Under My Skin

Specialty Traditions


Several years ago, a gynecologist came in to have me treat a wart. As I retrieved my can of LN2 spray, he asked, "Why do you use liquid nitrogen spray? Why not use a cryoprobe, the way we do?"

I felt like echoing Tevye in "Fiddler on the Roof" and saying: "So I'll tell you—I don't know. But it's a tradition."

LN2 spray may indeed be the superior method, but nobody ever told me why. Truth be told, I use liquid nitrogen spray because I was trained to use it, my colleagues use it, and my specialty equipment catalogs feature it. I wouldn't even know where to order a cryoprobe. Liquid nitrogen is just what us derms do.

"What derms do" describes more of our techniques than we might care to admit. Once, a patient asked me, "For a strep throat, you take the same dose of antibiotic for the whole 10 days. How come when you treat acne, you lower the dose after a couple of months?"

That struck me as a good question, so I wrote to a former professor, widely known for acne expertise, and asked him whether there perhaps were data showing sustained antibiotic levels in sebum during maintenance, or something like that.

There weren't. The tapering technique, he explained, is traditional.

Other specialties have traditions too, about which we learn only incidentally. Each has its own professional society, its own standard journals, its own canonical texts, and, of course, its own treatment conditions. The opportunity to share—or critique—the way we each do things from an outside perspective rarely comes up.

What prompted these reflections was a recent chance I had to discuss a particular issue with an STD specialist. I'll defer the details of that conversation to the next column. Meantime, here is a random list of glimpses into treatment traditions from other specialists whose methods differ from ours in conditions we see every day:

Pediatrics. During my pediatric residency, I learned very few things about skin, most of them wrong. One lesson I remember clearly: If a diaper rash involves the inguinal fold, it's always yeast. Well, it could be yeast. Then again, it could be the same kind of nonyeast rash that adults develop in intertriginous areas such as under arms or breasts.

Family practice. I once got an FP throwaway journal with an article on "sweaty-sock dermatitis." The description and photos were of typical lichenified atopic dermatitis on the dorsal feet and toes. I wrote to the author to point this out. His reply was that, as far as family physicians were concerned, rashes like this are associated with sweaty socks.

Ophthalmology. More and more patients without a single pimple or pustule come to me because their eye doctor told them they "have rosacea," based on an exam to evaluate dry eye. They've either started doxycycline or been referred to me to prescribe it. If I do, how will I know that it worked? And when will I stop? And why isn't there an ophthalmic metronidazole? Might be worth talking about all this with our ophthalmologist colleagues.

When it comes to blepharitis, ophthalmologists seem to reflexively recommend scrubbing the eyelids with baby shampoo. My dermatology sources don't even mention that method. It seems to be just something those eye docs do. Maybe we should too. Or maybe they shouldn't.

There are many other topics where interfield communication might be useful: with dentists about white oral lesions, with podiatrists about plantar warts, with surgeons about incisional biopsies. No doubt you can think of others.

I envision a comprehensive specialty parley, something like the United Nations, only less corrupt and dysfunctional. It might be more practical, though, to have a feature in each specialty journal called "Insights From Our Brethren." Finding out how other people do things could influence the way each of us goes about the business of training and practice.

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