TIP: How I Explain the TCI Black Box Warning to PatientsIt has been nearly 2 years since a scientific advisory committee of the FDA voted to recommend that a black box warning be placed on the topical calcineurin inhibitors (TCIs) pimecrolimus (Elidel) and tacrolimus (Protopic). As we’re aware, this decision was based upon studies of laboratory animals that were exposed to massive systemic doses and was done on the basis of the theoretic riskof malignancy. Many of my patients have expressed concern about this warning, as yours probably have as well. I think that several points are important to note when speaking to patients about this warning. First, it’s interesting to note that data from randomized, controlled trials in humans have demonstrated that both Elidel and Protopic decrease the risk of developing cancer compared with both corticosteroid and vehicle comparators. Note that the average patient is exposed to less than a single oral 5-mg dose of these agents per year.Nevertheless, cancers have occurred in the more than 10 million people worldwide who have used these agents. At the same time, cancers have been observed in the millions of people who regularly consume broccoli. This does not mean that broccoli is carcinogenic. I stress to patients that the reported cancer rates with pimecrolimus and tacrolimus are less than expected in the general population. In counseling patients and their families, I do state that laboratory animals were systemically administered huge amounts of these agents and did indeed develop cancers. However, in humans (and we are humans) rates of cancers are lower with TCIs than with other therapies, including steroids. I jokingly tell my patients that it is essential to avoid eating one or more tubes of the medication per day.Alan B. Fleischer, Jr., M.D.Professor and ChairDepartment of DermatologyWake Forest University Schoolof MedicineWinston-Salem, N.C. TIP: Reducing Bleeding When Removing Skin Tags and Small NeviMany years ago, I heard it suggested by Walter Shelley, M.D., that an effective way to reduce or eliminate bleeding when removing skin tags and small nevi was the following. Before I perform these procedures, I apply aluminum chloride to skin tags and small nevi for a minute or two before snipping them. This seems to reduce or eliminate bleeding a lot of the time, and it has not caused any problems with my instruments for the past 18 years. Kevin C. Smith, M.D., F.R.C.P.C.Niagara Falls, Ontario, CanadaTIP: Helping Patients Attain a More Realistic View of Internet InformationOften, my patients research their diseases or conditions on the Internet, or suggest that they will do so in the future. (This is especially true for potentially systemic diseases such as cutaneous lupus, morphea, etc.) When I know that patients will be doing this, I like to give them a word of caution beforehand so that they will not be scared or overly worried about the information they find. Here’s what I say to them:“Please feel free to look up information on the Internet. I encourage you to do so. However, please remember that what you find on the Internet will likely be a portrayal of the worst example of anything — so don’t let the information frighten you. “For example, I’ll bet that you have been in a car accident at some point in your life. Do you remember what it was like? Now, look up ‘car accident’ on the Internet and what will you see? You will see cars that have fallen off bridges, flipped in the air three times, and burst into flames, leaving only a charred mangled wreck. Similarly, with medical conditions, the Internet always shows the worst possible case. Don’t let it frighten you.”Norman Wasel, M.D., F.R.C.P.C.Edmonton, Alberta, CanadaTIP: Several “Rudolph’s Rules”1 a. If it looks funny clinically (and with magnification), then take it off and put it in a bottle. b. If it looks funny enough for you to perform surface microscopy (dermoscopy), then take it off and put it in a bottle. 2. If the condition doesn’t respond to what it’s supposed to, then it’s probably not what you think it is. Rethink.3. Never, ever, lie to a patient.4. Tell patients jokes: A laughing and relaxed patient will allow you to do almost anything you think appropriate in his or her case. A sour or scared patient will allow almost nothing. Robert I. Rudolph, M.D., F.A.C.P.Clinical Professor of DermatologyUniversity of Pennsylvania Philadelphia, PA  Do you have a better way to perform a clinical procedure, communicate with your patients or improve an office function? If so, please submit a brief tip (approximately 100 to 250 words) to Benjamin Barankin at:benbarankin@gmail.com.We will pay a $25 honorarium for published tips.