years I have seen facial scarring from those who used 5% on the face when 1% would have worked without causing the scarring.

The patient with gyrate erythema which is often associated with internal malignancy was refused to be seen by Lackland Air Force Base, saying that they were overloaded. She has not worsened and perhaps she does not have internal disease. Nevertheless I ordered chest X-rays and mammograms as a starter. History is negative for symptoms of internal cancer and physical examination is negative.

The oriental lady who speaks no English and who was suffering with contact dermatitis on November 27, 2005, was in and doing well. She does fingernails in a beauty shop, and it is not easy for her to totally avoid quaternarium that she is allergic to. She needed encouragement to stay with her management program.

Thursday February 16, 2006

A midterm high school graduate developed a rash on his great toe following surgery for an ingrown toe nail that was done a few months ago. His great toe nail was stippled which stippling of the nails is pathognomonic of psoriasis. Also it is common for psoriasis to show up in a fresh postoperative scar. The most patients with psoriasis presenting this way I have seen on abdominal surgery scars such as post cholecystectomy scars. This is the first time that I have seen psoriasis first show up in a post surgery scar for ingrown toenail.

Otherwise this was a routine day moving along smoothly.

Friday February 17, 2006

A teenager presented with erythema annulare cintrifugum (EAC) that had a rapid onset and is generalized in distribution, being worse on the thighs. The rash is pruritic and of 4 weeks duration. This appears to be the superficial type and not deep EAC. I sent a biopsy to Derm Paths. She had a normal blood count with no evidence of infection or allergy. Hydroxyzine 25 mg helps the itching. She has an older sister who visited shortly before this rash began. Her older sister had a bad skin sore that was infected. Hopefully this is an immune reaction from exposure to that infection and the rash will run its course. EAC is a type or variant of gyrate erythema and may at times be associated with internal disease. The patient's complete physical examination was negative.

A 60 year of age man had a verruca vulgaris (VV) on a toe. He has good pulses in the posterior tibial and dorsalis pedis arteries (aa) and thick hair growth on all of his toes. These are signs of adequate circulation for surgical removal of the wart. Under cryoanesthesia I curetted the bulk of the wart away; applied an acid salt which turned the edges of the remnant infected skin white and removed that portion of the skin with a curette. This procedure gives close to a 100% cure rate for VV rather than the usual 80 to 82% cure rate following usual procedures.

A 39 year of age former pro football player came as a new patient. He had two championship rings and was wearing one of them. I said to him, "That ring is something to be proud of." In a very humble manner, he said, "I am, I worked hard for it."

Monday February 20, 2006

Today is the first day that the temperature has risen above freezing since last Wednesday.

Four patients called early to cancel appointments because they became sick over the weekend with flu or flu like symptoms.

The last time I had seen the first patient was many years ago for a flight physical. Last week he had a pacemaker put in and has had two heart attacks since I last saw him. In the meantime he built two ultralights and flew them, which do not require a medical certificate to pilot. He sold his last ultralight when his heart became irregular. Today he had a keratoacanthoma that was in a location making it easy to remove.

The lady with an early melanoma on her breast has healed and her sutures were remove. Derm Paths has their computers down and no one has examined the tissue yet.

Tuesday February 21, 2006

Today was all procedural dermatology, i.e., all surgery patients.

Wednesday February 22, 2006

Today is George Washington's birthday. He was born in 1732 and was personal friends with my ancestors, Zackwell and David Morgan.

One patient had a severe rash on the sun exposed areas of the hands, forearms, and neck. He wears a hat and his face was less severely affected. He began taking atenonol and hydrochlorothiazide for a short time before the rash began. Both of these medications may cause photosensitivity. The hydrochlorothiazide may cause a toxic photodermatitis. Because of the severity of the rash on this patient (borderline toxic erythema), I had him leave off the hydrochlorothiazide and treat the rash with corticosteroids. This may or may not be all that needs to be done. He is to come back in 5 days and have his blood pressure rechecked as well as his rash.

Thursday February 23, 2006

A hodgepodge day. First a flight physical on an applicant diagnosed with diabetes since another physician did his last examination. A diabetic patient can obtain a medical certificate if the diabetes is controlled without insulin. There's a bit of red tape as to what is required, but the most important lab test is the HA1c. This applicant had a 7.2 which is above the upper limits of the normal 6 that the FAA probably requires. Either way a new diabetic applicant has to be deferred to Oklahoma City by the Aviation Medical Examiner.

My one merkel cell cancer patient was doing good without evidence of any cancer recurring.

Two patients had keratoacanthomas and there was the usual ratio of basal cell carcinomas and squamous cell carcinomas.

A physician friend brought in a list of medications prescribed by another physician that a patient had been taking before she expired. He wanted me to run the list through the Genelex Drug Interaction Software Program. She had been on seven medications and the mixture was causing a lethal dose on one of the medications. This coincided with the autopsy findings on this particular medication. An autopsy had been done and the death was reported to be death by medication overdose. This will go down as a medication suicide, when actually the attending physician had not monitored the patient closely enough to realize that her prescriptions when taken as directed were overdosing the patient. This is the saddest of all things to record in this diary. Old people do not tolerate the usual dose on most medicines and the usual dose in a normal metabolizer tends to slowly become an overdose without adverse drug interactions. I see this fairly commonly in blood pressure medications that are overdosed in these patients. The consequence of deaths that result are recorded under some other heading.

This may be the biggest problem in medicine today. The Drug Companies want to sell their drugs, the pharmacists want to sell the prescriptions, and the doctors who during the past years honestly depended on these two sources for help are now being held in the dark on the true severity of the problem. For example all of the newer psychiatric medications utilize the CYP-450 enzymes in the liver to convert them to water soluble components so that the body can secrete them. A close Psychiatrist friend recently went to a two week postgraduate course to learn about the newer psychiatric medications. I asked what he was told about cytochrome P-450 metabolism of these drugs, and he asked, "What are cytochrome P-450's? They were never mentioned."

This will all change in the next ten years, but it should have happened yesterday.

Friday February 24, 2006

A light rain fell all morning and then this afternoon at about the time I got home it began to pour. A few minutes later one of the office employees called and said that the roof was leaking in the break room. I called my roofer and he beat me back to the office to check on the leak.

One patient had been diagnosed with Grover's disease. Upon taking his history and examining him, I believe the correct diagnosis is medication rash. A biopsy should differentiate between the two.

A patient that came in for a sun spot had recently seen his ophthalmologist who sent him to Fort Worth for surgical removal of a tiny basal cell carcinoma on his right lower eyelid. Already he is beginning to have dysfunction of this eyelid. This dysfunction could have been prevented with knowledgeable use of cryosurgery for destruction of this tumor. Now he will be bothered by this for the rest of his life.

Three weeks ago I injected a post auricular epidermoid cyst on a man who was back today with complete resolution of the cyst. There are criteria to be met for this treatment to be successfully used.

Monday February 27, 2006

The man who came in last week for a photodermatitis due to hydrochlorothiazide returned. He is free of rash and his blood pressure remains at 128/70. He has no edema and it is most unlikely that the hydrochlorothiazide will need to replaced by another medicine.

Most of the patients were from out of town and when from elsewhere they are most often surgery patients.

One lady on chemotherapy for ovarian cancer was referred by her oncologist for an apparent melanoma on her arm. This was a circular lesion of about an inch in diameter and the skin lines did not tell which way the skin would want to close. In these patients I like to circle the lesion on the excision, wait and see which way the skin wants to close. Then I oval the lesion to prevent puckering at the tips. I had been doing this for about 15 years when Dr. Epstein at the University of California published a paper describing this technique in the literature for the first time.

Two patients appeared to have contact dermatitis. One is probably from quaternium in her shampoo and so far I have no clue on the other patient.

Tuesday February 28, 2006

A busy day without much that is different from the usual.

I excised two large epidermal cysts from a ladies scalp eight days ago. She came to have her sutures removed and was exuberant because she had not had her daily headache since the surgery. I remember removing a cyst from a man's left upper forehead which removal stopped headaches that he had been suffering from. Hopefully this lady will have the same experience that he had.

One patient who had a cat scan last December because of a melanoma continues to suffer from the rash that was caused by the IV given for the scan. He is slowly improving but requiring a tapering dose of corticosteroids. This was a day that all patients seemed highly pleased except for this one, and I can't say that I blame him.

Wednesday March 01, 2006

I took sutures out of a lady's cheek and the cosmetic appearance is excellent. She had what we once called a sebacious cyst and is now known as a tricholemmal cyst.

The next patient was for a post operative examination of the right lower eyelid where a basal cell carcinoma was removed cryosurgically. He has excellent lid function and very good cosmetic results. In the medical literature, most authors report excellent results using cryosurgery for the destruction of basal cell carcinomas of the eyelids. This has been my experience also. More patients would be better served if ophthalmologists read the dermatology literature in this regard.

A man with a medication rash was on ten different medications. There were four incompatibilities of significance when I ran the medications through Genelex Interaction Drug Report Software. This was on the assumption that he is a normal metabolizer. One drug interaction was severe and two medicines were causing the affected drug to be severely overdosed. I had him take a copy of the interaction report to give to his attending physician tomorrow and gave him some triamcinolone cream to help him get some sleep tonight.

Thursday Maarch 2, 2006

Today is Texas Independence Day. Not a single patient mentioned it and I saw nothing in today's Abilene Reporter News referring to this great event. Senator John Cornyn remembered it in his e-mail today. Since he is from San Antonio (the Alamo City) I suppose it was easier for him to remember. He has my congratulations.

A bald man came for scalp area actinic keratoses. He is a retired Cat mechanic and wants to buy my WWII D-6 that needs a new starting motor. I think some day he is going to offer me enough that I will sell it to him.

One patient had presacral area radiodermatitis from irradiation that was done many years ago. These lesions resemble actinic keratoses and I treated them with cryosurgery.

An overweight patient presented with intertrigenous dermatitis in the lower abdominal wall fold (prepubic fold). She had been on antibiotics for dental surgery because of metal in her knees. There are a few satellite lesions that indicate that this is actually a rash due to candida albicans (yeast). She is not diabetic and therefore should respond to medication.

An older lady who lives alone and has four cats as household pets had the itch (scabies). These animal mite rashes are presently more common than human mite rashes. In human mite rashes everyone in the household has to be treated at the same time. In this instance the person and the cats have to be treated at the same time. She left the office headed for the Vet.

Sunday March 5, 2006

Regular habits are the wings that take the immune system to the altitude of maximum performance. Even then there are storms to circumnavigate to prevent a fatal crash. Last Friday I started off with a dental appointment to have my teeth cleaned and to have routine dental X-Rays. I had barely got back to the office when the dentist's office called and asked to schedule another appointment for filling a cavity that showed on X-Ray.

The next disruption from the routine was that the roofers showed up early to replace the roof. When they started to scrap off the old gravel roof sometimes the patient and I had to stop and wait in order to be heard.

Friday was our 55th wedding anniversary and I had scheduled to finish early. Due to the terrible noise overhead, we canceled out part of the schedule. I ended up seeing eleven patients while waiting for the others to be reached in time to reschedule.

Then Saturday's routine was disrupted by a long drawn out but beautiful wedding of a former employee. She had planned to go to medical school and changed to dental school after making a higher grade on the prerequisite test for dental school. However she took the test for medical school before I loaned her grammar books on Latin and Greek to study. Studying the prefixes and suffixes as well as some of the word stems can be of aid on these tests.

Teenagers and college students have the biggest difficulty carrying out a regular schedule. For example, the ones who can be regular in their habits respond better to acne treatment than those who are erratic with their habits. I had two of these patients Friday. I request these patient to bring in their medicines on the return visit to let them know that they are going to be held responsible for following instructions. Also it is important not to make the next appointment too far into the future.

Monday March 06, 2006

The office sterilizer heating element went out today. All the patients were handled with cryosurgery except for biopsies which can be done with disposable punches. Due to the number of lesions scheduled for excision tomorrow, I will run out of sterile instruments then and be in a temporary bind.

Tuesday March 07, 2006

I did incisional drainage on one man who came with a lacrimal cyst on his eyelid. Usually these water cysts do not recur after drainage.

Two new melanomas were in today's patients. One was on the lateral aspect of the right arm. The other lady had one on her upper forehead to the left of the midline. Both are elderly patients and both melanomas are early enough clinically that a cure is most likely.

A near middle aged lady had a epidermoid cyst on her left thigh that had been excised twice before (done elsewhere). These usually recur because part of the cyst lining was missed or because the duct of the affected oil gland was left in the skin. This one did not have a visible pore opening and appeared to have recurred because some of the lining was left behind. If the walls of these cysts are not too thin from inflammation and swelling, their sac will retain enough triamcinolone acetonide to cause atrophy of the cyst lining. I injected 8 mg. into the cavity of this cyst and will recheck it in three weeks. There was no leakage of the Kenalog IM through a pore opening and the cyst accommodated the o.2 ml of the Kenalog without rupturing. These recurrent cysts are invariably adherent to the surrounding old scar tissue and are difficult to dissect out surgically. Her chances of responding to the intralesional Kenalog injection are excellent. If at three weeks the cyst is big enough to still retain some Kenalog, a second injection may be added for complete destruction of it.

Wednesday March 08,2006

A long time patient who suffers from atopic dermatitis and contact dermatitis presented with an acute flare in her contact dermatitis. She had been separated from her husband for eight years and they are now back together. She states that this happens every time they are together. He wears an after shave lotion with a "heavy" scent and the patient thinks that is what she is allergic to. Often a patient knows what their problem is, and I will proceed on the assumption that she is correct.

Another long time patient came in with an acute flare of contact dermatitis due to Neomycin. Several years ago she had a 4+ reaction to a Neomycin patch. She was given a material data sheet at that time listing all of the common topicals on the market that contain Neomycin. A couple of weeks ago she suffered a laceration on the left wrist. Her attending physician had her use Neosporin and she failed to tell him of her allergy and failed to read the label. I gave her another material data sheet on Neomycin, and hopefully the second time around will prevent her from repeating this mistake.

A Native American asked about the post inflammatory hyperpigmentation on her legs. She had been shaving her legs and then applying an after shave lotion containing fragrance. On the sun exposed areas of skin, fragrances may cause this kind of reaction. Especially Oriental and Hispanic patients have a predisposition for this sort of thing to happen to them.

Thursday March 09, 2006

A Sergeant with plaque psoriasis complained that his condition was worse since he had returned to Dyess Air Force Base from six months in Kuwait. The sun suppresses the Langerhan cells in the skin which are the antigen presenting cells, and this is probably why he did better in Kuwait. The new immune modulators have taken away the doubt that psoriasis is an immune problem. This patient has had treatment for active tuberculosis and so far as I am concerned this is a contraindication for the use of these immune suppressors. Winter is about over and he should do satisfactorily on conventional therapy.

I prescribed Fluoroplex cream 1% for a gentleman with diffuse actinic keratoses across the forehead. After two weeks I will check him and do cryosurgery on the thickest lesions and continue the 5-FU through 21 days on the diffuse thinnest lesions.

A 4 year of age female patient, accompanied by her mother, had pityriasis alba. This was primarily on the arms. She had been to her pediatrician who had given her a cream costing "a hundred dollars" that had not helped' Neither had he given her a definite diagnosis. Most dermatologist think pityriasis alba is a form of atopy. I gave the patient a print out obtained from Bernie Ackerman's Derm101 Web Site and prescribed Vytone 1%.

A retired pharmacologist who has bilateral amputation of both lower extremities had been to the Wound Care Clinic at Hendrick Medical Center for a pressure sore on his left buttock. The sore had doubled in size since being treated by them. The pressure is caused by the way he slumps in his wheel chair that places pressure on the inner aspect of the buttock. A proper dough nut cushion was prescribed which will prevent him from being able to sit with pressure on the sore. Bactroban ointment and Doxycycline was prescribed and the ulcer measured. He will be rechecked in ten days.

Friday March 10, 2006

The low point of the week was temperature control going out on my main sterilizer. I am still waiting for the part to arrive.

A patient from Florida and one from California had needs as different as the geographical locations of their residences. The one from Los Angeles needed a cutaneous horn (a type of actinic keratosis) on his right upper eyelid. About 5% of these may be early cancer and this has to be considered in removing them.

The Florida patient has multiple college degrees, does not work, and spends his leisure on the beaches in the Miami area. He maintains a sun tan and due to his light skin type he is headed for multiple skin cancers in the future. He needed to be treated for plantar warts and for perianal warts. These warts are caused by a viral infection and are contagious in nature. Going barefooted around swimming pools is a favorite place to pick up a plantar wart infection. I prescribed him Condylox solution for the perianal warts.

A lady with a Hispanic sir name complained of a painful keloid across the upper mid chest. The is no ICD-9 code for a painful keloid, only for a keloid. Medicare and most insurance companies consider treating a keloid to be a cosmetic procedure and will deny payment. This keloid is hidden by the blouse and treatment is only necessary because of the acute pain that it causes. It was so tender that just palpating it made her rise up off of the examining table. She had had a painful keloid on the left arm that resulted from the healing of a laceration. It became painful and elsewhere it was excised, relieving the pain but much keloid tissue is still present. The keloid on her chest apparently originated from an acne cyst. I injected the length of it with Kenalog IM (triamcinolone acetonide) mixed with lidocaine and then infiltrated the deeper border of the keloid and subcutaneous tissue. Years ago I failed to inject this border of tissue, which makes a world of difference in the outcome.

The last patient was referred by a physician in small town for a dermatitis on the dorsum of the left hand. History revealed that he had a small spot the description of which fit that of an irritated actinic keratosis. The patient applied Solarcaine (from over the counter) and with in a week the entire back of his hand was red, oozing, and pruritic. From there the rash moved up the forearm to midforeman level. This is a relatively common condition where an over the counter medication causes a moderately severe contact dermatitis.

Monday March 13, 2006

A man, who originally had a bad experience with an ophthalmologist's removal of his eyelid lesions and who had a good experience in my office several years ago, returned with two early lesions on his eyelid margins. These were treated cryosurgically and he will have excellent results.

The second patient was the daughter of a high school classmate of mine who graduated with me from Uvalde High School in 1941. He died a few years ago from cancer shortly after I saw him at our fifty years class reunion. This is the first time that I have seen his daughter as a patient. She brought me up to date on Uvalde. It has been many years since I've been back there.

A multiple skin cancer patient from Oklahoma that I saw two or three weeks ago returned. He has done well and is happy with the results.

Dermatitis herpetiformis was among the skin rashes referred today. I placed him on a gluten free diet and went over what he needed to do in detail. I am certain that he will do better.

The last patient was a lady whom I have known since the days when we both were more active in the Republican Party. She wanted to know what I thought about the President. I think she represents a fairly large segment of the Republican Party base that is somewhat disappointed in the way the leadership is taking the Party away from its fundamental precepts of smaller government, not more government to carry on our backs.

Tuesday March 14, 2006

A patient of more than fifty years sent a check to pay his bill of $20.88. The check was made out to me for $660020.88. He was referred to me first by the secretary of the attorney who was his legal guardian. She and many of her family were patients at the time and still are. The patient was in his early twenties then. His parents had been killed in an automobile accident. He had an older sister who was an opera singer in New York. Because his behavior was somewhat foolish in appearance to some, she succeeded in placing him under the permanent guardianship of this attorney who was milking his estate. Also she successfully gained inheritance to the front half of their big West Texas ranch. That included the house and all of the fertile land. He was given the rough back half of the ranch that was so poor that one cow needed 30 to 40 acres for grazing. The irony of the situation was that this more or less worthless land for ranching or farming extended into the Permian Basin oil field, and when he became my patient he was wealthy.

At the time he cried on my shoulder and inquired to me if I could advise him how to keep his attorney guardian from milking his estate. I advised him to marry the attorney's secretary, which he did within a few months. This got him out from under his guardianship and thereafter his wife was able to manage his estate. They have remained happily married now for fifty years.

I phoned him about the check. He said, "I'll be right down." When he arrived, he laughed and said, "I leaned on my check writer, and never looked at the check. Shred it and I will write you another." This is how my short term riches ended.

Wednesday March 15, 2006

A former WWII fighter pilot came for angioedema of the lips. This has happened several times, but this is the first time he has sought medical help. By the time he arrived at the office, the symptoms had almost completely subsided. He is on no medications and a review of systems for symptoms is negative. This is no doubt an acute allergic reaction. The cause effect relationship is usually brief and a diet diary may or may not be of help. Most patient fail in an attempt to keep an accurate diary of the food they have eaten. Because of the fairly quick onset of symptoms after eating the offending food, I usually ask the patient to write down everything they ate at their last meal and anything eaten after that time. Peanuts are a common cause and this patient had eaten peanuts when this happened.

The pilot from Florida that I started on 1% Fluoroplex for his diffuse actinic keratoses 25 days ago returned with a diffuse reaction that reminded me why this treatment to used for selective patients. It's not for everybody. The results are good and there are three areas that probably would have scarred if I had given him the 5% Efudex that many use. These three areas were treated with cryosurgery.

A gentlemen in his nineties and whose wife was for many years won the ladies club championship in golf at the Abilene Country Club needed some early actinic keratoses treated. He takes aspirin only, not that doctors have not tried to persuade him otherwise. I find this to be true of many who are past eighty that are alert and doing well. They don't take all of the many medicines that doctors push their way. He named a doctor who insisted he take an antihypertensive medication, but states that his blood pressure remains at 110/70 without medication. Also he has a regular heart beat and a regular pulse. What a sad commentary on modern medicine!

A new patient who has been under the care of a fellow dermatologist presented with four huge basal cell carcinomas. One on his right leg, one on his chest, one on his mid dorsal area and two running together on the left side of his nose. He told me how many thousands of dollars he had been charged and he had given the physician a year to help before leaving his care. I treated the 5 inch in diameter basal carcinoma on his back with cryosurgery. The large tumors of this nature can not be treated cryosurgically without adaptation of the situation to the equipment at hand. The typical cryosurgical unit can not cool the tissue to a low enough temperature over this large of an area. The unit can cool a limited area adequately. The lesion can be divided into overlaping parts and treated successfully.

A 3 1/2 year of age girl was referred for molluscum contagiosum. At this age, Aldara cream may be the best treatment. The usual treatments induce too much pain.

Thursday March 16, 2006

A new patient and an 87 year of age former Navy Retiree talked about serving on submarines during WWII. He was on a submarine at the time of the Pearl Harbor attack by the Japanese. Also he is the second reliable witness with first hand knowledge that has testified to me that the top brass both at Pearl Harbor and in Washington, and the President knew the attack was coming. He stated that the Navy (submarines) had sighted and followed the Japanese Fleet across the North Pacific and that this information was properly relayed to the top.

The other witness that gave me a first hand account of his knowledge was the Army ranking full colonel at the end of WWII. He had the distinction of being the only Officer in the Army who served the duration of WWII without a promotion. When I was one of the pilots for the African Middle East Headquarters Flight, I flew him on a number of missions to air bases throughout the Middle East and spent time with him in the Officers Mess Halls and Officers Clubs. On the morning of the attack, the Admiral and the General went to play golf and left the colonel in charge. He stated that for the three days leading up to the attack several telegrams were sent to and from Washington and specific orders from Washington were given for them to carry out no military action until war was declared. Being a graduate of West Point, he followed orders even though it was against his personal conscience. These men apparently found it in their best self interest not testify to these facts during the investigative committee hearings after the War. I can only state what these two reliable witnesses have testified to me.

An interesting patient was referred from Dyess Air Force Base with a tentative diagnosis of acanthosis nigricans made by a pathologist on the basis of a biopsy that he was told came from the patient's axilla. On examination I learned that the biopsy was taken from the posterior margin of the posterior axillary fold. For a pathologist to make an accurate diagnosis it is essential that good information is given along with the tissue sample. The distribution of the rash was that of clothing contact dermatitis where the perspiration of the axillae wash out the dyes in the clothing onto the skin surrounding the axillae. The armpits or apex of the axillae are exempt and free of rash, as was the case in this Airman. In Acanthosis Nigricans the axillae are usually broken out in a dark rash. It is a hyperpigmentation rash that may affect other areas as well. This patient has no hyperpigmentation. He is scheduled for patch testing to determine if the black T-shirts that he wears may be causing the rash. Dark blue and black clothing contain paraphenylene diamine dyes that are common causes of contact dermatitis.

An adult female acne patient returned for refills on Spirinolactone 100 mg per day that has completely arrested her acne.

Friday March 17, 2006

The first patient came in upset because his primary care physician tried to freeze off some "cancers" on his back. The patient refused to let him do it and came to me. He had a few small benign asymptomatic lesions of seborrheic kerstoses. Medicare will not pay for taking these off unless they are irritated or persistently pruritic. He needed nothing except reassurance.

A lady and also a male patient had severe seborrheic dermatitis of the scalp and face. Both had cheek erythema. The man had responded to treatment with Nizoral cream topically before and he needed a new prescription. The lady also needs to have tests to rule out systemic lupus erythematosis due to the severity and distribution of her rash.

I used a small cone to limit the freeze on an inner canthus lesion (seborrheic keratosis) that was pruritic and irritated from the patient repeatedly rubbing it. This is a superior treatment for these lesions when in this location.

A dermatofibroma (histiocytoma) was causing pain and tenderness on the arm of one patient. I treated this with cryosurgery. For some unknown reason excision of these often results in a greater than usual scar. In my opinion cryosurgery does better on a vast majority of these.

Patients usually seem surprised when they come for what they think are insect bites on the outside skin and are told that they have a cluster of fever blisters. This lady had a cluster her left buttock that had reappeared periodically. Fever blisters on the outside skin are relatively common.

The last patient today was recently placed on four medications and there was severe interactions between them. The Genelex Drug Interaction Software revealed that he was taking a 150% overdose on two of the medicines. These were prescribed by doctors with the highest reputations of any in town. He was complaining that he slept all of the time and had lost all of his strength. He came for ankle swelling that was beginning to affect the skin over his ankles and distal parts of his legs. I wonder how many patients are unknowingly killed by doctors in this country each year and how many billions of dollars are wasted on medicines because the drug interactions either nullify the medicine or the medicine could be dramatically reduced in dosage when the interaction causes an increase in the blood stream concentration of it. How long will it take us to wake up?

Monday March 20, 2006

It rained a little over two inches over the weekend. A close inspection showed no evidences of roof leaks in the new roof on the office building.

I suppose I could call this coaches day. When they grow old, football and track coaches can expect joint problems, especially knee joint problems, and multiple actinic keratoses and skin cancers. The patients today substantiate this impression. Abilene is a college town and a sports town. There are plenty of old coaches here.

Tuesday March 21, 2001

The first day of spring is a winter day and the weather is forecast to remain winter like for the next few days.

I started this blog on Nov 2, Daniel Boone's birthday and my birthday. I am a fifth generation descendent of a first cousin to Daniel Boone's mother, Sarah Morgan.

On the last patient today, I excised a melanoma from the forehead of an elderly lady. The melanoma is thin enough that she should be cured, but like all melanoma patients she is now a candidate for periodic check ups every three or four months for the rest of her life.

Another rash from Benadryl cream used on a forearm lesion of actinic keratosis was found on an early retiree.

One young man had a papulosquamous rash with associated hyperpigmentation to the the area of the face lateral to the outer canthus. There is some acne rash in this area and hopefully it is only postinflammatory hyperpigmentation. I prescribed 20% azelic acid cream and will recheck this area before three months are up.

Wednesday March 22, 2006

It's been cold and cloudy here all day.

Several patients came from out of town and the patient with the last appointment rescheduled due to car trouble.

An 88 year of age female patient was brought in from a nursing home for an acute generalized rash. A week ago the nurse practitioner added Singulair and Librax to the six other medicines she was already taking. By the third day she was red, swollen and itching all over. According to the Genelex Drug Interaction Software Program, these two new mediations were in the toxic range when given with the patient's other medicines. Both new medicines had been stopped since Monday. The patient was beginning to improve. I sent a print out of the Drug Interaction Report to the nurse practitioner.

These drug interactions are due to conflicts in the use of the Cytochrome P-450 enzymes in the liver that break down the drugs into water soluble metabolites for excretion. When there are conflicts, the drug can not be broken down at the usual rate and it accumulates in the body tissues, resulting in overdosing. In this patient the overdoses came up in red back ground because of their severity. What a waste of money and harm to the patient it was to give this 88 year of age patient Librax and Singulair on top of her other medicines!

Thursday March23, 2006

This was an uncommon day in that four patients waited until the last minute to call in sick and reschedule their appointments. The cold weather probably contributed to their rescheduling, especially among the wheel chair patients.

The airman that was in Monday for patch testing for possible paraphenylenediamine rash from his clothing sure enough did have a positive patch test today to this chemical, a dark blue dye for clothing. The biopsy report suggesting acanthosis nigricans I think is one of those situations when the pathologist was not given enough accurate clinical information and was at a disadvantage.

Three patients came in with drug reactions. All were on multiple medications. Two proved to have moderately severe drug interactions and one had a severe drug interaction.

I prefer to do surgical dermatology and never intended to get into the drug interaction phase of dermatology as much as I have. The need for someone to do this is astronomical locally and apparently so for the entire nation. The problem is so rampant that it can be said that medicine is in true shambles in the USA. I would offer an off hand guess that approximately 50% of the patients over 65 years of age who are on multiple medicines are suffering from moderately severe to severe drug interactions. Most patients that I see in this age group are on multiple medications, in fact nearly all of them.

Friday March 24, 2006

This week's highlight goes to the Dyess physician who referred the airman with the clothing rash. He referred him for a dermatology consultation because he was willing to challenge the diagnosis of a superior officer. My hat goes off to him. The final diagnosis is clothing allergy rash due to p-phenylenediamine dye and not acanthosis nigricans as reported by the pathologist. The patient is rapidly improving after discarding the offending clothing. The distribution of the rash was the chief criteria for questioning the diagnosis and the key factor in reaching the correct diagnosis.

A new patient age 47 presented with plaque psoriasis. Last week I read a report on plaque psoriasis responding to condroitin and will try this in addition to conventional treatment.

Monday March 27, 2006

The Monday last minute schedule shuffle continues. This is expected to happen but to a less extent that what it has been doing the last few Mondays.

One male patient complained of a pruritic rash with blisters in the perianal area. Upon examination he had an erythematous eczema with small vesicles. By history this started a day or two after he purchased some flowery colored toilet tissue that was scented. His wife had gone for a family visit and he assumed her job of grocery shopping for one time. He said she always bought white unscented tissue. He may be allergic to the coloring, the formaldehye, or the fragrance. The more expensive toilet tissue that is more difficult to tear contains more formaldehyde than the cheaper tissue. If worse comes to worse he can be checked with patch tests, but this probably won't be necessary.

Tuesday March 28, 2006

A 92 year of age male came for a hypertrophic erythematous actinic keratosis on the rim of his ear. Since I last saw him, he had a fracture of the right hip. Now his right foot points out to right like a left handed golfer at address over the golf ball. I have empathy for him because I have suffered for the past eleven years with my right foot pointing to the transmission when I am driving.

The second patient also was seen for a few actinic keratoses. He was the first patient to which I prescribed 5-flurouricil to for actinic keratoses. This was in the late sixties when I learned from Dr Dilliha how to have a 1% solution compounded in propylene glycol by the pharmacist. This was before Efudex and Fluroplex were on the market. This was based on Dr Dillaha's original research as head of the Dermatology Department at the University of Arkansas Medical School in Little Rock. He established that !% gave the best results on the face. I prefer the compounded solution to the ones marketed by companies except for the cost. The pharmacist has to charge for the entire ampoule of 5-FU to compound one prescription.

One lady suffered from skin erythema and pruritus (itching) for the past two weeks. The skin changes took place within a few days after her attending physician placed her on a strict diet for lowering her blood lipids. Her history was positive for carotid artery surgery for a stenotic plaque in it, and she was religious about following this new diet. She was consuming large amounts of cinnamon to flavor what would be a somewhat tasteless diet otherwise. I suspect this may be a factor since cinnamon is a common allergen. Like many on a similar diet, she was not eating salads with dressings containing high yeast content, but was using cottage cheese as a salad dressing. Yeasts are a common cause of rashes. She was not given any medications by her attending physician and I could elicit no history of taking herbal medications. She wanted to start with elimination of cinnamon and by going on a hypoallergenic bath program and a hypoallergenic laundry program.

Wednesday March 29, 2006

Patients had an interesting array of needs today.

One lady returned who had an epidermoid cyst injected on her leg three weeks ago. The cyst was approximately 3 cm. in diameter and had been surgically excised three times elsewhere. She did not want it cut on again, and I consented to inject it with Kenalog. Today the cyst is approximately half as large as it was 3 weeks ago. I was able to injected 10 mg of Kenalog in it today without it leaking out the pore. I asked her to return in 4 weeks.

The next patient was undergoing a divorce. It seems that his wife is divorcing him and blaming him for their young child's perianal warts. His wife was falsely claiming that he had genital warts and had given them to the child. The patient's lawyer asked him to obtain a statement from a dermatologist showing that the patient was free of warts so that he could file for child custody. According to the patient a third party friend of his wife was involved. Anyway the patient had no skin disease and had no evidence of any recent procedures done on his skin.

An elderly lady needed an interaction profile run on her medications. Recently an antidepressant had been added to her list of medicines. She took one of the pills and went to the grocery store. On entering the driveway back at her house, she ran over the gas meter and spewed gas into the air. She had a presence of mind, turned of the ignition on her automobile and called 911. Luckily no fire or explosion occurred. The antidepressant interacts with her blood pressure medicines, causing an overdose on the blood pressure medication. She was so advised.

The usual needs for skin cancers, keratoses, nevi, and insect bites were seen and rounded out the day.

Thursday March30, 2006

The pain that was caused by an ingrown toe nail kept one of my patients awake last night. Under nerve block anesthesia I removed the lateral 1/6 of the great toe nail and its matrix.

One postoperative examination was for a spindle cell carcinoma. These cancers often have a greater tendency to recur than do basal cell and squamous cell carcinomas. This patient is doing well.

The other patients were all for basal cell carcinoma except for one squamous cell carcinoma in situ and one keratoacanthoma.

One of the patients last week, who was having a toxic dose on her blood pressure medicine because of drug interactions came by to leave word that after reducing her blood pressure to half her previous dose she no longer has the bad symptoms. I can not help but wonder if the many patients who come to see me while in good health and then I hear about them suffering sudden deaths are victims of medication interactions. I do know I have had a greater number of patients suffer sudden deaths since about 1990 than before then when fewer combinations of medications were being prescribed.

Friday March 31, 2006

Three people came in for scars today, two from elsewhere and one post cryosurgical mildly hyperthropic scar that has spontaneously resolved by three months post operatively. This was from destruction of a basal cell carcinoma on the tip of the nose. The patient was pleased with what is a good cosmetic results.

One of the others was a post operative scar from surgical excision of a dermatofibroma. It has been my experience that the tissue in the neighborhood of these tumors are predisposed to scar formation. The other side of this story is that the tissue was first sent a general pathologist who diagnosed it as a fibrosarcoma. Her doctor requested a path consult with a dermatopathologist. A consultation was obtained from the head pathologist at DermPath in Dallas. He made a diagnosis of dermatofibroma (histiocytoma), a benign lesion. I know of one color blind pathologist and I am uncertain as to how much being colorblind puts a pathologist at a disadvantage.

The third patient with a scar has a true keloid that developed from an acne lesion on the upper anterior chest. I saw her three weeks ago and injected the keloid with triamcinolone acetonide. Today the scar was no longer painful and was much softer and thinner. I reinjected it again and will wait 4 weeks to re-evaluate it.

Early last week I excised a melanoma in situ from the forehead of a lady, taking the usual 0.5 cm. margin for an insitu melanoma. The path report came back showing the lesion extending to one lateral margin of the excised specimen. I can count on the fingers of one hand where microscopically the lesion extended this much past the visible margin of melanomas insitu that I have excised. This patient is very understanding.

The 97 year of age man who had a rather severe allergic vasculitis in his legs that was caused by his blood pressure medicine returned for a general skin check up today. He is now taking no medicine and his blood pressure has remained on the low side of normal. His rash subided. Importantly he is no longer listless and fatigued, but is very bright eyed and lively even for a man 20 years younger.

Monday April 3, 2006

Today ran more smoothly than Monday usually runs.

One interesting patient was a 49 year of age female with chondrodermatitis nodularis helicis. On palpation of her ears the cartilage was most firm. This is unusual at this age. I did not have the courage to ask for age verification. Maybe that is bad medicine, since age is one of the most important components needed for diagnostic medicine. But there are those who prematurely age in different ways.

The patient that was in a little over three weeks ago who had had an early (small) basal cell carcinoma surgically excised from his right lower eyelid by an eye doctor who specializes in eyelid surgery was seen. He had a bad inversion of the eyelashes that remain, and complains that it feels like he has a hair in his eye all the time. I have never had this complication on any patient on which I treated cryosurgically for basal cell carcinoma of the eyelid.

Tuesday April 4, 2006

The first patient was a pilot from Michigan for an FAA Flight Physical. He is a healthy young man who is doing well.

A 34 year of age Air Force Major came for a basal cell carcinoma on his left forehead. He had a previous basal cell carcinoma removed from his left temple a year or more ago. To have had two basal cell carcinomas by age 34 is not common. He has had altitude sun exposure as well as desert sun exposure.

An English lady who married a WWII soldier during WWII and who has been living in Abilene since then is now truly Americanized. Many years ago I first saw her as a patient. Then I had to listen closely to understand her English accent. Listening to her today I would never have guessed she is not a native American.

Wednesday April 5, 2006

With the change of time to day light savings time, patients are going into short sleeves and shorts due to the longer daylight hours in the evenings. Everyone seen to today was in the category of skin blemishes that show when wearing swimming suits, short sleeves, or shorts. These blemishes ranged from various nevi, including dysplastic nevi, actinic and seborrheic keratoses, warts, squamous and basal cell carcinomas, and one keratoacanthoma.

The only exception was a flight physical and this also is the time of year that I do more of these due to the increased time to take flying lessons in the evenings after work. These physicals are required every one or two calendar years depending upon the type of certificate sought. Once a student starts in the spring, he or she continue to come back on the calender date that their old medical expires.

Thursday April 6, 2006

With Easter coming up everyone seems to want to be more Christ-like, i.e., they want to be without spot or blemish.

Baptizo is a Greek medical word. The suffix means to change and the stem means to submerge in dye. So when a tissue is fixed on a slide and submerged in dye and washed clean, the color of the tissue is changed. Baptism literally means washing away the black blemishes of sins and dyeing the spiritual body snow white without spot or blemish. Thus by definition, baptism is necessary.

The first patient today had multiple abrasions received in a motor cycle accident. A driver ran a red light in front of him and he laid his motor cycle on its side to stop. He was fortunate to only end up with multiple abrasions. His helmet saved him from a probable head injury, when the helmet hit the pavement hard enough to make a big hole in it.

One lady had three angiomas that were symptomatic from her belt rubbing on them. These are least expensively removed by compressing and elevating them during the cryosurgery procedure. The compression stops the blood flow and the compression and elevation reduces the necessary depth of freeze. Cosmetic results are equal or superior to that of laser removal and time and cost saved is big.

An elderly lady presented with a pruritic darkened area on the anterior of her right thigh. The hair in the area is black and the hair around it is gray. This is probably a birthmark that she never noticed until the dry skin of aging began to cause itching, with the congenital nevus becoming drier than the surrounding skin. She declined biopsy, but I suspect she will consent sooner or later.

Friday April 07, 2006

A bad dust storm blew in late yesterday afternoon, and today one patient called in and changed her appointment due to an acute episode of hayfever.

Today the wind is blowing with faster gusts than yesterday and without the dust.

One lady was seen a few days ago for what I diagnosed as a fixed drug rash. She did not have a list of the medications she was taking and brought that in this morning. A few days before the rash onset, her attending physician added Bactrim (a sulfa drug) to her medications for a bladder condition. Due to the type of bladder problem she had, she was advised to stay on the Bactrim for a year.

She was also taking warfarin. A fixed drug rash may be caused from sulfa drugs as well as from warfarin. The Bactrim causes a major increase in the warfarin dose and the warfarin causes a 75=100% increase in the sulfa drug dose. The major increase (over 150%) in the warfarin dose is dangerous and the cause of the fixed drug rash may be the suddenly increased warfarin dose. She had a stroke in the past and her physician does not want to take her off of the warfarin. Substituting another medication for her Bactrim, should reduce the warfarin dose below the danger zone and hopefully the fixed drug eruption will disappear. This was left up to her attending physician.

Monday April 10, 2006

Today started and ended busily. A Fed Ex pilot came for his annual physical and we got to talking about the icing problems their airplanes have had. Next was a man with allergies to cat hair, greenish black mold, and dust mites, all plus 4 titers. This was followed by a man with an ingrown toenail. Then a couple of patients with skin cancers followed by a patient with a melanoma and dysplastic nevi. This was followed by a series of patients with skin cancers and sandwiched in between these were patients with atopic dermatitis, nickel allergy, and warts. Finally two patients came with acute contact dermatitis and the last patient was a young man on which I excised a basal cell carcinoma on his forehead.

In today's mail Stan K in Washington DC mailed me an unsolicited book on mathematics ignorance in this country along with a personal "Thank You". I have no idea who Stan is, but the book introduction is most interesting and the book appears to be most informative.

Tuesday April 11, 2006

Today was much like yesterday except all of the patients were long time patients. Yesterday there were new patients and several relatively new patients.

One elderly lady came for cryosurgical removal of hypertrophic and erythematous lesions of actinic keratoses on the dorsum of her right hand. She is an interesting patient because she is going on a twenty two year complete remission for severe generalized plaque psoriasis. Her psoriasis completely remitted after treatment 25 years ago with twice weekly injections of allergenic doses of influenza virus vaccine over a period of three years. She is one of several dozen patients that I have who have experienced long term remissions. I know of no other treatments, including the new immune modulators, that tend to give sustained remissions in a majority of psoriasis patients. Because the dose required varies with the seasons of the year and with other variable health factors of the patient, I generally do not prescribe this treatment for patients who can not be followed closely. I now have only two patients with psoriasis who live more than one hundred miles away who are faithful to keep their return appointments. Both are doing well, but if they lived closer I probably could see them more often and manipulate their treatment to obtain a complete remission. After many years of treating psoriasis patients, I find it is a mistake to try to treat a psoriasis patient who lives very far away.

Wednesday April 12,2006

A 56 year of age lady, whom I last treated when she was a teenager, came for an angioma on her left arm that was located where the edge of the short sleeve of her blouse irritated it. This was an elevated angioma of 15 mm in diameter and was amendable to cryosurgical destruction using compression and elevation of the lesion during the freezing process. She will obtain excellent results comparable to the best laser results at a fraction of the cost.

Thursday April 13, 2006

The March issue of Journal Watch Dermatology (Vol. 14 No.3) from the publishers of The New England Journal of Medicine on page 18 has an article from Arch Intern Med 2006 Feb 13; 166:338-44 that confirms what I have been saying about medicine in this diary. They report that "the Institute of Medicine's Committee on Quality of Health Care in America has determined that current medical practice is unsafe. In a large measure, the danger can be attributed to drug-drug interactions, poor monitoring of drugs, and provision of drugs contraindicated for a patient's medical condition."

This is what I am finding to be true in my dermatology practice. Today I ran a patient's medicine list through the Drug Interaction Software Program by Genelex, and there was zero interactions on the ten medicines that her internist had prescribed. This particular internist is the only one in our area whose patients come in with their list of medications and I consistently find no interactions among them. Also his patients seldom come because of a medication rash. Hopefully the pendulum is swinging away from the indiscriminate prescribing of combinations of expensive medicines that often harm the patient.

The first patient today was for treatment of actinic keratoses. She had breast cancer in the late sixties. Her breast cancer was discovered by palpation of the breast and could not be seen by mammography. Mammography has improved since then, but the point is that there is no substitute for a medical history and physical examination. Today the physicians that I have personally seen for my troubles go with scant histories and physical examinations and heavy on diagnostic tests. This trend marches on.

An adult acne patient, whom I would have placed on Accutane before the i-Pledge program, I placed on flutamide 125 mg per day. At this low dose the liver function tests should remain normal and the dose still be high enough to take care of the acne.

Closed for Easter Week End!

Tuesday April 18,2006

The wind felt scorching hot the last two days. Yesterday all the way from Seymour, Texas, to Abilene, my car thermometer registered 101 degrees F. The official T was 99, but the black top on the highway I am sure made that much difference.

This kind of weather is good for Vitamin D formation and recent studies reveal that is good for prevention of gastrointestinal cancers.

One lady came to have a 16 mm in diameter squamous cell carcinoma treated on the vertex of the scalp. She is elderly and on elderly patients it is not uncommon for surgery wounds to slough and not heal in this location. Therefor I choose to treat most of these cryosurgically, which I did today. Some cryosurgeons do not treat scalp cancers because of a less predictable results on these. Probably the two most important things to remember is that the scalp skin is thicker than other locations and that the scalp is very vascular. Scalp cancers not only take longer to freeze which is a detriment to a cure, but they thaw faster which is also a detriment to a cure. A larger aperture on the freeze unit helps to overcome the first problem. Watching the lesion thaw and watching for vascular hot spots that thaw faster than usual is the other thing that is helpful. That area of the lesion can be taken to a colder temperature with the larger aperture on a repeated freeze to produce the fast freeze and slow thaw time that is sought.

The hot weather also brought in one of my nickel allergy patients. The nickel in metal is nickel sulfate which does not cause the nickel rash. It is the sweat (perspiration) that furnishes the sodium chloride that converts the nickel sulfate to nickel chloride and the by product of inactive sodium sulfate. It is the nickel chloride that causes the rash.

Wednesday April 19, 2006

Today was one of those days when a number of patients seen are either famous or have family members who are. For example, one was the sister-in-law of a past Texas governor. Another had a well known band that played for a number of years on the strip in Las Vegas. There are other days that I see migrant workers who have little more than a shirt on their backs. The first half of practicing medicine is seeing the patients as people in the real world and helping them with their needs. The other half is medicine itself. Anymore the third half is taking care of all the load that the government hangs on our backs. The latter is what has impinged upon the first half named above.

A man presented with an erythematous nodule of 4 mm in diameter that had been present for two months. A month ago, his brother in San Diego, Calif., was diagnosed with Merkel cell carcinoma. This patient was concerned that he also may have this type cancer. Now we are waiting for the report from Derm Path in Dallas to give us the final diagnosis.

Thursday April 20, 2006

It has been thundering all around for the past 21 hours. It rained 1 inch last night and less than that through the day.

Usually when the weather is this stormy, the out of town patients cancel. This did not happen and the first was from Waco and the last patient today was from Arlington. In between was a farmer from elsewhere who set out 400 tomato plants in his 3 acre truck garden. To do this he had to get down on his hands and knees. He is past 80 years of age and and won't give up in spite of his stiffness from osteoarthritis.

One patient visit was for a preoperative evaluation of a melanoma that is scheduled for excision next week.

Friday April 21, 2006

The first patient was a postoperative examination on a male patient on whom I removed a basal cell carcinoma from his eyelid in January. The eyelid functioned perfectly and there is no distortion of the eyelid or eyelid margins. In fact, to find the operative site, I had to refer back to the drawing done in January. Excellent results on eyelid cancers are obtained by cryosurgically removing most of them. Even though such is reported in the cryosurgical literature, this is not general information among the medical communities as a whole.

The second patient was a two week postoperative patient who had two basal cell carcinomas on her face that were removed cryosurgically. She had been using Neosporin ointment on both operative sites and has a large area of pruritic erythema around each. This is a reaction to the Neomycin in the Neosporin, a fairly common cause of contact dermatitis. I gave her samples of Bactriban cream and Topicort-LP cream and discontinued the Neosporin.

The third patient seen was a 9 year of age boy brought in by his mother. The complaint was that of an rash on the anteriormedial aspects of the lower extremities. The rash was first noticed a day after he played in a field around a feed lot. This was 8 days ago and the rash is beginning to fade. The distribution of the rash is where his legs and knees pushed against the weeds as he walked and ran through them. This appears to be an irritation rash rather than an allergic contact dermatitis. He probably does not need any treatment. I advised the mother to use over the counter (OTC) 1% hydrocortisone cream, hoping that the inflammation will clear a little more rapidly.

The fourth patient had actinic keratoses that needed to be removed, but rosacea was the problem that caused him to make the appointment. He is allergic to sulfa drug, so I prescribed Metrogel 0.75% rather than sulfacetamide lotion 10% topically.

Later in the day a psoriasis patient came for a routine check. He stated that he went to the ER last night due to abdominal pain. One reviewing his symptoms he had an acute gastrointestinal upset, probably from bad food due to the time interval of onset after eating his evening meal. The sad part of the story is this: The ER doctor never palpated his abdomen nor did he listen to the peristalsis with a stethoscope. The doctor did order X-rays and scans on his colon all at a great expense to Medicare. He did talk to the patient and told him the studies did not show anything. This is what I call a Door Knob Doctor. Door Knob Doctors are the ones who are allergic to laying a hand on a patient and are one of the reasons for some of the high costs in medicine.

Monday April 24, 2006

Monday can be hectic. This one was.

It started with a 13 year of age boy who has a solid tumor as hard as a rock that was on the scalp and a nontender enlarged lymph node behind the ear below the tumor. The primary tumor measured 3.5 cm. in diameter and the skin over it is erythematous. I did a punch biopsy including tumor and skin in the biopsy. This one is scary.

Two patients had melanomas and one had a severe medication rash probably associated with Pacacerone. She is from elsewhere and promised to phone in a complete list of her medications as soon as she returned to her home.

Because I review problems of pilots who have coronary artery disease in doing flight physical for the FAA, a retired physician who had been scheduled for heart surgery brought in a DVD of his angiogram for me to review. He has a single blockage of one coronary artery with excellent collateral circulation. In my experience as well as hearing many lectures on this subject from FAA cardiologist, I know that a single stent or bypass surgery with excellent collateral circulation usually stops up soon after surgery.
This physician also knows this and wanted me to recommend an honest cardiologist, which I was able to do after watching the angiogram to be certain of not misguiding him.

Nothing happened that was any worse, and not much happened that could be called any better.

Tuesday April25, 2006

Today started off with an uncomplicated FAA flight physical, but the second patient was a severe NSAID medication rash. Any of the nonsteroidal anti-inflammatory medications such as Advil not infrequently cause exfoliative dermatitis and even Steven-Johnson Syndrome (where the skin blisters and sheds). If these rashes are not treated early, death can and does sometimes results.

Then a melanoma patient was followed by a patient with a larger then usual keratoacanthoma.

One patient of interest was a lady with onychomycosis of the great toe nail. Because of liver problems she could not take Sporanox or Lamisil orally. I prescribed topical 2% Efudex to apply twice daily. Today the proximal half of the nail appears to be normal and the distal half is thinner with less build up under it than when the medication was started. As previsously stated, this is a non labeled use for this medication. It appears to work at about the same rate of speed and with the same results as oral Lamisil, but I do not have enough patients that I have treated this way to be statistically significant. I do believe that 5% Efudex works faster than 2% but the 5% does cause a little irritation in some patients.

The last two patients had multiple basal cell carcinomas, which would take forever to treat them all if it were not for cryosurgical removal or electrocautery. The latter I do not use because the cure rate does not favorably compare with cryosurgery.

Wednesday April 26, 2006

The schedule ran smoothly, the smoothest since Easter.

The first patient, a patient forever, and I visited about our Uvalde High School Days before WWII. One of our class mates who did not seem to be too bright in high school is now a multimillionaire with a business known by all if I mentioned it.

The pathology report came back on the patient whose brother has Merkel cell carcinoma. His erythematous nodule was simply an inflammatory reaction. Of course he was excited to learn that he did not have a Merkel cell carcinoma as does his brother.

One patient with a granuloma annulare to whom I had prescribed betamethasone proprionate ointment returned. The granuloma annulare had responded to this treatment, and he will not need to have it injected with triamcinolone acetonide or have it frozen.

A patient on acyclovir for genital herpes is responding to this preventive therapy. His acute episodes are getting further and further apart.

Thursday April 27, 2006

The breakroom stayed empty all day and the coffee pot was full at closing time.

Nothing new, just long hard work that required a great deal of twisting and bending like the dentist has to do when he does a root canal.

It amazes me when I see a new patient with psoriasis that has been under the care of a dermatologist who tries to blow smoke back down the chimney. That is what happens when trying to treat a patient with psoriasis when the patient is on a medicine that is known to aggravate psoriasis. A lady presented with plaque psoriasis who is from elsewhere and goes elsewhere to her internist and dermatologist. For several years she has been on blood pressure medicine that aggravates psoriasis, and for almost as long her dermatologist has been treating her first with methotrexate and then with Enbrel without success. Now he wants to treat her with Humira. To keep from trying to blow smoke back down the chimney, the first step is to work out a medication routine with her internist that does not aggravate psoriasis after which a treatment for psoriasis may have a chance to help.

All day today was replications of these sorts of problems. Hopefully the break room will not be for naught tomorrow.

Friday April 29, 2006

The hour is late and I would like to write about several patients of interest, but will limit it to one.

Dr Essary from Derm Path called to tell me that the 13 year of age boy with the lump on his head (biopsied last Monday) has a lymphoma. The lump grew from no one knowing it was there to about 3 or 3 1/2 centimeters in diameter in two months time. Within the last four weeks a lump was noticed behind the ear.

Derm Path is consulting with pathologists at Parkland Hospital to do special stains and to try to classify the tumor as to the type of hymphoma.

It rained this morning o.1 inch and again this evening and tonight a little over an inch.

Monday May 1, 2006

Last week was a sad week. Several melanomas and one lymphoma.

Busy today with more than average number of patients seen due to several patients with urgent needs.

Dermatology offers few true emergencies. One patient from DAFB is scheduled to be deployed and had to be worked in before he leaves in order to excise two dysplastic nevi that had been biopsied. Another had a painful skin infection on the foot.

An 85 year of age lady for whom I delivered several babies about 40 to 48 years ago came in with medication interactions due to the Pacerone that had been added to her other medications. The Pacerone is causing overdoses on three other medications. Also she is on Synthroid but has all of the signs and symptoms of continuing hypothyroidism. She may be one of those patients who does not convert T-4 (the only ingredient in Synthroid) to T-3. The Synthroid may need to be changed to Thyrolar or to Armour's Thyroid Extract USP in order to get the T-3. She was referred by a good physician, and hopefully the consult will help him straighten out her medications provided he will be able to work with the cardiologist that prescribed the Pacerone and some of the other medications that need doses adjusted.

Lots of skin cancers today and lots of skin cancer post operative visits.

Tuesday May 2, 2006

Electrical storms have abounded late today and tonight. Will not stay on computer.

Patients were procedural dermatology save three, a black rubber rash, psoriasis in an HIV patient, and scabies in a young boy. I may mention the psoriasis in HIV patients when it is not stormy.

Wednesday May 03, 2006

Psoriasis in an HIV patient may seem like a paradox. The reason for this is that patients who suffer from psoriasis almost invariably give a history of seldom suffering from upper respiratory tract infections, i. e. they give a history of seldom being sick. They tend to have a hyperimmune system. It is not so stated in the medical literature, but psoriasis may be thought of as a hyperimmune disease. All of the medications that help psoriasis the most are immunosuppressive medications such as the anti-rejection drugs (cyclosporine for example), methotrexate, chemotherapeutic drugs for cancer, and cortisone. Because HIV is immunosuppressive, I would expect HIV patients not to suffer from psoriasis. However, the drugs used to treat psoriasis do cause psoriasis and these patients do come down with psoriasis. In my practice they have been unpredictable in response to treatment.

This is the third consecutive day to see patients with melanomas. There were two today.

A man age 46 was referred for chrondrodermatitis nodularis helicis. Again this is a very young age for this condition.

The 13 year of age boy with the lymphoma went into Cook's Children Hospital in Dallas this morning. The pathology has been narrowed down to either lymphpblastic lymphoma or Burkitt's lymphoma. Special stains are being done and an addendum report is to follow. He was supposed to have the lymph node from behind his ear removed this morning so that flow cytometry studies could be done.

Thursday May 04,2006

A lady whose myxoid cyst of her left index finger I treated on 01/25/2006, returned for a followup visit. I am continuing to read current medical articles describing surgery for these myxoid cysts as if there is no other way to treat these. The myxoid cyst usually presents as a painful cyst between the distal interaphangeal joint the the base of the finger nail. These cysts are filled with a clear sticky mucoid fluid. Hand surgeons have done surgery on these for years and with a significant failure rate. That is the reason articles continue to appear in medical journals advocating an improved surgical method or technique for contending with these.

Actually these cyst all have a communication channel with the distal interphalangeal joint. The joint develops fluid in it due to arthritis. The joint space is tight and limited so that the fluid pressure pushes a herniation through the capsule of the joint and forms what appears to be a primary cyst that is external to the joint. By injecting the joint with triamcinolone acetonide which is a white colored liquid, the whit fluid can be seen to travel from the joint through the herniated joint capsule and into the cyst. I have never seen one of these where this is not true. A sufficient amount of triamcinolone acetonide reduces the fluid formation through its anti-inflammatory action and closes down the herniation. I have had the most consistent results injecting the joint and also injecting the capsule of the joint at exactly the point where the herniation occurs in the capsule.

The lady today with this condition had perfect results and there is absolutely no evidence that she ever had a myxoid cyst on the affected finger.

Another lady had a cluster of fever blisters on the flexor aspect of her right wrist. I have found that it is not knowledge among most people that fever blisters can and do occur on skin on any part of the body. This lady had been to her new and young family physician who missed the diagnosis and prescribed a treatment that only benefited the bottom line of the pharmacy where she filled her prescription.

Friday May 05, 2006,

A sad week but not as sad as last week a final diagnosis of lymphoblastic lymphoma in a boy age 13. He is now under the care of Dr Paul Bowman at Cook's Children Hospital in Dallas.

One of the highlights of the week was the return of my star patient from Dallas who a year and a half ago lost enough weight that his diabetes came completely under control without medications. His weight has stabalized and his blood sugar checks out consistently at 100.

A lady came for her 3 month postoperative check on the removal of a basal carcinoma of her eyelid. The eyelid has perfect function following the cryosurgical destruction of the carcinoma. It is impossible to overemphasize the the superiority of cryosurgical destruction of these cancers when found on the eyelid.

A 22 year of age patient was referred from DYAFB for Accutane for her acne. The dermatologists using the i-Pledge Program tell me that there is a five day skip in medication each month because of the red tape time between getting the pregnancy test and obtaining authorization to refill the prescription. I will not take part in this haphazard treatment program until it is corrected. I added spirinolactone and tarazotene to her Doxycycline with special instructions. Hopefully she will respond satisfactorily.

I excised a solid tumor 15 mm in diameter from the lateral margin of a man's upper eyelid today. So many times these subcuticular solid nodules in this area are metastatic cancers.

Monday May 08, 2006

A followup on a barely past middle aged lady who had multiple actinic keratoses on her legs and forearms for which I prescribed Efudex 5% twice daily for 21 days shows good results. She will have some discoloration (residual erythema) for several more weeks. The only problem was that she applied it to the antecubital area which reacted due to the moisture and not due to sun damage. It is the same erythematous reaction that 5-fluorouracil causes when it is applied to the corners of the mouth, the edges of the nares, or too close to the inner or outer canthus of the eyes.

A girl wearing a dental retainer came for a diffuse pruritic erythema of the entire lower lip. The retainer had been put in during December and the lip rash had been present since early January. Her peditrician had been treating her for herpes simplex and had prescribed every antiviral medication available for the treatment of herpes simplex. The problem is a contact dermatitis from the metal retainer. If the rash can not be controlled with topical midpotency corticosteroid cream, the retainer probably will have to be removed.

Two sisters who are time patients came from a distance for their yearly check up for sun damaged skin (actinic keratoses and skin cancers). These two are several years apart in age but sound so much alike that I have to be looking at them to tell which one is talking.

A man in his late eighties is coming in more often than needed for skin check ups for possible actinic keratoses. He recently lost his wife. He is going on a long trip to the Northeast and on into Canada with his daughter. Hopefully that will help him to recover somewhat from his lonesomeness.

A wonderful small lady in her mid nineties returned for a post operative examination for a squamous cell carcinoma on her scalp. In the elderly scalp surgery is somewhat like surgery below the mid calf. It does not always heal easily. This cancer was treated cryosurgically and the results are excellent with completely healed soft skin and soft scar where the cancer was.

Tuesday May 09,2006

The slowest day since Easter due to three no shows.

Wednesday May 10, 2006

For the past two weeks the schedule has been loaded with professional people and members of their families, including lawyers, medical doctors, and dentists. It is an honor to see fellow physicians who know medicine. On the other hand because they know medicine it is more difficult to persuade them to return for the needed and proper followup visits, especially after surgery. I suppose this is because they know enough to realize whether or not they are doing OK. In dermatology there is no substitute for early detection. It is seldom that a female patient comes too late with a skin cancer to effect an easy cure. Men do not fit this profile as a general rule.

A man with 28 mm in size basal carcinoma on his ear came and did not realize he had this skin cancer. I was able to treat this cancer with cryosurgery under local anesthesia. The skin at the edges of the tumor developed cracks on thawing which is common on hard freezing cancers of this size. These cracks tend to bleed and require procedures for hemostasis. This type situation is all too common in professional people. I guess I should say professional men.

A 20 year of age patient with acne had taken Accutane when she was age 14 and again at age 17. She is taking Lexepro, a selective seratonin reuptake inhibitor(SSRI), used in treating depression. Her expressions are flat. The Lexepro was prescribed not long after she took her last Accutane. Accutane has been reported to cause depression. If this patient's depression is related to Accutane, it is the first one that I have seen since Accutane came on the market many years ago.

Thursday May 11, 2006

A 43 year of age female was referred for inframammary fungus or yeast infection. The onset was 5 years ago. During that time she has been treated with every antifungal medication imaginable without response. No corticosteriods have been prescribed. She does take nonsedating antihistamines for allergies. Examination revealed a pruritic erythema along the lower elastic margin of the bra. I am doing patch tests on her to determine if this is a rubber contact dermatitis from the elastic in her bra. The is my impression.

An 85 year of age lady with an ischemic ulcer of her leg returned for a recheck visit. Her 83 year of age sister accompanied her. The sister is a registered nurse who was in the John Sealy Nursing School at the time I was in medical school at Galveston. John Sealy who donated funds to get the medical branch started in Galveston was the uncle to George Sealy, who was a class mate of mine at the one-teacher and one-room Leona Valley School in Uvalde County. George's parents lived in a mansion on the beach near the west end of the sea wall in Galveston. He had a huge play area in the basement of the home and was not allowed to play outdoors because his parents were afraid he would be kidnapped and held for ransom. George's grandparents owned the Pecan Plantation south of and adjacent to the Leona Valley School. He was sent there to school until he became old enough that his parents no longer feared that he would be kidnapped.

Friday May 12, 2006

Today I saw something that I had never seen before, but had read about it in the dermatology literature. An HIV patient complained of his toenails, which were covered with a white fungus. This white fungus is superficial and invades from the top side of the nail. It is seen in immunocompromised individuals. The oral antifungals are not suitable due to the medications immunocompromised patients need to take (have to take). The usual onychomycosis infection causes a yellow-brownish thickening of the nail beginning distally and builds up beneath the nail like the little critters shown in the Lamisil advertisements.

Another patient told a sad story. She had a nevus on her shoulder that was the deep reddish brown color on the edges that is seen often in melanoma and in addition had a small ulceration in the most suspicious appearing part of the nevus. A sadder part of the story is that she has a brother, age 50, who is a professor at a major state university in another state, and who did not seek medical help until his melanoma ulcerated and bled.

Another melanoma patient who has had two melanomas over three years complained of recent upper mid-chest intermittent pains of brief duration. I referred him to his internist and suggested a chest X-ray because of the history of melanomas. A yearly chest X-ray is the one lab test that has been said to be cost effective in following melanoma patients whose melanomas were less than 0.8 mm thick or maybe up to 1 mm thick. For thicker melanomas, other post treatment tests may be indicated.

Monday May 15,2006

A big heartbreaking finding on one patient was metastatic breast carcinoma in the skin. This patient has a barrel full of problems. She had a recent demise of her husband; has a 24 year of age daughter who is addicted to drugs; and breast cancer first in one breast and then three years later in the other breast. She had not seen her oncologist for three months and last saw her family physician for what he called eczema. He prescribed clobetasol propionate topical ointment. Since this ointment was not helping, she came from out of town to see a dermatologist, not liking her home town dermatologist. Examination reveals multiple coalescing erythematous 3 to 5 mm solid nodules in the skin on the superior anterior fold of the axilla and a diffuse erythematous thickened skin over the upper mid-breast area. Both skin lesion areas cut like cancer on biopsy. Often the first signs of breast cancer metastasis are lesions in the skin. This is most often in the area of the skin near the breast cancer sight. This patient did not receive irradiation treatments. If she does not have metastasis elsewhere, then this was a mistake in hindsight. Oncologists recently in this area have steered patients away from radiation. They all need to see this patient for their own educational benefit. This ladies skin would hit them like a sledge hammer between the eyes.

Follow up reports came in on the 12 1/2 (13) year of age boy with the non Hodgkins lymphoma (blastolymphoma) from the metroplex. Further studies fail to find leukemia, or other involvement other than the primary scalp lesion and the upper neck lesion. He has been started on appropriate chemotherapy. He has good bone marrow and good peripheral blood counts. There is hope for him.

It was a pleasure to do a flight physical on a newly commissioned second lieutenant in the Air Force who got his commission at Texas A & M.

Tuesday May 16, 2006

None seemed to come at their appointed time. Consequently the waiting room was continually overcrowded. I have always taken pride in running a schedule on time. By my giving this respect to the patients, they should respect the other patients and hold to the scheduled appointment time. Sometimes emergencies do prevent a timely schedule. A recovery can be made from one patient having such emergency. When they all abuse the schedule, then they all pay for it with their wasted time waiting. Maybe they plan to come and read magazines and visit. I hope this was the case today. Any way none complained about it.

One patient has an acute and extensive exfoliative dermatitis secondary to Grispeg prescribed by his internist. This is where the skin turns red all over and sheds like a snake skin. This patient gave a history of penicillin allergy. Since Grispeg is a chemical related to penicillin, the rash would be likely to occur but not an absolute expectation. Another had a myxoid cyst on her middle finger of the left hand. This had been treated surgically, which failed. She has arthritis in the distal joints of her fingers. Hopefully one injection of Kenalog into the associated with the myxoid cyst will take care of it.

More patients with dysplastic nevi and dysplastic nevous syndrome. I can not help but run scared on these patients, and wonder how many lives are saved and how much is really necessary.

Good cryosurgical results on a lower eyelid basal carcinoma.

A patient with recovery from an acute episode of urticaria (hives) sought information about the condition since he is leaving the country and will be where medical care is limited.

Otherwise mostly sun damaged skin and skin cancers were seen.

Wednesday May 17, 2006

The only skin disorder seen today that has not been discussed in this diary was perioral drmatitis in a recent university graduate. This condition was first described in Europe in the 1950's. The cause is unknown. Some research suggests it is caused by irritants, but treatment is not that of an irritant dermatitis. In my experience topical treatments do not work well if at all. Tetracycline or Doxycycline invariably work well. I prescribed Doxycycline for this young lady who is seeking employment and needs a definite remission as quickly as possible.

Thursday May 18, 2006

Dermpath called early this morning and the lady with the thickened erythematous skin and solid erythematous papules in the skin at the anterior axillary fold and above the old scar of cancer breast surgery does have metastatic breast carcinoma to the skin. Nothing is more frightening in appearance than the diffuse thickened erythematous skin on the upper chest and over the upper half of the breast skin than metastatic breast caracinoma in the skin. This is never the news a physician wants to give to a patient.

A man presented with a rash of one leg and foot that meets the rule of thumb that when a rash of some duration is on one hand or one foot and not bilateral, it is a fungus infection until proved otherwise.

A lady came for hair loss that was typical of the pulsion alopecia that I saw so much of when I trained in Chicago at the County Hospital. Doing the hair up tight for prolonged periods of time causes permanent hair loss. The best that can be hoped for is to discontinue the process so that the problem does not worsen.

A typical brown recluse spider bite reaction was seen on the leg of a middle aged man. At the bite site violaceous erythema of the skin extended twice as far from the bite site on the distal side of the bite. I know of no other red-violaceous skin lesion that spreads more distally than proximately. Also by history a brown recluse spider numbs the skin at the time it bites and the bite is totally painless. Hours later the bite site becomes visible and eventually turns necrotic and sluffs if not treated. These bites do not respond well to the medical literature recommendations for treatment. I treat several of these bites per year. For about 25 years I have used either Ultravate or Temovate cream under absolute (airtight) occlusion for 24 hours a day until all erythema disappears. All bites without exception showed continual improvement from the time the treatment began. It usually takes about two weeks of occlusive treatment, depending upon how early the treatment was started. This treatment entirely prevents the need for surgical intervention. The clobetasol propionate (Temovate) and the Ultravate are not recommended for use under occlusion. The brown recluse spider bite is the one condition where this rule should not be applied.

Friday May 19, 2006

I was a first time great grandfather today at 3AM.

One lady had a history of recurrent purpuric lesions not related to trauma. I sent her for blood studies. Now and then leukemia presents itself this way.

A new patient, who is the grandmother of one of my grand-daughters college golf team mates when they went to nationals, came from out of town because she had lost faith in the dermatologist she had been seeing.

The last patient seen was recovering from an extremely severe medication rash caused by a reaction to the high iodine dye used for heart scans. She came close to death from the acute reaction. She has psoriasis and this also has flared since having been placed on a beta blocker for her heart condition. Modern medicine is something we can not do with or without and carries risks far beyond the imagination of most of us. My patients that do best for the most part do without it (modern medicine).

Monday May 22, 2006

Due to one employee having a new baby and two having to go to a funeral of a close relative, it was a rushed Monday handling it with a skeleton crew. This is when all the paper work piles up and it takes days to get caught up again.

The first lady in today had a 4 plus reaction to patch testing for nickel and for colophony. She has been suffering from eczema of the hands for the past three years for which the military doctors finally gave up on and referred for dermatology consultation.

An elderly man had the most severe rash from tinea pedis that I have seen in several years. The rash started between the forth and fifth toes which is typical of how tinea pedis presents.

A flight physical failed his vision tests and was sent for ophthalmology consultation.

A lady was improving nicely on 4 % hydroquinone cream for bleaching the post inflammatory hyperpigmentation that was caused by facial glycolic acid peels done by another dermatologist's nurse practitioner. The most severe post inflammatory hyperpigmentaions on the cheeks (darkest black cheeks)that I have seen have been in patients of hispanic origin who had glycolic acid peels.

Tuesday May 23, 2006

A man who retired early and is relatively young had a painful plantar wart on his heel. The pressure of walking on a wart in this location causes the wart to go deep and even sometimes hourglass through the skin into the subcutaneous fat. This type of wart can be treated with hard deep freezing without immediate removal surgically. By waiting two or three days the wart will blister and the stalk that hourglasses through the dermis comes out in one piece with the wart. He is scheduled for cold knife removal of the blistered tissue two days from now. There is pain associated with the tense blister and this pain has to be taken into account.

A man was not able to sleep last night due to pain and swelling behind his left ear and of the ear. Examination revealed early erythematous area that had not yet blistered, but had the appearance of early herpes zooster. By starting him on Valtrex and not waiting to be absolutely certain of the diagnosis of herpes zooster is probably the difference between his having post herpetic neuralgia and not developing it.

Sometimes it is difficult to believe what your eyes are telling you. A lady came for a pruritic rash over the lateral aspect of her ankle. She had seen her doctor who did a biopsy on the most prominent part of the lateral malleolus. The problem is that she is elderly, has poor circulation in her leg, and sleeps on that side. The biopsy made a terrible sore from the pressure of her weight on the ankle while sleeping. This is the most stupid thing that I have seen in a long time, even more stupid than some of the things that I have done in the past.

Wednesday May 24, 2006

Patients came from three houses down the street, from south Texas, and from as far away as Portugal today.

A pathology report came in over the fax from DermPath in Dallas on a patient who lives three counties north of here. He has had a rash on his lower back, hips, and upper buttocks that has flared up twice within the last few months. The second time it flared, his doctor sent him to me for consultation. A red erythematous rash that was slightly raised and appeared to have wheals in three confined areas covered the described skin location. He gave of history of previous psoriasis rashes. This rash resembled psoriasis but not exactly so I did a punch biopsy. The glistening white scales were absent and the sharply demarcated edges of psoriasis were not convincingly present. DermPath reviewed the slides with intradepartmental consultation and came up with the rather rare condition known as neutrophilic urticaria. This is sometimes called Sweet's Syndrome. It may be associated with blood disorders such as leukemia and also this patient needs to be screened for hepatitis B. He will have initial testing done at home for convenience sakes.

A man returned, who a year ago came for T. rubrum rash of the torso and toenails. At that time he had suffered from the rash since Korea War days. I prescribed Sporanox pulse dosing for three months and from a clinical viewpoint he cleared up completely . The last few days have been on the hot side and the rash on his torso began to return. His toenails were clear except for the left great toe nail. I place his back on the Sporanox and probably will extend the treatment for one or two months longer than before.

The man who had suggestive symptoms of herpes zooster (shingles) yesterday returned after having a good night's sleep. I had placed him on Valtrex 1,000 mg three times daily and had soaked the area of symptomatic skin with 3% dialdehyde. Today the early lesions of herpes zooster were visibly stained from the dialdehyde, and all of his symptoms had subsided. Some dermatologists are afraid to use dialdehyde because of the possibility of sensitizing a patient to formaldehyde. Formaldehyde is in stay-pressed clothing and in all tissues such as toilet tissue, face wipes, etc., to make the paper tougher. The dialdehyde is viricidal and soaks into the skin deep enough to kill the herpes virus with which it comes in contact. When shingles are treated early enough, the dialdehyde can stop all symptoms without the use of an oral antiviral such as Valtrex. After using this treatment on shingle patients a dozen or so times a year for about 30 years in my practice, none have become sensitive to formaldehyde.

I am the aviation medical examiner for a man who two days ago saw his family physician for acute balanitis. The doctor had placed him on proper medication for the condition and had mentioned to the patient that he may need a biopsy to rule out basal cell carcinoma. The skin and mucous membrane involved does not appear to contain any tumor. I suggested he follow the treatment program already started for ten days and then return for another evaluation.

Thursday May 25, 2006

Getting ready for a long holiday weekend is trying.Too many need last minute things done for them.

The man with the early shingles is escaping the deep jabbing pains seen in herpes zooster when treatment is not begun the first day or two.

Plavix is being taken by more and more patients who come in for surgery. There is no antidote for Plavix which makes it a dangerous drug if taken in the event of an accident or in the event of surgery. When a patient's physician frightens the patient into taking it to the point that he refuses to leave it off, the problem compounds. This may sound like an utterly ridiculous situation, but not uncommon in my practice. If the surgery can be done cryosurgically, I can accommodate most of them. Even then care must be taken, because it is obvious on examination that some skin cancers are going to bleed after being treated cryosurgically.

The man who was seen two days ago with the deep plantar wart returned. A large blister was present as planned. The peripheral margins of the blister were incised with a cold knife and the wart fell out, taking about a 4 mm margin around the visible part of the wart. A 5 mm skin margin would have given a higher chance of the wart being cured, since the viral DNA can be found in the skin around a wart for up to 4 to 5 mm. I find that I have to make myself be radical enough on warts to prevent relapses, and when I do the warts rarely if ever come back.

The 85 year of age truck farmer who set out 400 tomato plants this year brought a fresh box of yellow squash for the office employees.
Cooked in the microwave with a little water, butter, salt, black pepper, and cheese made a good lunch vegetable dish.

Memorial Day, Monday May 29, 2006

Although I have seen no patients since Thursday, May 25, I can not let this day go by without dedicating this diary to my friends who gave their lives during WWII that I might enjoy the past 61 years of freedom for which they sacrificed the ultimate gift, their lives. A close friend and high school classmate, Archie Robey, gave his life in a dog fight over the North Sea. Then there was the Captain of the 317th Depot Repair Squadron, who was kind enough to transfer me out of the Squadron to aviation cadet training one half hour before he froze the squadron for shipping out to a tiny island in the Pacific Ocean. He and the entire squadron, including my dedicated tent mates, sacrificed their lives less than two months later when the Squadron was over run by Japanese soldiers in the middle of the night. Not a man was saved. Greater love for country has no man than these, for in the 317th there was no survivor to tell their story and their love for you and me. I am the closest to being a survivor and therefore I dedicate all that I have done in life that is good to those of the men of the 317th Depot Repair Squadron, now and forever more.

Tuesday May 30, 2006

A patient with biopsy confirmation of papular urticaria probably is allergic to flea bites. The late Dr Pinkus, famous dermatopathologist at the University of Michigan, indicated to me at one time that he believed papular urticaria was usually caused by flea bites. This patient is around a lot of animals, especially cats and dogs. Hopefully with this information, he will do better.

An out of town patient presented with the pearly nodular lesion with visible blood vessels in it that is diagnostic of basal carcinoma. He is on coumadin. Rather than have him make an extra long trip to come back when he is off the coumadin, I cryosurgically treated this skin cancer without biopsy confirmation.

I surgically excised a nevus on the plantar surface of a young lady who has had a melanoma and five dysplastic nevi removed during the last few months.

A mother had a poison ivy rash after working in her yard in Austin. Poison ivy rash is usually easy to diagnose because there are scratch streaks of blisters out from the main vesicular erythematous rash. This lady had enough will that she did not have these diagnostic streaks of blisters, but she brought her daughter with her who helped in the yard and did have the scratch streaks. Usually after these rashes get a few days old, it takes systemic corticosteroids to bring them under control.

Wednesday May 31,2006,

A 30 year of age female patient made an appointment for a boil (furuncle). When I examined her, she had a 3 cm diameter elevated erythematous mass in and under the skin of the medial aspect of the left breast. She had been treated with antibiotics for a methicillin resistant staphlococcus aureus (MRSA) infection with partial improvement. The mass was firm and somewhat appeared to be a furuncle, but not exactly. I did a biopsy of the skin and underlying firm tissue that did not appear to be granulomatous and necrotic and purulent as expected. The lesion extended to a depth of about 2 1/2 cm and probably through the subcutaneous fat and into breast tissue. I continued her Augmentin 875 mg twice daily.

I enjoyed seeing an alert 94 year of age lady who had an irritated seborrheic keratosis on hairline of her forehead, probably irritated from the use of a comb.

A man wanted his rosacea checked. He is responding extremely well to Metrogel 0.75 % twice daily. He did complain of the cost of the Metrogel.

Through the years I have had a few patients allergic to acrylates. Methyl methacrylate before it polymerizes is a severe neurotoxin. These allergic reactions also cause contact eczematous dermatitis. In these patients, it defats the skin and causes dry, exfoliating skin, skin cracks (fissures), and sometimes just severe erythema followed by exfoliation. The hair, eyebrows, and fingernails usually remain normal in contrast to these changes in patients with dry skin from hypothyroiodism.

The manufacturers have succeeded in suppressing the reports that tell the true nature of this dangerous chemical because it is a multibillion dollar industry that has been around since Plexiglass was first placed in airplanes in the 1930's.

Acrylates become inert when heat dried and the heat dried resin is not a powerful sensitizer. However the self-cured acrylic monomer contains residual acrylic monomer and causes reactions in sensitized patients.

If a person does not tolerate fresh acrylic wall paint on the walls of their home, then in all probability they have a sensitivity to acrylics.

Toxic doses of the acrylic monomer cause ascending paralysis in rats, although to find the reports on these experiments is time consuming research. I have seen one patient who ran the same course of ascending paralysis after acute exposure to acrylic monomer as do rats. In any reference made to these rat studies, the author of the paper quickly adds that rats are not human beings and makes a denial of the importance of the rat studies. There is no antidote for acrylic monomer poisoning. In my observations, acrylic monomer poisoning of the central nervous system leaves permanent residual impairment in human beings of the same nature as it does in rats.

Today I saw a patient who is so sensitive to acrylics that she developed acute exfoliative dermatitis on the back of her neck and shoulders three days after using hairspray containing acrylics. This had been diagnosed previously and she had refrained from using these hair sprays until a few days ago.

Thursday June 1, 2006

I had the lady with the acrylate hair spray reaction go home and shampoo her hair for ten minutes and rinse it thoroughly. Today her eyes no longer burn, but the eyelids remain erythematous and slightly swollen where she previously spread the acrylate by touching her hair with her hands and then rubbing her eyes. The exfoliative dermatitis on the neck and shoulders is less acute appearing. For a change, she slept well last night.

The first patient came for a secondary infection in a herpes simplex lesion. He is scheduled to have new batteries placed in his pacemaker and wanted to make certain that he did not have a bacterial infection remaining when this is scheduled to be done.

In reviewing his medicines for compatibility with the antibiotic, I learned that he had been on atenolol and Norvasc for sometime when his cardiologist added Pacerone (amiodarone) without adjusting the does of atenolol and Norvasc. The Pacerone causes a one to one and a half fold increase over and above the normal dose on both Norvasc and atenolol. I don't know if this sort of thing is done in ignorance, the physician doesn't care, or in the belief that older patients tolerate higher doses than normal, so what, side effects and cost of medicine don't matter.

One thing that is involved is the attending physician's ego, and it is a good way to lose referrals if too much fuss is made over these mistakes. Then if you lose the referrals, the patient never knows the truth and never has a chance to correct the problem. I think once the patient knows, they are obligated to be responsible for themselves.
I believe that physicians should step forward to stop this injustice on patient's pocket books, which in this patient a reduction to proper doses would have saved him considerably each month, and now it will.

Not long ago I excised a basal cell carcinoma from a man's nose and closed the wound by advancing a flap. The distal portion of flap sloughed. Only last week, in one of my plastic surgery journals, I read and learned for the first time that flaps done in smokers are 12 times more likely to slough than in non smokers. Enough of the flap survived that I will be able to revise the scar now without out doing a flap. He seemed to be pleased with this news, and I scheduled him for surgery.

A four year of age child complaining of skin rash had asteatotic eczema. His mother has a similar problem.

I learned that the doctor doing the biopsy on the lateral malleolus of the lady seen recently was a podiatrist and not a medical doctor. Today it appears that she will heal without undue suffering.

Adult acne in a man past sixty has required continuous antibiotic therapy. He refuses to take Accutane, which with the i-Pledge Program I can't afford to mess with anyway.

Friday June 02,2006

A lady who was not easy to please when she was a new patient several years ago has developed full trust in me and sent me many patients. She was in for actinic keratosis today and is now a pleasure to see.

New patients with psoriasis are commonly on beta blockers which aggravate their psoriasis. Their cardiologists seem to never be aware of this conflict. A new patient with painful pustular psoriasis of the palms and soles of the feet was a good example today.

Micrographic surgery failure is probably more common than reported in the literature. A new patient was seen this morning with the relapse of a squamous cell carcinoma on the forehead. His micrographic surgeon does microcraphic surgery on most if not all of his patients with primary cancer. When I did radical cryosurgery of the lesion, the skin cracked on thawing and the cracks outlined the margins probably about as well as can be done using the micrographic surgery procedures. It has been my experience that a 4 to 5 mm margin past the lateral margins of the cracks never fails to result in a cure. Where there is residual scar involved and the lesions is deep, I also use three freeze-thaw cycles instead of two. When possible, compression and elevation of the lesion during the cryosurgery procedure enhances the depth of freeze as well as the speed of freeze and the slowing of thaw time. I don't anticipate any problem on this patient.

Monday June 05,2006

A fairly routine Monday with all patients coming for skin lesions, benign and malignant, except for a flight physical and a lady with a rash.

The flight physical had a positive test for sugar in his urine, so he had to be deferred to Oklahoma City.

The lady with the rash had a an erythematous pruritic rash on the sun exposed areas of the arms and forearms. The erythema cut off at the end of her short sleeves. Also the lower posterior neck and upper dorsal area where the sun hits was erythematous and pruritic. She does not use fragrances or scented soaps. The only medicine taken which is known to cause photodermatitisis is Ambien. The pruritus is generalized and she has a hint of a rash on the left upper hip. She is not a sun person, but it only takes going in and out of the house for shopping and errands for the sun to induce a photo sensitivity rash. I hope I succeeded in having her discontinue her Ambien and gave her a Medrol dospak and Dermasmoothe/FS Eczema oil.

Tuesday June, 06, 2006

A lady past age 85 came in for post operative examination of the basal cell carcinomas that were treated several months ago. In the interim she and her husband signed up for a Medicare HMO that had been highly advertised on local TV for paying for medications. The advertising never explained that it was an HMO and had a limited number of doctors participating in it. This particular HMO cheated me out of slightly more than $4,000.00 the first two years it was in business. At the end of the second year I did not renew my contract with them because of their dishonest policies. The sad part of the story is that the HMO sold the insurance to this lady and her husband without explaining to them what an HMO is and that there are numerous restrictions on usage of the insurance.

This lady had a new basal carcinoma on her upper lip. They chose to remain patients and pay cash rather than go to the HMO doctor.

A man on his second kidney transplant came for a squamous cell carcinoma on his left cheek. The anti-rejection drugs depress the immune system and one of the problems is an increase in skin cancers which also have to be treated somewhat more aggressively than on patients with normal immune systems.

During his first transplant he was maintained on cyclosporin and had more skin problems than he is having this time around. The new anti-rejection drugs do not result in the high number of squamous cell carcinomas of the skin that we used to see.

The last few days have been extremely hot and due to increased perspiration one of my nickel allergy patients flared up. These patients need to remain as cool as possible so that there is less sodium chloride on the skin with which to convert nickel sulfate to nickel chloride.

Wednesday June 07,2006

There was a good mixture of skin conditions today.

One young lady had both lichen simplex chronicus rash and a psoriasis rash. There is one thing about psoriasis and lichen simplex chronicus that is in common. If a patient with psoriasis scratches the skin in one place repeatedly and long enough a lesion of psoriasis at that site will appear. This feature is also present in lichen simplex chronicus which is a skin rash caused by habitually scratching a given area of skin. Some refer to lichen simplex chronicus as neurodermatitis. In my practice psoriasis and lichen simplex chronicus are seldom seen in the same patient. Also in lichen planus itching is produced by scratching, but in this skin condition the scratching causes such severe burning and itching that the patients quickly learn to avoid scratching. They won't scratch. In lichen simplex chronicus (LSC) the cause-effect is not immediately recognized by the patient and they just go on scratching.

Thursday June 08, 2006

A hispanic patient with vitiligo is responding to Protopic ointment applied twice daily as well or better then would be expected with a corticosteroid cream. The Protopic was started early in the course of the disease. At least the patient is satisfied.

A foreign patient of African descent returned after several months on Azelex (azelic acid cream 20%)cream. He shows little if any improvement in postinflammatory hyperpigmentation secondary to acne. He has outgrown the acne, but the hyperpigmentation remains. I had given him the Azelex because of some possible residual acne at the time.

He should do better on a more standard treatment of hydroquinone cream and sun screens. Keratosis pilaris rubra is also present on his arms and shoulders. I had given him 6% salicylic acid lotion for this and he is much better, but not satisfied. Perhaps Keralac ointment will control the mild sypmtoms of roughness and dryness associated with the keratosis polaris and make him feel better.

Friday June 09, 2006

A university student aged lady presented with pityriasis rosea inversus. PR usually presents in the spring of the year and this is the first patient with the inverse form that I have seen in some time. Usually a herald patch shows up on the trunk five to ten days before the rash spreads.

Her primary care physician diagnosed this as a fungus infection which is a common mistake made by nondermatologists. The Lotrimin cream she was using was of no help during the past five days used and new lesions continued to appear.

Pityriasis lesions differ from ring worm (fungus) skin lesions in that the lesions follow the cleavage plains and are oval in that direction. The ring worm lesions are round and not oval. Also the edge of the shelving of the shedding skin cells usually points in opposite directions, PR shelving toward the center of the lesion.

Usually PR requires no treatment, but in the inverse form, the face may have so much rash that treatment is mandatory, especially in a young beautiful lady in school.

Allergenic doses of influenza vaccine will arrest PR within a week to ten days and do so without remission. Also prednisone will arrest the rash within about a week, but has to be continued in small doses until the PR runs its course of 7 to 9 weeks. Otherwise the rash relapses. This patient was not amendable to taking shots and a prescription for prednisone was given.

Monday June 12, 2006

Monday often has its share of patients with complex evaluation and management problems.

A 66 year age of female who tends to and feeds horses and other domestic animals had an erythematous area on the lateral aspect of her right ankle with three areas of spontaneous ulceration within the area of erythema. The hair growth and circulation are good in the area. There is no history of injury. I will start out treating this as if it is a bacterial infection and re-check her in 5 days just in case it is the beginning of a deep fungal infection.

The man with the severe tinea pedis seen on May 22 returned. Apparently his fungus infection was severe enough that he had some reaction to the kill-off of the fungus. The dorsal areas of his toes remain eczematous as well as the interdigital interspaces. The rash has receded by about half. I gave him a Medrol 4 mg. dospak to reduce the inflammation and will recheck him in five days.

A 77 year of age man had a angioma above his right ear about 12 mm in diameter and elevated. The barber has trouble cutting his hair without causing injury to it and the ear piece of his eye glasses keep it irritated. For a Medicare Fee of less than $56.00 I was able to treat this vascular tumor cryosurgically using compression and elevation of the lesion during the cryosurgical process. The cosmetic results and relief medically speaking will be equal to or better than laser treatment and a whale of a lot cheaper and quicker.

The lady who had photodermatitis from Ambien who was in three weeks ago returned. After leaving the Ambien off for the three weeks, the reaction has faded and the rash is no longer visible. Ambien is one medication that does cause photosensitivity and this lady's rash is a good example.

A 69 year of age male patient was referred by another dermatologist for a non responding rash on his fingers. Usually the secret to helping these patients who have been resistant to treatment is to keep taking history until the patient finally tells what is wrong with them. This patient is a welder and drives a pick-up in his work. He has a habit of grasping the steering wheel between his left index finger and the left middle finger exactly at the location of the rash. I did patch testing on him and made a Vaseline patch of scrapings from his steering wheel. Hopefully this will tell the tale. A few years ago I had a lady who was allergic to the steering wheel of her automobile that I was able to diagnose by using a steering wheel scrapings patch test.

Path reports came in on eight patients and one of them was a melanoma that I had done an excisional biopsy on last Wednesday. I call patients personally to give them the results of their pathology reports. This made a long tiresome day.

Tuesday June 13, 2006

Another patient with pityriasis rosea, but not of the inverse form, came today. This tends to be a seasonal skin disease.

A lady with generalized pruritus (itching) and mild urticaria that was in a few weeks ago returned. I had referred her back to her family physician to change her blood pressure medication that I believed to be the cause. When she went back she saw the nurse practitioner who was afraid to change any of her medications. The patient has never seen the physician and probably never will. I am going to have to discontinue her hydrochlorothiazide and recheck her every few days to find out if that is the cause and if she really needs the hydrochlorothiazide.

A gentleman who moved here from a big city where he had a basal cell cancer removed from his back by Mohs Micrographic Surgery. He now has a recurrent cancer at the medial end of the scar, confirmed by biopsy. I treated this cryosurgically with three freeze-thaw cycles rather than the usual two because of the scar and tumor mixture.

It is feared by some cryosurgeons that scar tissue inhibits the expansion of ice crystals and the cancer cells fail to rupture. If the Indians cracked rocks using the expansion of water to ice, it seems that scar tissue is hardly harder than rocks. I have never been able to determine that scar tissue is an inhibition to cryosurgery.

But just in case that I am mistaken, I used a 2 minute halo thaw time instead of the usual 90 second halo thaw time. Halo thaw time is the time it takes the ice ball to thaw back to the peripheral margins that are desired to be taken around the tumor. It is easier to get radical with cryosurgery than with cold knife surgery and this cancer has a higher percentage chance of being cured than if micrographic surgery were tried again.

I excised a nevus that may be an early melanoma from the flank of a man who has a history of having had a melanoma removed from his back a few years ago.

A young man presented with a severe rash on his face. A small area of irritation occurred on his left cheek. He applied triple antibiotic to the small irritation three times daily. Within a week both sides of his face were a solid rash with the right side being the worse. He is allergic to the Neomycin in the Triple Antibiotic ointment. His right face was exposed to the Neomycin that was rubbed off of his left cheek and onto the pillowcase. He sleeps mostly on his right side. This is how the right side of his face got the exposure.

Wednesday June 14, 2006

An all uncomplicated surgery day except for two patients.

One had a pruritic rash on the instep of one foot. Usually a rash present for several months and remaining on one foot is tinea pedis. This is a working man that needs his foot well. He is wearing sponge rubber insoles in his Red Wing boots. Rashes from Red Wing Boots have been nonexistent in my practice. I will treat him for tinea pedis and do a patch with the insole just in case this is a rubber rash.

The other nonsurgical patient has a healing ulcer on his ankle. He is near dismissal, probably one more visit.

June 15,2006

The first dermatological surgery patient had a keratoacanthoms on the dorsum of her right hand. She had seen her primary care physician who, not cognizant of the correct diagnosis, lanced the lesion. This is not unusual due to the inadequate dermatology training in most medical schools and Family Practice Residencies. In my opinion the American Academy of Dermatology (AAD) is largely to blame for this. In the past there has been a tendency for the AAD to stick their noses in the air (probably more accurately stick their heads in the sand) when it comes to encouraging other physicians to learn dermatology. Outside physicians have to go through red tape and pay exorbitant fees to attend their meetings, i. e. their meetings are for practical purposes closed, not that the wall can not be penetrated.

A new patient had a severe medication rash from the maximum dose for Lisinopril for blood pressure. She is age 63 and probably too old to tolerate the maximum dosage. Her blood pressure was 102/62. I will have to taper her dosage and follow her until she is able to see her internist who would not give her an appointment until the last part of July. How sad!

Another patient in his eighth decade of life had a severe rash with its onset after his Cardiozem dose was increased to the maximum adult dose. The Cardiozem causes an increase of more than 150% in the Plavix and the Ambien and of one other medication that he also takes. So the possibilities are that he broke out from the increased doses of one of these other medications rather than Cardiozem, or that the rash is from the Cardiozem. His family doctor is easy to work with, so I sent the patient back to his primary care physician with a print out of the drug interactions so that the dosages may be adjusted.

Thursday June 22, 2006

A patient with psoriatic arthritis who is taking Humira is responding better than he did on Enbrel. He is being monitored closley.

A man who was adopted at birth came in to have his skin checked for moles. I surely do miss it when no family history is available.

A male patient who had an inguinal herniorraphy 8 days ago came for removal of a basal cell carcinoma that was on his left shoulder. He asked about the skin around the herniorraphy incision which was bruised badly. The skin of the incision had been glued together and reinforced with steristrips. I am of the opinion that the raw skin can not be glued together without giving the patient a small dose of meth methylaccrylate which is a neurotoxin for the short period of time that the glue is drying. I do not use the stuff in my practice, even though it could be a time saver.

The lady with the iatrogenic (caused by a physician) ulcer on the lateral malleolus from biopsy by the foot doctor is slowly healing. I estimate it will be another 3 weeks before I can dismiss her.

While my computer was disabled, there were a number of patients with interesting rashes and one melanoma patient. Some of these will be seen in followup visits.

Friday June 23, 2006

After finishing today, I was on my way home when the office called and said an elderly patient had scratched the eschar off of a biopsy wound on his ear and was bleeding profusely. I met him back at the office and stopped the hemorrhage using electrocautery under local anesthesia with lidocaine. It is a common problem to have postoperative bleeding during the postoperative global period and there are codes and modifiers to use for this when filing insurance claims. Since this has been a non existence event in my practice, the codes are virgin to us.

One lady had a tick bite on her lower back. She lives on a farm.

Another lady was exhausted because her spouse has dementia and she is the lone caretaker.

The man seen on 5/22/2006 for severe tinea pedis returned. It has taken this long for the raw skin on the top of his toes to heal over. Thanks to Lamisil tablets for knocking out the fungus except for the onychomycosis.

I biopsied a nodule on the vermillion border of the lower lip in a smoker. If this is squamous cell carcinoma caused by smoking, it will require fairly aggressive treatment.

Lumps on the lower lips in smokers scares me about as much as do melanomas.

The hand dermatitis caused from the rubber covering on a steering wheel of the patient's pick-up has subsided except for minimal residual post-inflammatory hyperpigmentaion.

Monday June 26, 2006

I signed and returned my biography for the 2006-2007 Edition of Marquis Who's Who in Science and Engineering today.

Except for a 5 year of age TriCare patient with warts and one with acne vulgaris, all patients were old friends of from families of old friends; some from long distances.

A 25 year of age school teacher returned for his yearly check up. A year ago I removed a basal carcinoma from his scalp. Basal cell skin cancers do occur in young adults. This reinforces the need to keep babies with their young tender skins protected from the sun.

A physician's wife came for an acute rash that is obviously caused by an allergic reaction to Neomycin in Neosporin ointment. The truth is that my receptionist told her to use Neosporin on an insect bite site until I could see her. OK advice gone bad.

Tuesday June 27, 2006

All patients today were surgery patients.

The pathology report came back on the melanoma that was excised last week. The exicisional biopsy left scar of operation with multiple levels showing only scar of operation. Good news.

One retired man had a basal cell carcinoma on the palm of his hand. It has been many years since I had a patient with a basal cell carcinoma on the palm skin. These are most uncommon on the palms. However basal and squamous cell carcinomas often encroach on the flexor skin of the fingers.

The last patient had a small (4 mm dia.) basal cell carcinoma on his mid forehead, but also had a medication rash of a few days. He did not have a list of his medications which included some recent changes. I biopsied the basal cell carcinoma as scheduled and asked him to bring his list of medications to the office for evaluation in the morning.

Wednesday June 28, 2006

I rarely use some type of corticosteroid for acne. The exception is when a patient needs sudden improvement for an immediate special occasion such as being in a wedding. Then cortisone can be used temporarily for quick results and then discontinued. I saw such a patient today.

Another patient had angular stomatitis. Again I rarely use anything with boric acid in it. Adult angular stomatitis usually responds well to a zinc oxide ointment with boric acid and is one of the exceptions. Dr. Smith's Adult Care Ointment is an example of such product that is sold over the counter. I recommended it to a patient today. Boric acid is never to be used on children or infants since it can be absorbed through the skin of a young person and be toxic.

A patient with vasculitis secondary to lisinopril that she was taking for her blood pressure and that was seen two weeks ago came in today. She is free of rash and has a normal blood pressure after being tapered off of the lisinopril. I sent her back to her primary care physician for re-evaluation of her hypertension treatment along with a consultation report.

A new patient with psoriasis plaques on her knees, elbows and legs has become worse after she had been placed on Cymbalta. She was taking Plaquenil when placed on Cymbalta. These two medicines interact with one another and now she is getting an overdose on her Plaquenil which is one medicine that aggravates psoriasis. She stated she had felt generally bad since starting the Cymbalta. Cymbalta causes about a 2 1/2 times increase in Plaquenil dosage. Plaquenil causes somewhere between a 75%-150% increase in Cymbalta. It would be unrealistic to expect her psoriasis to improve until the dosages on these two medicines are adjusted. About ten per cent of patients are slow metabolizers, and if she happens to be a slow metabolizer the situation is worse than stated above. The tests to determine this are too expensive for this patient to afford. Hopefully a therapeutic change based on a 90% chance will be correct and she will respond to conventional treatment for her psoriasis.

Thursday June 29, 2006

The first patient is one with plaque psoriasis who claims that he is getting worse instead of better. On examination he is found to be correct. On subtle inquiry into the the medication amounts on hand and which if any had been refilled, he is found to be in noncompliance with his treatment program. This is usually the situation found when a patient fails to do better. The problem may be multifocal, but at least in part it is due to a delay in treatment response. When with one dose of a medication a patient does not see a response, the next dose or application perhaps is more easily forgotten. It is the physicians responsibility to encourage compliance, but even the best of efforts often fall short. Under these circumstances when the patient continues in noncompliance referral to another physician with a different personality may be in the best interest of the patient. Now a days this is more difficult due to HMO limitations. HMO's are bad at best.

Friday June 30, 2006

Today I treated patients from Mississippi to Alaska, but all in all it was a day for physicians and members of physician families. Six patients fit this description. Back in the old days these six patients would have received 100% professional discounts and the honor of treating them would have been more than honor enough to be payment in full.

Three patients today have been patients for more then fifty years and several almost that long. This, too, I consider an honor because they have no special connections with me other than just being patients.

There were four new patients which is about average for my practice.

Today's diagnoses included herpes simplex (2), basal cell carcinomas, actinic keratoses, dysplastic nevi, irritated intradermal nevi, advanced actinic keratosis, squamous cell carcinomas, stasis leg ulcer, irritated seborrheic keratoses, medication rash, one patient for a skin check up without any diagnostic findings, keratoacanthoma, and an irritation rash.

Thursday July 06, 2006

One patient returned for a follow up visit on his facial rash caused by neomycin in triple antibiotic ointment that he had used. He is recovering about as rapidly as can be expected.

All the other patients were surgery patients, one of which also had onychomyosis. She has a friend who responded to a mixture of Lamisil and DMSO. The patient has to totally comply with the instructions for this compounded antifungal topical solution to help.

A patient with a second kidney transplant came for his usual two or more skin cancers.

Two ladies who are twins mentioned that they had seen someone for evaluation of facial hair and were scheduled for laser hair removal. Their facial hair is white from age, white as snow. I did not ask and did not want to know who promised them the moon.

Friday July 07,2006

An 8 year of age boy presented with psoriasis of the scalp. The scalp rash had not been previously diagnosed. His mother as well as the patient appeared to be a persons who would comply with treatment instructions. I prescribed Derma Smoothe FS Scalp Oil.

The tissue report on one lady showed melanoma in situ. I could not work her into my schedule for excision before she leaves on vacation. I sent her to her brother-in-law who is a general surgeon.

A retired colonel came for a basal cell carcinoma on the bridge of his nose. When he first retired from the Air Force, he got a job with Abilene Aero. I had a friend who owned a Cessna 210 and was a student pilot at the time. He asked me to fly him to Bridgeport, TX, to look at some property. When I landed at the airport in Bridgeport, the Highway Patrol met me as I got out of the plane and requested me to show my pilot's license. I learned that the airplane had been tracked from Abilene to Bridgeport and that the High Way Department had been notified a man was flying the airplane with out a license. The colonel does not know that I am the one he falsely turned in for flying without a license, or else he would not have had to face to show up in my office today.

The man who had to have 3/4 of his forehead skin removed by Dr Taylor in Dallas after a local board certified dermatologist tried to treat his basal cell carcinoma with Aldara Cream came in today for early treatment of multiple actinic keratoses. This patient travels in substantial circles. I am glad I am not the dermatologist who swallowed 3-M Company high pressure sales details on Aldara.

Monday July 10, 2006

Today patients talked about everything from diabetes to the migrant problem. I finally caught up with phone calls that piled up over the holiday.

Did a second stage on an angioma on a lady's thigh. Cosmetic results are going to be excellent.

Cartilage was exposed following cryosurgery for a basal cell carcinoma on a physician's ear. Usually Bactroban cream three times daily will take care of this. Years ago we were told that skin would not brow over exposed cartilage. Now I know of three medicines that usually make this a false statement. Bactroban is one of them.

Wednesday July 19 2006

After being in medical lectures from 8 AM to 5 PM for several days last week and part of this week, I am exhausted.

Back in practice today.

One lady seen is worth mentioning. Three years ago she was diagnosed by her rheumatologist as having systemic lupus erythematous. Her interval history confirms the correctness of this diagnosis. She has been on the largest recommended Plaquenil dosage and several other medications. When her husband died a year ago, she was placed on Paxil and Reglan, both of which cause a triple or more increase in dosage in the Plaquenil and two of her other medications. Her present complaint is generalized pruritus for the past year(itching). The Plaquenil dosage was not reduced at the upper limits and without reduction at the time the Paxil was added. Usually Paxil is not needed past 9 -12 months following the death of a spouse, and one of the psychiatrists lecturing last Saturday confirmed the fact that Paxil should be discontinued as soon as is feasible (without giving it forever the way some doctors do). I hope I am on the right track when I sent her back to the referring physician with a print out of interactions with her medications with the Reglan and Paxil and one without the Reglan and Paxil.

Thursday July 20, 2006

I have scheduled one flight physical every day for a while in order to get caught up on these after attending a Federal Aviation Medical Examiners Seminar. Luckily today the pilot had no significant history and no significant physical abnormalities.

All of the other patients were dermatological surgery patients except for a lady with lichen simplex chronicus (a rash caused by scratching or at least maintained by scratching).

Friday July 21, 23006

The flight physical for today is a crop duster with 19,000 hours. Almost every year he pays tribute to the fellow crop dusters that were lost. He said that this year, the summer drought has been so severe that he has done little work. In one county, rains on some of the farms was good and the crops are good. The problem is the county has been declared a drought disaster area by the government, so all of the farmers are collecting their government insurance in preference to working for their money. He said out of 400 farmers that he normally sprays for, all are taking the handouts in preference to working. Then we wonder why our taxes are so high.

One lady came in for a post operative examination on a skin cancer on the posterior part of her neck. She grew up on the farm. Her grandmother used to sow her beautiful dresses with matching bonnets. She said she would hide the bonnets and never wear them, and if she looked she probably could still find their remnants. Only if grandmother's wisdom were heeded!

A female patient on blood pressure medications for the past 10 years came in with a general erythematous and pruritic rash typical of a medication rash. She has been on a Dyazide and Hydrochlorothiazide combination along with metoporol. I have had several patients develop medications rashes from Hydrochlorothiazide after they had been on it for 8-12 years, and am taking her off of the diuretics. Her blood pressure and weight will be monitored closely until a determination can be made on the cause of her rash.

A 14 year of age boy came for a recheck on his acne and for a plantar wart. He is leaving for Camp Bandina, a Christian Camp between Bandera and Medina, Texas. I refilled his clindamycin solution, which is controlled his acne nicely. Bandina Camp is a fun place in the Hill Country of Texas. My children went for summer camp there during the rebellious 60's. I think it is a wonderful place for children, especially since my three children turned out well even though brought up in trying times for them. I deferred treatment for the plantar wart other then bicholoroacetic acid application which should get him through camp without significant pain from the wart.

The last patient was a neighbor 51 years ago and his two sons grew up with my son. They both turned out well. His two boys were brought up as devout Methodists, both have engineering degrees, and have been successful family men and bread winners.

The father of a physician came recently for a recurrent squamous cell carcinoma that had been treated elsewhere with micrographic surgery. I treated it radically with cryosurgery and it has healed smoothly with soft tissue in the entire area. Cryosurgery can be superior to micrographic surgery when the cryosurgeon is knowledgeable and experienced in cryosurgery.

Monday July24, 2006

Today was an all surgery day. These days are always interesting, because no two skin lesions are identical and no two patients are ever the same.

For example one retired ranch lady came for skin surgery. Many years ago for many years I hunted on her ranch. She brought me up to date on her grandchildren who are now in college and excelling.

Another example is a man who had a small mole on his nose for many years that suddenly grew to 13 mm (1/2 inch) in diameter. I did a deep shave biopsy and will await the dermatopathology report to see if this is a melanoma. If so he probably will lose part of his nose and have to have it rebuilt. He is a new patient and friends of two men who have been patients for years.

When surgery takes up the entire schedule, there always seems to be one or two sad situations. One man whom I have known for over fifty years came for skin surgery. Since I last saw him, he has developed the stone face of Parkinsonism. Another man that came in lost his wife from myasthenia gravis since I last saw him.

Tuesday July 25, 2006

The first patient was a postoperative check on a benign sweat gland tumor of the scalp. Periodically she has acute lymphangitis of the left upper extremity that is secondary to a modified radical breast removal for cancer of the breast thirty six years ago. This is one of those times, and I prescribed Zithromax 250 mg dospak. Erythromycin always worked for this in this patient, but she prefers to take the Zithromax since it has been on the market.

In the medical literature, one of the complaints filed against cryosurgery is that for skin cancer it often leaves a hypetrophic scar. What is not in the literature is that the hypertrophic scars resulting from cryosurgery respond miraculously to intralesional Kenalog injections and are dramatically more responsive to this treatment than hypertrophic scars caused by any other means. The second patient today had a hypertrophic scar on the distal bridge of the nose from cryosurgical treatment of a deep basal cell carcinoma. Sometime ago I injected the scar and one injection completely obliterated the scar. These scars do not relapse as do keloid scars. At the present time there is no way under heaven that a better cosmetic result could have been obtained by any other surgical method.

The last patient had a dusky hyperpigmentation around the lips and mouth suggestive of Addison's disease. I referred her to her internist for a general work-up.

Wednesday July 26, 2006

The first patient today was the first patient to whom I prescribed compounded 1% 5-fluorouracil lotion to for actinic keratosis. He has done well these past 37 years. His latest is a stent (upside down Y stent) for an abdominal aneurysm. The surgeon inserted the main stent and the right branch of the upside down Y up from the right femoral artery and fastened it in place. Then he inserted the left part of the Y upward from the left femoral artery and fastened this branch in place. He had to go to Dallas to have this procedure. Amazing!

A physician's wife whom I treated recently, brought in a pan of home made cookies that were loaded with fresh nuts for the staff. Still hot!

A lady had the first diagnosis of scalp psoriasis made today. She has a grandson with generalized plaques of psorisis. About one in three patients that have psoriasis is able to give a positive family history of the disease. About the cheapest treatment that often works is DermaSmoothe FS Scalp oil. She chose to start this treatment.

Four months ago, a middle aged lady who had had three major surgeries before 1992 was diagnosed with hepatitis C. She completed her treatment a month ago. She has a low lymphocyte count of 10 % and a borderline ANA test for lupus and a normal sedimentation rate. Her complaint is that her skin feels as if it is burning from the sun. There is little if any definite rash. She believes that her symptoms are a residual from the interferon or possibly from the antiviral medication that she took. I would guess that it is the interferon and that it will take six months or longer to know where her symptoms are going to have long term significance. I sent a skin biopsy to DermPath in Dallas.

Thyrsday July 27, 2006

A new patient from Dallas, Tx, came for a basal cell carcinoma on his left forearm. He is younger than usual for skin cancer and I could find no other areas of visible sun damaged skin.

A lady who had a basal cell carcinoma cryosurgically removed from her right lower lid several months ago returned for routine check-up of her skin. The eyelid scar is not apparent without using a magnifying glass and the function of the eyelid is absolutely normal. I am proud of the results.

An older lady has a severe rash that is apparently due to Plavix. The incidence of skin problems due to patients taking Plavix is relatively high when compared to other medications. The Company that makes Plavix has done a high pressure sales job in this area. Whether it works better than an aspirin a day probably has yet to be fully established. It is difficult for paid researchers to not be biased in favor of the source of their money. Once these biased reports make the print there is no monetary incentive to continue to compile the volume of statistics that are needed, especially where the drug may in the end prove to be less effective that a much cheaper and safer competitive drug.

Friday July 28, 2006

The lady who had been on hydrochlorothiazide for ten years before it caused a rash called today and her rash has almost completely subsided. She is due to return on August 11 for evaluation of her blood pressure after leaving off the hydrochlorothiazide that long.

A 42 year of age female was referred for a "papulosquamous rash" of 4 months duration. Upon examination the rash is lichenoid rather than papulosquamous. It had its onset on the feet and ankles in April of this year and since has spread to the trunk and the upper extremities. Although she states that the rash at times is intensely pruritic, there are no scratch marks. When asked if scratching made the itching worse, she answered an emphatic affirmative answer. Inside her buccal near the 3rd molars on each side was the typical white raised lace-like rash with associated erythema that is indicative of lichen planus. The lichen-like skin lesions were elevated round, oval, hexagonal, and triangular that is also typical of lichen planus.

The cause of lichen planus is not known. It occurs more often in women than men. It may be severely aggravated by severe stress. This patient has a spouse away in the foreign desert. Stress enough! Accutane may be of a little help, but prescribing Accutane takes a couple of hours or so of a physician's time. I prescribed Retin-A o.1% topically with clobetasol propionate to apply on over the Retin-A. If this does not help, then I will paint the lesions with 3% dialdehyde which usually helps. How dialdehyde works on lichen planus lesions is unknown, but when all else fails it invariably helps.

A basal cell carcinoma was present on a lady with extremely fair skin in the unusual location of the inframammary area. She denies having sun bathed. Maybe the article that made the retrospective study and proposed that basal cell carcinomas are mostly caused by early childhood and infancy sunburns has some merit after all.

Monday July 31, 2006

Today was beautician's day on the schedule.

Contact dermatitis is common among beauticians. They are exposed to many sensitizing chemicals. Nickel and para-phenylenediamine were the offenders today.

Also beauticians and barbers are a great referral source. I am fortunate to have more than my share of patients among these professions.

Tuesday August 8, 2006

After coming back to the office from being absent due to a grand daughter's wedding, things were calm.

Three patients were in for post melanoma surgery and doing well with negative examinations.

The tissue report from the dermatopathologist came back on the big nevus that I sent in two weeks ago that covered the left side of a man's nose. It turned out to be melanoma in situ as I thought. He is due in tomorrow and I will talk with him about having plastic surgery.

The post operative examination on the man who had had micrographic surgery on a skin cancer on his forehead that had recurred has responded well to radical cryosurgery. He has completely healed and has reasonable cosmetic results as well as an apparent cure. His son is a physician elsewhere. The family is well pleased. Due to lack of training that results in a lack of understanding, many physicians fail to appreciate the advantages of cryosurgery over other modalities in use.

Wednesday August 09, 2006

An elderly man whom I last saw in 2001 for psoriasis (severe generalized), came for another problem. His psoriasis remitted completely six months after I took him off of his beta-blocker blood pressure medicine. He has remained free of psoriasis since then. I was the last dermatologist in all of West Texas that he had not seen when he came to me. What I am wondering is how many patients are out there unecessarily getting these highly dangerous new immune modulating drugs such as Humira and Enbrel simply because some dermatologist failed to take a medication history in relation to the patient's psoriasis. I'll bet it is a bunch.

The patient with the large melanoma we set up to see Dr. Taylor in Dallas.

One patient had a papular rash that is not exactly any that I remember seeing before. The rash started soon after her ophthalmologist started her on Vigamox eye drops. This is a quinolone type antibiotic that causes rashes and non ocular rashes from 1% to 4% have been reported on this medication. I took a punch biopsy and asked her to report to her eye doctor.

The remainder of the patients were surgical.

Thursday August 10, 2006

It is not the purpose of this blog to tell things outside of the practice of dermatology, but this is a day that I shot my age in golf at the Country Club. Also this week I received confirmation that Marquis Who's Who is including me in the 2007 editions of Who's Who in America and Who's Who in the World.

The first patient had elevated lesions of seborrheic keratoses on the eyelids which were partially obstructing her vision. I had a benign lesion of the lower eyelid removed by fulguration 40 years ago by an ophthalmologist. The residual scar at the mucocutaneous junction where it was removed still bothers me. I have never had a patient complain of residual complications from removing these lesions by cryosurgery. Cryosurgery requires elevating the lesions with smooth curved thumb forceps and shielding the eye during the cryosurgical procedure. I am not aware of any physician in this entire area of Texas who knows how to remove these as described. I often see patients who have residual discomfort of the eyelids following the use of cold knife surgery or fulguration to remove these.

Another patient had a scrotal erythema and pruritus. His family physician had prescribed ketaconazole cream, which of course it did not help. Ketaconazole cream is an anti-yeast and anti-fungal cream. The temperature of the scrotal sac is too high for yeast and fungus to grow there and scrotal rashes are never due to these organisms. The higher temperature causes greater perspiration in the area and the residual fabric softner, laundry soap, or additives to the soap, or bath soap are invariably the cause of these rashes. Many patients are so sensitive to fabric softner, that drying their clothes in a drier without fabric softner but in a drier where previous loads were dried with fabric softner sheets will cause severe scrotal itching. These patients have to eliminate detergent additives by using laundry detergent such as Cheer-Free, a second rinse cycle to remove residual detergent, and no softner in the washing or in the drier, and using a drier that no one uses with fabric softner.

The patient seen recently with lichen planus returned today, and is responding surprisingly well to topical Retin-A 0.1% twice daily.

Another patient who had been in prison and at which time he developed delusions of parasitosis of the skin presented with ecoriated dermatitis. He has a healthy heart and a negative electrocardiogram, so I am trying him on 1/2 mg of Orap daily for three weeks at which time I will recheck him.

Friday August 11, 2006

Today consisted of mostly cosmetic procedures. There is no cosmetic procedure that can take the place of a twinkle in the eyes, a smile, and a kind heart. However some cosmetic procedures can be helpful to a patient.

One patient was a Major in the Air Force who is young enough for Propecia and/or 5% Rogaine to help his early male pattern baldness. Even these medicines can be helpful to a young major who doesn't want his companion and/or subordinates thinking that he has gone over the hill.

Monday August 14, 2006

As are many Mondays, this was an overloaded schedule, overloaded with new patients with skin cancers, who came from out of town.

Several of these patients had multiple skin cancers. One dermatologist competitor will only do one cancer on a patient at a time. I suppose the reason for this is to collect the full usual fee, because Medicare and the insurance companies pay reduced fees after the first one is removed at a visit, usually half the usual fee after the first one. When these patients come to me some have been getting new cancers faster than the old ones are removed.It sometimes takes six months to a year to get caught up on them.I do limit the number of cancers removed at one time to five that because Medicare requires a narrative report on doing more than five. When patients come from distances and have five cancers, I do all five. This is what made this a long tiring day.

Also I had to work in a patient with acute herpes zooster (shingles). If these patients are to be helped, they need to be seen when the illness is early, the earlier the better.

An atopic dermatitis victim was so bad that she had to be seen in spite of the full schedule.

Tuesday August 15

An all surgery day except I had to work in four patients with acute rashes.

One man age 25 has atopic dermatitis, but came for periorbital edema and rash that is typical of contact dermatitis or possibly wind blown contact dermatitis such as ragweed dermatitis. He is on allergy injections for his hayfever. If the allergen given is too strong, this may be a factor in his rash. Many of these patients also suffer from contact dermatitis. I patch tested him and will see him in three days.

Another patient came with photosensitivity from amiodarone. This drug is reported to cause photosensitivity in from 10 to 30% of the patients taking it. I referred him back to his internist with the soft ware report that indicated he was overdosed on the amiodarone due to a drug reaction with another prescription he was taking. I am personally convinced that for many patients for whom amiodarone is prescribed, this anti-arrythmic drug is more dangerous to take than not to take.

Wednesday August 16

Except for one acne patient who is doing well and for the herpes zooster patient seen last Monday, all patients were for surgery.

One patient who had a nevus excised from his ear last week, returned to have this melanoma excised. This required partial removal of the ear. It appears that he may not need reconstruction of the ear since I think that after it heals, it will look cosmetically satisfactory to him and his family.

Thursday August 17, 2006

The first patient was a heavy equipment dealer who needed a flight physical. His eyes correct satisfactorily for distance vision, but he is virtually blind without corrective lens. He inquired about eye surgery for correcting his distal vision. Because he had no ophthalmologist already, I recommended to him Dan Wilson, MD, in San Angelo, Tx, as the most meticulous eye surgeon that I know. He has done Laser corrective surgery on 4 members of my family. All four had excellent results without any corrective revision surgery being necessary. He is the best from my viewpoint.

A man who has suffered from severe seborrheic dermatitis in the past was in for removal of actinic keratoses. He wanted a refill on Nizoral Shampoo 2%. Most patients with seborrheic dermatitis do well by alternating shampoos of Head and Shoulders in the dark blue bottle containing selenium sulfide with the regular Head and Shoulders Shampoo containing zinc pyrithione 1%. This is a lot cheaper than using the ketaconazole shampoo, but once in a while the latter shampoo seems to be necessary.

The lady that was in about two weeks for a rash due to Plavix returned today. She is improved after leaving the Plavix off, but due to the long lasting half life of this drug, she is not yet completely recovered.

A 17 year of age white male patient had a classical rash of guttate psoriasis. His skin had been biopsied and the specimen sent to the general pathologist. The report was given as skin not being diagnostic of any skin disorder. I re-biopsied the margin of a lesion and sent it to DermPath in Dallas.

The man with the rash and puffy eyelids that I patched tested last Monday came back a day early because the skin under the patches was severely itching. The nickel sulfate and Thiuram patch areas were swollen, blistered, and erythematous well past the margins of the patches for these two chemical. I gave him material data sheets on these two contact allergens and will have him check to determine if any of the other patches cause a reaction by tomorrow. Rarely patch take up to 4 days to cause a reaction in the skin under it.

The last patient had severely irritated lesions of seborrheic keratoses in his intergluteal area which is an intertrigenous area of skin. I treated one side (one buttock) of the lesions with cryosurgery and will wait about a month to treat the other side. Seborrheic keratoses in this area become irritated easily the same as often seen beneath the breasts in female patients.

Friday August 18, 2006

The first five appointments were filled with new patients. Four of the remainder of the appointments were for new patients. The employee that answers the phone and makes the appointments was absent today. Such a schedule lacks the use of common sense and corrections will be made in the way the appointments are given.

The first patient was an eighty year of age male who has an apparent skin rash due to Plavix over dosage over a period of time. The half life of Plavix is long enough that it will take some time to be sure of the diagnosis. He was getting an overdose of Plavix due to an interaction with another medicine.

Two other patients had rashes that appeared to be due to overdosing from drug interactions. Biopsies done on both. To have three patients in one day in which the interaction software shows over dosing on two medications or more per person and per physician for that person goes to show how under trained the present day doctors doing primary care are. When physicians with their amount of training make such awful mistakes, how can a Nurse Practitioner or a Physician Assistant in their short training courses be safe for the patient see? Consumer (patient) beware!! The patient has the final responsibility in this matter and a few of my patients are beginning to learn how to exercise their responsibility.

I removed two keratoacanthomas today. Also checked several for nevi, some with relatives with a history of melanomas or dysplastic nevi.

Monday August 21, 2006

The air conditioner was not cooling and the AC people were prompt to come. However the first three hours were hot. The first patient who was scheduled for 45 minutes of surgery I rescheduled. That long under hot surgery lamps in mid ninety degree weather is enough to dehydrate anyone.

An eleven year of age female presented with the white spots of pityriasis alba. Her father is an asthmatic. Pityriasis alba patients often have a family history of asthma. I reassured her and her mother.

A soldier who has suffered from severe plaque psoriasis is doing wonderfully well after being placed on Ceftin 250 mg twice daily for the past 30 days. When he first came to me, he was discouraged because no physician had been able to help him with this particular flare-up. This treatment for psoriasis I copied from Walter B Shelley, MD, who wrote several books. So far as I know he is retired and living.

Another patient who had been suffering from severe psoriasis came to have his IVV no. 4 refilled. He is doing well with no rash and very slight itching of the skin. No 4 IVV is a 1:625 dilution of influenza virus vaccine (killed vaccine) diluted 1:10 times and administered subcutaneously in the amount of 0.5 cc twice weekly.

A 29 year of age female had perioral dermatitis. Her physician had prescribed erythromycin which was not helping. It has been my experience that tetracycline remains the treatment of choice for this condition.

Tuesday August 22, 2006

Today was reassuring. The third patient came to me 3 months ago for mycotic fingernails. She had been to a lot of doctors none of whom had helped her with her painful tender finger tips. About every prescription and over the counter (OTC) product imaginable had been tried. I had her family doctor check her for diabetes mellitus. After three months of careful control of her diabetes and the use of antifungal medications, she has the best fingernails that she has seen on her hands since 1978.

The man with the severe tinea pedis and onychomycosis who came to me 3 months ago is finally well. At that time his feet were raw and it has taken 3 months on Lamisil for his skin to fully recover. He does not have diabetes.

Wednesday August 23,2006

A WWII fighter pilot was first today. He was in a talkative mood and told about day in 1944 that he was shot down over France. He still flies a restored AT-6.

I was seeing one man for actinic keratoses of his face. It had been awhile since he had been in the office. When I finished with his face I had enough presence of mind to ask him if he wanted me to check his back. Sure enough there was an early melanoma there that I did an excisional biopsy on.

Another man had what appeared to be a melanoma on his right lumbar region that I also did an excisional biopsy on. He had a melanoma in situ on his right temple that I excised in 2001. When a patient has had one melanoma, a second melanoma is more likely to occur than in the average patient.

A man returned after biopsy of a dysplastic nevus for complete excision. There was a second nevus that was suspicious looking and I biopsied it also.

Thursday August 24, 2006

It has been somewhat over a week now since I have not seen at least one or more keratoacanthomas on a daily basis. In my practice over the past year there has been an increase in the number of these tumors seen. At this point in time I do not know if this is a national trend and that these tumors are becoming more common or not.

The patient with the melanoma on his ear came to have the sutures removed. He is happy with the cosmetic results of his partially remaining ear as well is his spouse and his children.

I had a lady who felt terribly bad with symptoms of about every system on systems review. Her chief complaint was a generalized pruritic blistering (vesicles on examination) rash, typical of drug rash. She was on an overdose of Toprol due to drug interactions with several other medicines. Drug overdosing due to drug interactions is now the most common problem in my medical dermatology practice (non surgical dermatology) , even more common that acne vulgaris. This is known as iatrogenic disease (caused by physicians). I know that this may be somewhat repetitious, but it is so rampant that it deserves the emphasis of repetition.

Friday August 25, 2006

On some days we have a few patients who do not have any medical insurance. These are usually young to middle aged male patients who are in good health and always pay cash. Seeing these patients is like practicing in the mid 1950's when most patients did not have insurance that paid for visits made on an outpatient basis. With them there is a more direct doctor-patient relationship that is present, making the decisions more simple and meaningful. Today was such a day, sort of enjoyable.

One man had a nevus on the back of his neck that appears to be an early melanoma. I excised it and sent it to DermPath.

Monday August 28, 2006

Over the summer there has been a slowly increasing number of patients making appointments to have there "moles" checked.

There were four patients who specifically made appointments for evaluation of their nevi today and one of them had a definite early melanoma that I excised. Another had a probable melanoma.

It rained an inch and a half here over the week end and the temperature has cooled down significantly. When it is as hot as it has been the past few weeks, I expect to see and did have some of the patients show up who have nickel dermatitis. Because nickel sulfate is accumulative in the skin, it is almost impossible to steer completely free of nickel.When the weather is so hot that the skin stays drenched with sodium chloride from sweat, the accumulated nickel converts to newly formed nickel chloride on the skin and does its dirty work.

Tuesday August 29, 2006

Except for a Flight Physical on a physician, every thing else was procedural (surgical) dermatology today. I was able to do all of the procedures cryosurgically, which saved money for the patients. In trained hands and contrary to many published reports, the final cryosurgical results are almost always superior to those of other practiced procedures.

It took the usual forty minutes to make all of the phone calls to give patients their DermPath reports.

Wednesday August 30, 2006

This year I have been seeing more epidermoid (sometimes known as inclusion or sebaceous) cysts this year than in any year that I can remember. It coincides with the time frame of the big push to use less antibiotics. The correlation between the two probably is not coincidental but real.

Today I saw more patients with symptomatic epidermoid cysts than with skin cancers. This has never happened in my practice before.

A nurse came in from up country due to an anti-venom rash. The anti-venom was used in treating a rattle snake bite and was given on three different times. Each time she went into anaphylactoid shock and her husband says she died each time that happened. Due to the amount of the glucosteroids she was given, her diabetes mellitus flared-up severely. She is in distress emotionally and I did something I almost never do. I prescribed Lexapro in addition to treating her rash.

Three patients were treated for drug interactions and this continues to be a growing problem in the practice of dermatology.

Thursday August 31, 2006

A lady came in for a place on her neck, whom I delivered two of her babies by C-section over 40 years ago when I was doing OB-Gyn. She was a nurse and said she came to me because I was the only one that she observed who didn't hug and pat his patients on the buttock. Back then we had no female physicians who practiced OB-Gyn at this hospital.

The patient who was patch tested last Monday had a positive reaction to the wool alcohol patch. This chemical in present in many cosmetic products.

I am finding that Hylira hydrating lotion is most useful for patients with dry skin. The number of refill requests is usually a good indicator of the usefulness of this type product.

Friday September 1, 2006

A post operative examination on a lip cancer patient reveals that he is doing good at this point in time. Since it is secondary to actinic cheilitis, I anticipate no problems.

The second patient seen has been running cable lift Caterpillar tractors since WWII.

One patient had moderately severe asteatotic eczema of the legs and th fourth patient had moderately severe pruritus (itching) from seborrheic keratoses on the legs and mixed with it mild asteatotic (dry skin) eczema of her legs. The sad part is that she had been to the emergency clinic where the doctor diagnosed her problem as vasculitis and referred her to another dermatologist. The patient claims that this dermatologist just read the referral note and wrote her a prescription without ever examining her legs visually. She of course continued to get worse. The seborrheic keratoses will respond to cryosurgery and the asteatosis is mild enough that she will do well with a moisture lotion containing a corticosteroid.

A young lady had a pyogenic granuloma on the flexor part of her thumb. These are vascular lesions that bleed easily and do not spontaneously subside. Some advocate biopsy of all of these lesions to rule out amelanotic melanoma. I have seen hundreds of these over the years and all have been benign.

Monday September 4, 2006

Holiday.

Tuesday September 5, 2oo6

Started off the day with a dental appointment for routine cleaning.

The first two patients were seen for skin cancers on the rim of the ears. To prevent partial loss of the ear, these are best treated cryosurgically.

The third patient came for a post operative examination following treatment for a basal cell carcinoma on her left forearm. An incidental finding was a myxoid cyst on her thumb between the distal joint and the proximal nail fold. The percentage of cure is as good injecting the distal joint with Kenalog as the hand surgeon obtains as huge differential in price.

Another patient who has made the circuit with non responding psoriasis was found to be on a beta-blocker. As soon as his cardiologist is able to change this medicine to one that does not cause psoriasis, he should begin to improve.

A new patient with angular stomatitis should respond to Dr. Smith's Adult Care Ointment. This ointment is to be kept out of reach of children and can be purchased over the counter.

Wednesday September 6, 2006

The first ten patients were for lesions of the skin, mostly skin cancer.

Then came a lady with acute contact dermatitis of the upper chest primarily. She had clothing marks and the rash had margins as does contact dermatitis often have. She was too acute to patch test so to get her out of her misery I gave her 80 mg. of Kenalog I.M. Kenalog needs to be given in gluteus maximus muscle. If this medicine leaks back into the subcutaneous tissue it causes a sterile abcess of bloody water, usually huge. At one time (many years ago)I let the nurses give these injection, that is until I had to drain one of these abscesses after my best nurse had given the injection. Since then I have given all of these injections and have never had another problem. The best way in my opinion to prevent the problem is to hold pressure on the injection site with the finger for thirty seconds. This seems to work better than the method of sliding the skin to make an s-shaped injection track that once was recommended for preventing iron injections from leaking out of the muscle back into the subcutaneous tissue and skin surface.

The next patient had an acute and severe contact dermatitis starting on top of his foot after wearing a new pair of imported shoes. He used various over the counter topical products several of which are notorious for causing contact dermatitis. The rash spread and is too severe for safe patch testing at this time. I gave him a Kenalog injection and had him discontinue all of the products he had been using. It is common to see a patient with a localized contact dermatitis that becomes a generalized contact dermatitis secondary to a topical allergen used for treating the original problem. Neomycin in Neosporin ointment is one of the most common topicals where this is seen. This patient had been using Neosporin ointment.

Another patient with contact dermatitis from a necklace was seen toward the end of the schedule. On reviewing the history in detail, it is probable that her rash started from wearing what she called a platinum necklace. I prescribed triamcinolone acetonide cream and she probably will do well.

Thursday September 07, 2006

The lady with the contact dermatitis due to wool alcohol was in and is almost completely clear after leaving off her offending cosmetics and toiletries.

The patient with the melanoma on the shoulder returned to have all of his sutures removed except for two central retention sutures. The tissue report came back as scar of operation, no tumor seen, indicating that the melanoma was removed on the excisional biopsy.

A man who deals with merchandise over e-Bay and has a pawn shop was in and told me that the set of Hickory Shafted Irons that I bought from him about 15 years ago are now going for three times what he sold them for. He has been a good friend and patient for a long time.

Friday September 8, 2006

A lady who came in last Monday for herpes zooster deserves to be named the patient of the week. She began to break out about 12 hours before she called and came in. If herpes zooster (shingles) can be treated within the first three days of onset, treatment usually helps considerably. I soaked the lesions with 3 % dialdehyde and prescribed Valtrex 1,000 mg three times daily. She took one Valtrex tablet and before it was time to take the second dose, she broke out in a severe erythematous rash and had swelling of the lips. The one tablet of Valtrex was all that she took, which probably had no bearing on the course of her illness. She returned daily through Thursday for dialdehyde soaks and had no pain after about noon on Wednesday. Benadryl took care of the rash by Thursday. She never complained and sent me another patient during the interim. No new lesions of herpes zooster appeared after the first soaking with dialdehyde. This is the treatment I depended upon before the oral antiviral medicines were available. Sometimes it is comforting to back in time and to realize that those times had their ways that worked.

This morning a new patient, age 21, had herpes zooster. Usually the younger the patient, the less likely they are to develop post herpetic neuralgia. This patient has no pain associated with the shingles even though the onset was six days ago. It is too late to expect Zovirax, Famvir, or Valtrex to help him. The duration of the rash probably can be shortened with dialdehyde soaks and at least make it less contagious.

A retired school teacher who taught all of my children came for a basal cell carcinoma on his nose.

Some patients are big people, and one such lady went to one of the rest rooms and fell against the commode. Her fall knocked the commode water chamber loose from the water line that went into the bottom of the back of the commode. Water sprayed over all of the rest room and one of the nurses drenched reaching under the back of the commode to turn off the water line that emerged from the wall. Also the floor was flooded.

September 11, 2006

Among the evaluation-management patients, I saw one with a rash from paint thinner, one with Grover's disease, one AART patient with a folliculitis of the buttock, one with asteatotic eczema, one doing well with her acne regime, and one with respiratory allergies and atopic dermatitis.

The procedural patients were mostly skin cancer and actinic keratoses severe enough to require cryosurgery. One patient had a lesion of leukoplakia on the lower lip that required a shave biopsy.

Tuesday September 12, 2006

Except for two patients, one who had a rash from Paxil and the other had a localized contact dermatitis (balanitis), all patients were surgical dermatology patients.

Of the procedural dermatology patients, one appeared to have a lentigo maligna of the face. It may be a developed melanoma. It was large enough to have progressed that far. I'll be anxious to get the path report.