1. Who is this Guy? B.A. Chemistry ‘79 Baylor University M.D. and Residency ‘87 UTMB - Galveston Mohs Fellowship ‘88 Duke University Professor of Dermatology University of Arkansas Private Practice Little Rock, Arkansas Scott Dinehart, MD

2. Conflict of Interest Speaker and Consultant for Genentech

3. Clinical and Practice Management Tips Scott M. Dinehart, MD

6. “Realize that acne can be made worse by refined carbohydrates and certain dairy products, particularly skim milk”

11. “Facial acne severity improved more on the low glycemic index diet” Reynolds, et al. Nutrients.Oct 2010;2(10):1060-72.

13. “Glycemic load and frequency of milk and ice cream ingestion were positively associated with acne” Ismail, et al. BMC Dermatol. 2012;12:13.

14. “Subjects adhering to a LGL diet resulted in clinical and histopathological improvements of acne” Kwon, et al. Acta Derm Vener. 2012;92(3):241-6.

15. “Regular consumption of sweets, nuts, chocolate, and oily foods were recognized as risk factors for acne while spicy foods and fasting were not associated with acne severity” Ghodsi, et al. J Invest Dermatol. Sep 2009;129(9):2136-41.

16. Causes Lactoferrin, an anti- inflammatory milk protein Hormones in milk Insulin?

17. “Substitute high glycemic index foods for low glycemic index foods, and avoid refined carbohydrates whenever possible” Scott Dinehart, MD

18. Clinical History A 44 year old physician has a changing mole on his back You decide to biopsy the lesion using a shave technique

22. You Make the Call A. The lesion needs no re-excision B. The lesion can be re-excised but only needs a wider shave because the deep margin is clear C. The lesion needs full thickness excision D. A and B are correct approaches

23. You Make the Call A. The lesion needs no re-excision B. The lesion can be re-excised but only needs a wider shave because the deep margin is clear C. The lesion needs full thickness excision D. A and B are correct approaches

24. Re-excision of Dysplastic Nevi Pathologist deserves a vote Clinician deserves a vote But in general….

25. “there is mounting evidence that re-excision of lesions with low- grade atypia (mild and moderate DN) may not be necessary, even when positive margins are found; the recurrence rates of these nevi are low, and there are no reports of subsequent development of melanoma in these lesions” Duffy et al. Arch Dermatol 148:259, 2012

26. May not need to re-excise mild to moderate dysplatic nevi If you re-excise it is important to know if deep or lateral margins involved If lateral margins present, can re- shave Severely dysplastic nevi need full thickness re-excision with minimal margin

27. Dysplastic Nevi Tip #1: Trend is not to re-excise mild and moderate dysplastic nevi Tip #2: Work with your dermatopathologist. A shave removal can often work for mild or moderate dysplastic nevi that you want removed if only the lateral margin is involved Tip #3: Start the shave removal more lateral to avoid lateral margin positives!

28. Wet hair in high risk scalp cancer patients

32. Use of a hair dryer Hair dryers on “warm” can dry the scalp Hair dryers on “warm” can dry the scalp

33. Use of a hair dryer Hair dryers on “cold” can be used to Hair dryers on “cold” can be used to EXAMINE the scalp EXAMINE the scalp

34. Use of a hair dryer Only needed on selected patients to find lesions on the scalp Only needed on selected patients to find lesions on the scalp

35. “There are only two times when you need to consider doing a KOH examination”

37. KOH Preparation Use KOH with DMSO (no need to heat) Dip blade in KOH prior to scraping lesion (scale will stick to the blade) Look on high power for hyphae (look like thin black lines)

38. Identify the “red dot” basal cell carcinoma