TIP 1 — Skin Type Influences Disease PresentationIn patients with Fitzpatrick skin type IV and above, you might see different cutaneous symptoms than you would see in patients who have Fitzpatrick skin types I through III. For example, where you’d normally see scaling in Fitzpatrick skin types I to III, in patients who have darker skin, you may instead see papules — papular atopic dermatitis, papular pityriasis rosea, etc.Steven D. Emmet M.D.Clinical Prof. of Dermatology (volunteer)University of California at San Diego Solana Beach, CATIP 2 — When Patients Pressure You to Commit FraudOver the years, I’ve had problems with patients asking me to put another family member’s name on their prescription because these patients didn’t have insurance coverage — but their family members did. Of course, I would explain that this was fraud, but patients wouldn’t accept that as a legitimate reason. Obviously, I refused to do as these patients asked, but much unnecessary frustration was expended each time these requests were made. After years of dealing with this type of situation, I finally came up with the perfect answer. Now I say, “If I would lie for you, then don’t you think I would lie to you someday? And would you be comfortable with a doctor who might not tell you the truth?” I began to ask these patients this question, and in each case, the discussion ceased and the patients no longer asked me to engage in this illegal activity. Michael Greenberg, M.D. Elk Grove Village, ILTIP 3 — The All-Important Wallet CardSimple everyday activities such as grocery shopping can become difficult and cumbersome when the consumer is a patient suffering from allergic contact dermatitis (ACD). Often, the names of the allergenic chemicals are difficult to remember, which is further complicated by the fact that there are many unrelated chemicals with similar names! Examples include polyquaternium-10, quaternium-18 and quaternium-15. Polyquaternium-10 (quaternized hydroxyethylcellulose) is a polycationic polymer used in hair products, such as shampoos and conditioners, to neutralize the negative charge of the hair proteins and the hair products and keep hair manageable. Quaternium-18 bentonite, however, has been added to lotions and been shown to be effective in preventing or diminishing experimentally produced uroshiol ACD. Meanwhile, quaternium-15, a formaldehyde-releasing preservative, is the most common cause of preservatives-related ACD.To ease the shopping for allergen-free products, we have made available the trusty wallet card (see image) — in which the names of the specific allergens (to look for on products) are printed on standard business cards or on a label maker and adhered to the card. With this handy tool, patients can quickly reference chemicals that they need to avoid.— Sharon E. Jacob, M.D.Director of the Contact Dermatitis Clinic at the University of Miami Miller School of Medicine, Miami, FL— Carmen B. Gelpi, M.A.Miami, FLTIP 4 — Explaining Steroid Strengths to Concerned PatientsMany patients who have been prescribed an innocuous topical steroid, such as hydrocortisone, will tell me that they have heard that cortisone can damage the skin. When this happens, I recall an analogy often used by one of my colleagues, and I say the following to my patient:“You're right. It is absolutely true that cortisone can damage the skin, and I'm glad that you asked. Now, I want you to think about a water pistol and a water cannon. They’re almost the same. Both contain water. But the water cannon can hurt you quite badly, while the water pistol cannot hurt you at all. Some cortisone creams are strong like a water cannon, but that is not the kind of cream that I have prescribed for you. Instead, I have prescribed for you a mild cortisone that is more like a water pistol. It will not hurt you, so you do not need to be concerned. Just remember — the pistol and the cannon.”Norman R. Wasel, M.D., FRCPCEdmonton, CanadaTIP 5 — Differentiating CARP from ANIf you cannot decide if an eruption is confluent and reticulated papillomatosis (CARP) or acanthosis nigricans (AN), even after you perform a biopsy, treat the eruption with minocycline or zithromax.If the lesion resolves with this treatment, then it is CARP. If the eruption does not resolved after treatment with minocycline or zithromax, then it is AN. Stated differently, CARP is defined by the response of a reticulated eruption’s response to minocycline more than anything else.Noah Scheinfeld, M.D. Assistant Clinical Professor Columbia UniversityNew York, NY TIP 6 — How Do You Know if It Is the Correct Diagnosis?After I’ve given a patient a prolonged explanation of the diagnosis and treatment plan, the one question that irks me the most is when a patient asks: “But, doc, how do you KNOW that’s the correct diagnosis?” I finally came up with a superb answer. I hold up my thumb and ask the patient:“What finger is this.” Of course, they reply: “The thumb.” To which I inquire, in retort: “How do you know that’s a thumb?” Most of the time, the patient almost immediately gets the idea of how I diagnosed something.Ted Rosen, M.D. Houston, TX TIP 7 — Black Tea Compresses for Weeping LesionsIn cases of weeping, irritated lesions particularly in the groin or in other flexures or even the face, I often start treatment with strong black tea compresses. The temperature of the tea may vary from just tepid to cold (never hot). After the compresses, the affected area is softly patted dry and active medication is added in the form of eyedrops. An amazing combination of substances is available in eyedrops including steroids, antibacterials and antibiotics. In one case of Hailey-Hailey disease of the groin, I saw very marked and quick improvement using a Gentamicin and corticosteroid eyedrop preparation. Surely enough, I soon ran across a short paper by Kellermayer et al1 praising the use of topical aminoglycosides in the treatment of Hailey-Hailey disease. The effect is allegedly based on the ability of these antibiotics to induce readthrough of nonsense mutations in human cells. 1Kellermayer R, Szigeti R, Keeling KM, et al. J Invest Dermatol. 2006;126: 229-231.Mauricio Goihman-Yahr, M.D.,Ph.D.Professor of DermatologyVargas School of MedicineCentral University of Venezuela