Dermatology with Dr. Newsha Lajevardi

Virtual shadowing by Med School Coach brings you up close and personal with physicians from many different specialties. Walk through tough cases with each doctor and learn about their triumphs and the challenges that they face on a day-to-day basis. To view the video that this audio is from and to take the quiz that is associated with each podcast, visit shadowing.medschoolcoach.com. Today we are joined by Dr. Nusha Legivari, she is a dermatologist. Dan and I will spend about the first 15 minutes or so talking to Dr. Legivari about her journey into medicine and into dermatology, and then we'll get on to some interesting cases. So first off, Dr. Legivari, I want to say thank you so much for joining us. We're both really excited to hear about dermatology. Thank you so much for having me. I'm really excited to share my experience. So I'll start with a pretty basic question here. What motivated you to pursue a career in medicine? It's a great question. Growing up, I actually was drawn to medicine, not because I had anyone in my family who wasn't medicine necessarily, but I honestly loved going to my pediatrician. And so I was drawn to the sciences, just loved the idea of being able to help people. So even as a child, I was fascinated with medicine, and I had this in the back of my mind entering college. And so, knew I would be pre-med in college, and I'm sure we'll get to how I ended up going to medical school. But interestingly, I did take a nontraditional path in the end in attending medical school. Can you talk a little bit more about that nontraditional path and what you mean by that and how you ended up getting to the point of applying to medical school? Yes, absolutely. So for me, I did up, I'm from Miami, it was born and raised in Miami, went out of state to school, went to Northwestern, was a pre-med there, but also was a psychology, had a degree in psychology or got my degree in psychology. I knew that I needed to sort of beef up my academic record. So I pursued a master's in medical sciences at Boston University, knowing that I wanted to enhance my record and put myself in the best position to apply to medical school. So I then moved to Boston, I pursued this degree, this master's in medical sciences for two years. The first year was more upper level, upper level science courses where I actually took some first or medical school courses. There was more laboratory research, so I worked in a lab in dermatology actually in the dermatology department, completed a thesis, and then I, at that point, even thought, okay, well maybe I want to explore research a little bit more. So I actually ended up doing two additional years of clinical research, and during these two years, I applied. So the first time I applied to medical school, I actually didn't get in. So I was a reapplicant and then reapplied and was successful. And so my journey really from undergrad to medical school was four years. So it sounds like you had some idea then that you wanted to go into dermatology. Maybe if you were doing dermatology research, is that the case? And the, you know, me being connected to the dermatology laboratory at Boston University was totally by chance. I needed to pursue a position in a lab to complete my laboratory thesis. And I had just emailed a bunch of different departments and dermatology got back to me. They had a position. And so I was connected with them. And then that is when my interest in derm peaked, because, or was peaked, I could say, because I started to talk to the residents who worked in the lab. And they were, they've just loved the field. They told me a little bit about it. They had nothing but positive things to say. I definitely was drawn to the research side of what I was exploring. And so when I did finally enter medical school, I also had in the back of my mind that possibly dermatology may be a good fit for me. And it was very open-minded. I was also very much drawn to pediatrics and was wasn't necessarily committed to derm even as I entered medical school, but I thought it could be a possibility just given my background in it. Sure. Right. So, I mean, it's no secret that dermatology is extremely competitive, especially these days. And for somebody to even get into a dermatology residency, it's, there's a lot of chance involved. There's a lot of time people have to spend kind of like you said, beefing up their application almost, I know a lot of people take years off to do research during medical school as well. I kind of advise you have to students who may be interested in dermatology in our pre-meds and want to kind of get a running start when they enter medical school. That's an excellent question. It's true. So dermatology residents, you're landing a dermatology residency can be really competitive. And so my advice is if there's even a little inkling of being interested in dermatology to explore that interest as soon as possible. So that may mean shadowing dermatologists early on. So I would say even in the pre clinical years of medical school. So that means the first and second years of medical school. And perhaps pursuing research opportunities research is huge in landing a dermatology residency. So sometimes that means just as you said, taking an extra year during medical school. So usually that's between the third and fourth year of medical school. Or perhaps pursuing research opportunities while in medical school if you are someone who's really good with time management. So research is really important. And in pursuing clinical opportunities early on so you can really solidify or determine whether a term is where, you know, you want to be. Now, were you able to pursue research opportunities in medical school? I know it's extremely busy. Was that something you did. Well, for me, I, it was different for me because I actually had a year of germ research before going to medical school. So really, really helped me. What I ended up pursuing while in medical school was more case studies and case reviews things that I could do on the side while being a full time medical student. I do think it's very difficult and challenging to be part of a lab and also maintain your academics. And that is why so many students who want to go into dermatology end up doing this gap year. And another piece of advice I would say is sometimes students are hesitant to take extra years because they think they're older. They don't want to waste time. They just want to go through. And in the grand scheme of things, if it will help you get your end goal, one year means nothing and it ends up being so instrumental in getting, you know, to your life goals. So if there is a pre-med or a medical student who's entertaining dermatology, who really needs that research year between third and fourth year, I would really encourage them to take that year because really again in the grand scheme of things one year, it's just, it's nothing at all. And that's a fantastic point because, you know, one year compared to a lifetime of a career so small, but it makes such a big impact on, you know, what kind of training you get and making sure that the field is right for you, that it's, it's a pretty worthwhile investment. And although we kind of get into this mode of trying to rush through our education, education is a lifelong journey and one year of taking a year off and getting researched on is just a really small part, like you said, and yeah, I wanted to kind of talk a little bit about that because, you know, when you went to medical school and you knew that you had certain interests, how is your experience overall, like, what was it like being a medical student in general? So being a medical student, you know, for me, especially as a reapplicant, I was extremely excited to be in med school and pursuing my dreams and just, you know, in my eyes really at one of the final stages of getting to where I wanted to be. So very excited, but also extremely overwhelming. So I think the amount of information that one receives during the pre clinical years is a lot. I think the first year is very overwhelming, but completely manageable. So I think, you know, that was part of it to being excited, being overwhelmed, adjusting, learning a lot, and then, you know, once you get through all those studies and the pre clinical curriculum, entering the rotations is wonderful because that's when you get to be hands on, that's when you're applying everything you've learned to the real world, so to say, that's when you meet mentors, that's when you're inspired. So it's really an extremely, you know, unique experience overall. Now, last question here before we go into your slides, is there anything that you look back at now that maybe you didn't understand about a career in medicine that you could tell pre meds and medical students that would be helpful for them? Yes, probably a lot of different things, but one thing that comes to mind is, I guess I didn't actually realize that you are truly a lifelong learner and medicine evolves. So just as a person grows, so does medicine, their new medicines, new, you know, pharmaceuticals, new studies, new diseases, and to be a really great clinician. always have to be up to date and to be up to date that actually requires keeping up with journals, you know, attending conferences, talking with colleagues. So and I'm happy that this is the case because I love learning and I love knowing everything about my field and trying to be up to as up to date as possible. But I don't think I realized that as a medical student or as a pre-mad, I thought, okay, I'll go to medical school and I'll do my residency and then I'll know everything there is to know and that's it and that's just not true. So you have to be ready to understand that in order to be a really great clinician, you always want to be learning and you always want to be motivated to learn. To receive one hour of credit for this shadowing experience, take a brief five-question quiz at shadowing.medschoolcoach.com. Pass the quiz and you'll receive a certificate of completion from medschool coach. Now back to the show. All right, so I will be presenting on dermatology as part of our med school coach virtual clinical education series. Again, my name is Yusha Lajvarati. I have an MD and the MA is for my master's in what the FAAD means is a fellow of the American Academy of Dermatology which shows that I'm board certified dermatologist. And here we go. Okay, so disclosures, I have no conflicts of interest to disclose. And objectives, we're going to go through the day-to-day of the specialty of dermatology. We'll go through what, how long really a dermatology training is, if there's fellowships involved and so forth. And then we'll wrap it up with some clinical cases. All right, so first I'm going to just start with a typical day as a dermatologist. Of course, it depends on what type of dermatologist you are. So there are actually multiple types of dermatologists. You can be what's known as probably by most people a medical dermatologist who sees patients in the office and sees patients of all ages. So that would range from pediatric all the way to geriatric. Then there are specific pediatric dermatologists who will only see pediatric patients or children. We have most surgeons and most is a type of skin cancer surgery. It's most micrographics surgery. And basically a most surgeon is someone who is trained in treating skin cancers. And this is a very special technique where the skin cancer is removed in stages. And the same surgeon is also trained in looking at the specimens under the microscope to determine whether there's any cancer cells still remaining. There's also dermatopathologists. So these physicians are doctors who are dermatologists, but also have additional training in pathology so they can reach slides, specifically biopsies from skin. And we have cosmetic and laser dermatologists who may only, let's say, specialize in cosmetic and laser procedures. So again, the typical day depends on what type of dermatologist you are. I would say that most dermatologists practice a combination of medical, surgical, cosmetic, and laser dermatology. So that's one of the fantastic parts about germ is there's a lot of variety, which entails seeing patients for medical visits, for skin checks, for acute visits, being able to do your own surgeries, and then also being able to engage in some cosmetic summators. So again, to my point, a variety of patients and procedures, all in an outpatient setting for the most part, there is part of dermatology that is developing now more as an inpatient dermatologist and one who does consults at the hospital as well. But typically, a dermatologist is going to see patients in the office. You know, for me, personally, my day starts around 815. That's when my first patient is scheduled. And I have patients every 15 minutes throughout the day, apart from my lunch break, and usually my last patients at 4 p.m. And as an attending now, I do work four days a week. And interestingly, as a dermatologist, there is perhaps some call or hospital call involved. I personally work in a private practice, but prior to working in the private practice that I'm at, I was in an academic department. And when I was in an academic department, as an even as an attending, I did have call, which meant I did have to cover the hospital consults. So that those are patients who are hospitalized, maybe for other reasons, but then happen to have a dermatologic emergency or a skin issue that's more urgent and needs to be seen at the hospital. And so, depending on the practice that you're at, you may actually have to cover call or hospital call. Call may also mean that you have to cover patient phone calls. So just after our emergencies, let's say from surgeries and so forth. And as a dermatologist, I would say typically you see patients every 15 minutes in clinic. Obviously, some patients, patient visits take much longer than this. Some patient visits are shorter than this, but this is how we're scheduled. And then, you know, depending on the way your days are divided, you may have a surgical day. For me, for example, on Wednesday afternoons, I do mostly all my surgical decisions, which means I'm taking out skin cancers. I am taking out cysts, maybe lipomas, which are fatty tumors. And then I do have a cosmetic day. So these are the days or laser day two. These are the days where I may do more cosmetic procedures. So this would entail injectables, like toxins and furs, and then lasers, which we do for a variety of reasons. So there's a lot of different things or components to my day. And Dr. Legevarty, based on all of that, what's your favorite thing to do on any day? Like what's your favorite procedure, your favorite way to treat somebody or the favorite thing to do overall as a dermatologist? That's such a great question. You know, I love my procedures, which also, I should say, dermatologists do a lot of small procedures like biopsies. But I really think at the end of the day, my favorite kind of visit is a visit where I've seen a patient for a rash that, let's say, they've gone to other doctors for who didn't know what it was. And I've biopsied it. I've, you know, gotten a diagnosis. We've discussed therapy. And I put him on a medication, which has totally cleared the rash and changed their life. So for me, that's actually the most fulfilling type of visit. Nice. Great. So, oh, and of course, we have lunch in the middle of the day. At the end of the day, a lot of times I'm reviewing my biopsies. So these are again, our biopsies of skin that I have done on my patients. I get the results back. I'm looking at the results and following up with my patients, if they have a skin cancer, let's say, a melanoma returning patient calls and just wrapping up my charts through the electronic medical record system. All right. So dermatology training. So this is basically, you know, what it takes to be a dermatologist after medical school. So after four years of medical school, we start our residency. And for dermatology, we have to match into both a one-year preliminary residency. So you can think of this one year as sort of like a general residency. And then the dermatology residency itself is three years. And the match happens in our fourth year of medical school. So you would match into both components of the residency at during match day, basically spring of fourth year of medical school. Okay, here we go. So in essence, dermatology training, dermatology residency training is four years total. This first year can be an internal medicine. That's personally what I did. I did what's called a preliminary internal medicine year. It could actually be done in general pediatrics. It could be done in general surgery, or there is such thing as a transitional year residency, where you kind of get a little taste of all different specialties. And then you have three years of actual dermatology residency. You do take your dermatology boards exam to be board certified dermatologist at the end of residency. Typically, this is in July after your last year of residency. And then I also just wanted to mention that even after dermatology residency, although dermatology is a highly specialized field, a lot of residents choose to pursue a fellowship. So by and large, I would say most dermatology fellowships are one year. And the fellowships that are most common are most surgery, where you can become a most surgeon, which I discussed at the beginning. You could do one year of pediatric dermatology fellowship. You could do a year of dermatopethology, where you can read slides. And recently, I would say in the past five to 10 years, there's more cosmetic dermatology and laser surgery fellowships. Some of these specialties require additional board certification. So you may end up taking additional boards to be board certified. Let's go back. Oh, and then another thing I wanted to mention, continuing medical education requirements. So beyond residency, you're always going to be responsible for getting more CME credits. This is part of a life being a lifelong learner. And then every 10 years, you are expecting to take your board's exam to be re-certified there may be or there are some other American board of dermatology requirements as well. All right so that wraps up you know this first part to do you have any questions or should I just go on to the clinical cases? One one question that comes to my mind is you know you talked about how how big of a variety of patients you have is there any type of patient that shows up a lot or is it really so so much of a variety you can't even pick out like kind of a typical patient? So another fantastic question I would say that when you are in private practice and practicing as a general dermatologist you are going to see a lot of full skin checks. So these are patients who are coming in to get their entire body scanned for skin cancers. While they come in for you know maybe this one thing the full skin check they may have other issues so they may have let's say eczema or atopic dermatitis they may have psoriasis they may have lupus and you may address these issues in these visits as well. So I would probably say the majority is going to be full skin checks for you're basically doing a surveillance and screening for skin cancers and then biopsying any you know specimens or moles let's say your growth that seems suspicious and then the other majority or part of what I would see mostly is rashes or chronic skin problems just like we mentioned things like eczema psoriasis acne are the most common things. Any other questions? All right should I move on to the clinical cases? Okay perfect. So I chose cases that are very much bread and butter dermatology and you know they you may not feel or some people may think that there's not too much to these types of diagnoses but I figured they would be valuable in sort of getting a taste into germ. So here are just some photos of some patients and I would say probably most people would look at this and say these are pictures of the face of course okay this looks like pimples and that is right this is just non inflammatory or comodonal acne and I'm going to flash some other photos again some acne this looks angrier I think most of us could agree you know the pastures the redness just a lot of erythema so this becomes inflammatory acne and so inflammatory acne is made up of papules and tustules so in dermatology we have a lot of terms basically describing morphology of skin lesions so that's really important to us in dermatology inflammatory acne is made up nodules and cysts it can result in scarring post inflammatory hyperpigmentation so that's a type of scarring essentially where you hyperpigment and then what's important to know with acne is there's different types of it so like I showed there's inflammatory acne there's non inflammatory acne there's even acne that causes fevers and joint pain and this is this last bullet point here acne conglubata it's a severe form of nodules cystic acne that presents us really really inflamed acne along with joint pain in the knees the back maybe the elbows and then fevers well and this is again inflammatory acne let's go back and you can just kind of see obviously this other picture here on the right is scarring acne and then there's a lot of other subtypes of acne like I mentioned there's acne form anans which is a type of inflammatory acne and like the one that we talked about with fever and systemic symptoms there's interesting some interestingly something called acne scorea has its own diagnosis and this is a even thought of as more of a psychological condition what some people may not know about dermatology is there's a huge psychological psychological component of it into its diseases as well but this is when patients actually pick at all of their acne lesions and then there's acne and it's all women which looks different than typical teenage acne or some of the acne that we saw and I'll show some photos of that as well so this one actually is a these are photos of acne form anans or acne conglubata which is again extremely you know angry acne very inflamed huge pastels and sinus tracks it almost exclusively affects males particularly young males and again they're gonna have systemic symptoms and that means they're gonna have symptoms like fever and joint pain so we treat this with steroids to calm everything down and then also with a type of acne treatment something known as acutane or isotratinoin what causes that type of acne is is there a known cause no we don't really know it's a great question we don't know if there's maybe an autoimmune component involved in this or it's just you know someone who has terrible luck and has awful awful acne and it's just so much inflammation in the system that it's not only presenting in their skin but it's also affecting their organs internally essentially so we treat it as almost an autoimmune disorder which is where the steroids come in where we have to calm down all the inflammation and once things are calm then we can actually address the acne yeah all right so this these are females and you know we talked about acne excoriate you can see every single little lesion on their faces is picked at so this is acne excoriate it also has a french name acne excoriate desion feel which just means excoriate acne of young females and when you're talking to these patients you know they really they don't want to pick at their acne it's just a habit that has formed and a lot of time there there may be some underlying anxiety involved and it is a really really tough habit to break but very satisfying if you can get these patients clear so this requires a lot of counseling with patients a lot of talking sometimes we even have to get you know cognitive behavioral therapists involved or psychologist involved to sort of address the picking part of it while as dermatologists we try to clear their skin of the acne so there's no more lesions for them to pick at all right and so here are some female patients with acne all along the jawline and what this is is basically post adolescent acne or acne and adult women so there really is another entity entity of acne in women who are about 25 and older who basically present with maybe never had acne as teenagers maybe they did but then in their adult years just have really inflamed sort of deep rooted deep seated nodules around their jawline we think maybe this could be due to some androgen excess so that's excess of certain hormones like testosterone these patients sometimes also present with something called charsetism so increased hair growth on the face and sometimes they may actually have polycystic ovarian syndrome so they may have irregular periods and cysts in their ovaries and so this also becomes and you know involves sort of addressing the acne not just the acne component but the part of the disease which is the androgen excess so we'll oftentimes treat this type of acne with anti-androgen so those can be oral contraceptive pills or a medication known as spinylactone which is diorotic but it also helps control testosterone or hormone levels all right so you know my point with this is you know a lot of times you think of dermatologists you think of pimple poppers and just acne and that's all they're doing but as you can see there's a lot of different components to acne and for many dermatologists it's one of their favorite diseases to treat because number one it's so satisfying to have a patient clear of acne number two honestly acne has a huge impact on quality of life so to be able to get patients clear is very satisfying and and then number three there's just a lot of different tools we have in our toolbox so it's important for the acne to be addressed in the right way so when you see a patient with acne sometimes you can be fooled so they're actually maybe you know bumps are not always just acne so there could be something like molaskum which is basically spread through a virus it looks like pink flesh colored papules or bumps on the body other adnexal tumors so adnexal means tumors that derive from either you know hair follicles basically or glands so those can look like pimples because they just kind of look pink and bland sometimes it can be folliculitis which is just inflammation of hair follicles you want to ask the patient about their history you know are they male or female how old are they what is their occupation let's say they're sweating a lot or you know these days we talk about mask knee all the time because it truly is a thing right and that has its own diagnosis that's just mechanical acne, which is basically acne due to the mechanical rubbing of a certain of something on the face. You want to ask them about their skin care habits, their desire for treatment, you know, how aggressive do they want to be, are they looking to be totally clear, do they want to take pills, they want to take more of a natural route, family history of acne is also important. And then we go on to the physical examination, so we're looking at the skin type of the patient, which really means their pigmentation, you know, we have fairer patients all the way to darker skinned patients and acting presents in different ways and scars in different ways in these different patients. Is their skin type oily, is it dry, what are their lesions like, are they scarring, where it's the distribution, is it just their face, is it their face or chest and back, you know, here's the two of them is the increased hair group that we talked about, is there a deep voice involved, which would then again indicate more of a hormonal component and then the severity of acne, which is rated really mild moderate and severe. So treatment modalities for acne, so we obviously have topicals, which are going to be creams and washes top things like topical retinoids, so everyone, you know, a lot of people hear about retinols in the media, topical antimicrobial, so these are things like benzal peroxide, clindamycin, oral antibiotics, but we really use this more short term. These days, this was something that dermatologists may have used long term many years ago, but what we know about antibiotics is they do change the good gut flora in your intestines, so it's really just use as a temporary bandaid and we want to take you off of it quickly if you're on an antibiotic. Oral contraceptive pills are FDA approved for acne. Spurnal actone, as I mentioned, it's a diorotic, this is actually not FDA approved for acne, but is used extremely commonly off label for acne and adult women. Oral isotretinoin, so this is a type of synthetic vitamin A, it's also known as acutein and that's really our magic bullet for acne that gives us a cure or the best chance of cure. There's light based therapies, so we might do things like blue light or red light we can do chemical peels and of course patient education is really important because whatever we do there's always a routine involved to spending lots of time with your patients, so they're really clear on their routine. So we'll run through this quickly, but basically mild acne, you'll start with a topical, maybe a topical retinol, then a topical antibiotic, you might throw in some chemical peels, treatment of moderate acne, usually we'll do the oral antibiotic short term with a retinoid second line, an antibiotic with a retinoid other topicals like as like acid, and if someone's scarring will start to have that conversation about acutain or isotretinoin. For female patients, we'll think about birth control pills, the oral contraceptive pills, plus or minus spurnal lactone. And then these are just, you know, for anyone who's interested, we've got different oral contraceptive pills who do have that which do have the FDA approval for acne. And then spurnal lactone dosing and then of course oral isotretinoin, which I called the magic bullet because it really is meant to cure patients of acne if they go through a course of oral isotretinoin. I would say 70% of patients don't get acne again, 30% do what do we do in that case a lot of times they'll do two or three courses of isotretinoin. And then treatment of moderate to severe acne really we're talking about oral isotretinoin here there's some other orals that will that we can sometimes use we may inject their big pimples to that's institutional catalog on the right. Okay, so we're going to the next case this is a photo of the back of gentleman he is covered in these plaques with soberly scale. And I'll show another picture here, but this is an extremity of a patient again with these really well demarcated arithamides pink plaques with silvery scale. And so this is psoriasis, which is huge these days because there's so many commercials about all the therapies involved and biologics that you can use along with all of their crazy side effects. But this is the typical type of psoriasis that we know of and that we commonly see it's called chronic plaque type psoriasis. And then chronic plaque type psoriasis presents as relatively symmetric arithamides, which means pink or red, scaly plaques, so when I say symmetric, I mean mostly both sides, right, so you're going to find it on both elbows let's say both knees behind both ears, okay. Not usually on one side or the other that's not impossible, but not usually most common type of psoriasis for 45% of patients agenda tail is involved so it could be in their buttocks it could be in the front side, but this is an important area to address to. And the parks, you know, unfortunately, they can persist for months to years and they can get worse and worse so it can be a progressive disease and we do have this rating scale to help us figure out whether a patient is eligible for a medication such as a biologic medication, which would meet injections it's known as the psoriasis area and severity index a lot of times these are used in articles and clinical trials. Of psoriasis as well and we'll get to the treatment of psoriasis because that's a really important topic to. And one thing that I didn't put in the slides, but you know psoriasis does seem to affect adults more commonly we do have pediatric or childhood psoriasis as well. It's to kind of affect middle age I'd say men and women and another thing interesting about psoriasis is it does seem to have associations with basically metabolic syndrome so that means diabetes hypertension high blood pressure cardiovascular disease. So once a patient is diagnosed with psoriasis will often write a letter to their primary care or give their primary care doctor a phone call just to make sure these patients are screened for these other routine things as well. Okay, so this you know these are two pictures. Now you see these tiny tiny tiny little pink papules with delivery scale so kind of similar to what we saw but now so many more of them and so much smaller. And this is another form of psoriasis, this is interestingly called gut tates, rises. So it looks different and I actually got a lot of referrals from other doctors like primary care doctors who are not sure what this is let's say or even I would say more so maybe urgent care where they think maybe it's an allergic reaction. So for dermatologists we very you know we can recognize this as gut tates rises because it's treated differently as well. So gut tates rises it's really uncommon in adults we see it much more commonly in children and adolescents and in young adults I would say. So over half of these patients they have these elevated ASO titers so really what that means is a lot of times what happens to these patients if they have a strap throat infection or other type of strap infection and then interestingly they present with this rash sometimes it doesn't have to be necessarily a strap throat infection it can be some other virus. But oftentimes the history will be that they had a strap throat infection and then all of a sudden their strap throat was fine after they took antibiotics let's say but they then they presented with this rash as well. And then one more bullet here OK so it can clear spontaneously in weeks to month so unlike chronic plaques rise this which really persists gut tates rises may just go away completely on its own but oftentimes if they're coming to see us or coming to see the dermatologist it hasn't gone away and we usually end up doing NB UVB is narrow bands UVB light treatment so this is UV light treatment we have these light boxes. Patients come in let's say two to three times a week for up to six weeks or minimum of six weeks up to a few months for narrow bands UV light treatment and this can suppress your immune system and clear them of their skin. So unlike chronic plaques rises where we really think the patients are going to be dealing this sort of dealing with it lifelong gut tates rises we expect to clear up. Is this an autoimmune condition it is an autoimmune condition yeah so chronic plaques rise is definitely is and gut tates rises is some sort of autoimmune condition that seems to be triggered by the strap infection or other infection seems like there's something primed or triggered on the immune system that that presents with this gut tates rise this rash. Okay so let's talk about treatment of psoriasis and this is going to refer specifically to the chronic plaques rises basically the general psoriasis that we think about so first line is always going to be topicals and this includes topical steroid creams high potency steroids so just high over the counter hydrochlorosone isn't going to cut it. We often pair it with something called calcuba trying, which is a vitamin D cream. Prior to the use of steroids in calcuba trying, maybe let's say many, many, many years ago, a lot of times tar was used, the literally cold tar. I rarely see patients who use this. I think that this has kind of been phased out with newer medications, particularly with these new biologic medications, which we're going to talk about. Sometimes we'll use retinoid or retinoid really exfoliates skin. If you remember, we use it commonly in acne. It can actually help thin out the really thick plaques of psoriasis too. And then these macro lactams, these are also topical creams, but they're non-staroidal, which may help. I don't find these as useful in psoriasis, but the issue with topical steroids is that it fins out your skin over time. So we're really limited in how long we can use topical steroids for. Another great treatment is narrow-banned UVB light treatment, which we mentioned with gut taste psoriasis. It is successful in clearing chronic plaques psoriasis as well. I included the wavelengths because, you know, when you explain this to patients a lot of times, they'll say, "Well, water, I just like go out in the sun or why don't I actually go to a tanning bed?" But it turns out that the light box has a very, very specific wavelength, which makes it a lot safer. So yes, exposing to UVB light will always increase our risk of skin cancer, but it is just so much safer than a tanning bed or even going out without having any sort of control of the wavelength, the timing, and so forth. So we often have to explain this to patients that this is very different than just going to a tanning bed, which we don't want you to do ever. Then there's a laser. It's called the eczema laser. It's in the 308 NM wavelength, and that can be helpful. Maybe just for people who have very localized psoriasis, it's tougher to treat with this laser if they have a large body surface area that's affected. Okay, so we'll go to the next page. So what happens if you do creams and they're not getting better or they just have way too much body surface area to really be addressed with creams? So that's when we talk about systemic medications. So these are medications that patients take internally. So whether that be through pill form, orally, or injections, these are medications that are going to alter or suppress the immune system to help clear our patients of psoriasis. So the gold standard still is something called methotrexate. And methotrexate is also a very popular chemotherapy medication, but it's very effective in a variety of autoimmune disorders. And it's taken to clear patients of psoriasis. And I won't get too much into the pathophysiology, but basically it works on a particular enzyme that has to do with folic acid and then alters the immune system, and therefore it can be really effective. It unfortunately can have some major side effects to and can affect the liver. So we do have to monitor patients very closely on it. This second medication acid triton is another vitamin A derivative. So it's similar to isotretinone, which we use for acne. But if this one is much stronger and stays in the system for a lot longer, I would say that we often turn to acid triton more for something called palmo planter psoriasis. So this is psoriasis that affects the palms of the hands and the bottoms of the feet, the plantar feet. And then most popularly are our biologic therapies. So you know, we used to be really limited in biologics. So biologics are this class of medications that work very specifically in the pathway of psoriasis in the immune system. And they basically target molecules that are overexpressed, so to say. So the first generation were really these TNF alpha inhibitors. So something like a tannera sap, which is known as embral, which is still used for psoriasis. Actually, let me just also say that psoriasis patients may also have arthritis. So they have something called psoriatic arthritis. And if they have psoriatic arthritis, it's not, you know, topical creams are not going to address the arthritis. And that's when we'll often just go right into using a biologic therapy. So a lot of rheumatologists also use these medications. So just back to the TNF alpha inhibitors, we have influxemab, which is known on the market as remicade. And we have humera, which is also commonly known. Since the TNF alpha inhibitors, there's been a lot more specific biologics. Because TNF alpha is a very general molecule. It's involved in a lot of different pathways. But what we've discovered is in psoriasis, there's a very specific interleukins that are overexpressed. And so over time discoveries have been made that if therapies are targeted to these specific interleukins, you might actually decrease side effects while still addressing the psoriasis. And so something known as telara is an interleukin 12 and interleukin 23 inhibitor. And then these are the newest ones that probably lots of people see commercials about all the time. And so the newer class are basically our interleukin or IL-17A and interleukin 17 are inhibitors. So these are medications, which on the market, brand name are known as cosentics, tauts, and silique. And then we have trumpfaya. And then there's a primalast, which is actually not necessarily a biologic therapy. But it's a pill that's taken, it's known as otesla, that also helps with psoriasis. -After life, it's already. It's so interesting how you mention all these things because we learn about a lot of these medications in medical school. And for those who are going to be studying pharmacology, you're going to see these names. But it's so funny because some of these medications are so new that we've never even studied some of the ones on this slide. There's so many things coming out. -Exactly. It's honestly, I had to educate myself on these newer molecules because even I graduated residency in 2016 and we were not using cosentics, we were not using tauts, silique, trumpfaya, otesla, none of those. They were just starting to be talked about. So you're absolutely right. This has been changing so much and it's such an evolving field or area. And that really speaks to my point of having to just be up to date because technologies advancing. And we have a lot more tools for our patients and we have to make sure that we can offer those tools to our patients and medicines. So yeah, you're right. And I definitely didn't learn about any of this in my pharmacology class in medical school because that was years ago now. -And just to piggyback off that real fast, how all these drugs coming out so frequently, how do you stay up with all of it? Are you reading like the clinical trials as they come out and saying, oh, this one looks better than the one before it? Or how do you stay on top of all that? -It's so hard and it's such a, again, such a great question. I would say a lot of times it's the journals. So for dermatology, the two big journals, for example, there's a few, but journal, the JAD, it's known as basically the Journal of the American Academy of Dermatology and then JAMA, which is the Journal of American Medical Association, but the Dermatology version, they will put out papers based on the clinical trials and based on this sort of, you have to read those articles to kind of become familiar with the medications. I would say also conferences are important to attend because this is where the leaders of the field, like huge psoriasis, thought leaders will come and they'll talk to you about what's on the horizon or what they're using and they'll be very practical in their information of what to monitor for, what labs to do, and how to use these medications. And then, you know, at the end of the day, I know like pharmaceutical companies and reps get a bad reputation, basically, but they do help us in sort of introducing medications. So they'll come by and they'll say, hey, we've got this new medication on the market. Do you want to learn about it? They'll leave information about it and then it's up to the doctor to really explore and read about it. But it does take, you know, motivation and some onus on the part of the physician to be up to date with these medications. And then I think also just talking with colleagues, you know, like, you'll have one colleague start to use a biologic and have really good success and feel comfortable with it and then you'll realize, okay, well, I can do this too. Let me read about it. And you just, you got to just kind of jump in after you've done your research to use it because your patients are going to ask for it. I've had so many patients ask for these medications just based on advertisements, right? So different avenues reading mostly would be the most important I'd say. Yeah. Okay. And just quickly, biologic therapy, pathophysiology. So what we talked about TNF alpha inhibitors, just TNF alphas made by a lot of different cells in our system, basically, it's made by T cells, dendritic cells, macrophages, keratinocytes. And what we know is terroreotic skin and serum has increased levels of TNF alpha. And you give more TNF alpha. but correlates with level of severity. So that's where the TNF alpha inhibitors come in and are able to address psoriasis 'cause basically you're inhibiting all that TNF alpha. And then like I said, there's other interleukins implicated in psoriasis and therefore biologic medications will inhibit or block or neutralize these interleukins. So those are the more specific biologics that we talked about, what's nice about the more specific biologics is that because they are acting on a very particular interleukin, it helps decrease the risk of other side effects. Whereas when we totally knock down something like TNF alpha, we may have increased side effects 'cause TNF alpha is so ubiquitous and is available, I guess, in so many different cells. And just quickly, method Trexay, just 'cause I did mention it and it's more of our old school medication. It works by immunosuppressing T cells. So that's some pathophysiology. And this is just a little animation. Basically, you know, we have these TNF alpha receptors and then you'll see basically the TNF alpha receptors and these antibodies, like influx-map, humera, edelomeumab, embral, which go ahead and kind of block these little TNF alpha receptors that are floating around. Okay, so this is kind of how it works, basically. All right, so in summary, finally, we're at the end. Dermatology is awesome. Obviously I'm biased since I'm a dermatologist, but I think there's a lot of amazing components to dermatology and while it can be really competitive to get into, it's 100% worth it. And it's definitely worth taking the time like we discussed today to achieve that goal if that's something that you want to do. And we have incredible breadth and depth of disease and patient variety, which I think is actually important to know because a lot of times you think like there's not much to skin, but there's so much to skin. There's so many different diseases. You know, I just touched on acne and psoriasis, but we have skin cancers. We have other autoimmune disorders. We have, you know, procedures we can do. There's just a lot, a lot, a lot of different things. And then you see patients from, you know, infants all the way to like 100 year old. So it's really neat in that way. These are just my resources. And this is just a wrap up of my presentation. So any other questions? - No, thanks so much, Dr. Legerady. That was very informative. And, you know, I know that everyone who's interested in dermatology really likes the field. And I can tell that you really like the field as well. Overall, taking everything in picture, what is the best part about being a dermatologist? - I think the best part about being a dermatologist truly is the variety. I feel like I am someone who can treat my patients from beginning to end. So for example, I can detect a skin cancer. I biopsy it, I diagnose it, and then I get to solve it by actually doing the excision. So that's just an example of really being able to take care of my patients from beginning to end. And even having the long-term relationship with patients where you get to see them over time. So that's what I think is the most exciting thing about it for me. - That's great. Are you familiar with Dr. Temple Popper? - Yes, of course, wonderful. - So you said earlier about how kind of the, some of the perception of dermatology is like, oh, you're just popping zits. Do you think that part of the blame is to be put on Dr. Temple Popper? - So actually, I don't only, I see, of course, her name, but I think she's been really great in showing that it's not just about popping pimples, but you actually get to do these really awesome procedures that are like these huge cysts and huge lipomas. And is it frozen? Okay, here we are. There's a little bit frozen. But I actually think she's been instrumental in educating the public about how much dermatologists can do 'cause I don't think people know that dermatologists are surgeons. So I actually think, yeah, I think she's done an incredible job of showing just the public that we actually can take things out and excite them. And we can help patients. They don't necessarily have to go into an operating room to get these things done. Like we can do this for them in the office. - Right. Well, thank you very much, Dr. Legiabarty, for coming on, for talking to us about dermatology and about your experiences and for providing advice for pre-med students who are interested, although they can't really come into the office right now. They're able to learn something at least as Sam and I both did today about the field. So thank you so much once again. - You're so welcome. It's my pleasure. I was so happy and honored to be invited to be part of this series. So thanks so much for having me. - I loved all the path of physiology too. That was good, very interesting. I can see that you really enjoy teaching. - I do, I love teaching. I really do. And so yeah, I loved it in my prior position in academia and I still do. So I'm glad that you enjoyed it as well. - All right, well thank you. We appreciate it. - Yes, of course, my pleasure. - Thank you for listening to the virtual shadowing podcast powered by MedSchool Coach. Watch each physician present their cases along with fascinating images and visuals at shadowing.medschoolcoach.com. There you will also find a quiz that accompanies each specialty.