Dr. Amanda Swain (Host): Welcome to the Penn Primary Care Podcast. I am Dr. Amanda Swain. And I am so pleased tonight to welcome Dr. Temitayo Ogunleye, a Professor of Clinical Dermatology at the University of Pennsylvania. She's also Associate Director of Academic Excellence and Community Engagement in the Department of Dermatology.

Welcome, Temitayo. I'm so happy to have you. Thanks for coming on.

Dr. Temitayo Ogunleye: Thanks for having me and happy to be here.

Host: So. I speak, I think, for all primary care physicians when I say I have a very, very long list of questions about dermatology. So much of what I see ends up crossing over into dermatology. Oftentimes, it's not the primary reason that people come into my office. But invariably it's one of those like hand on the doorknob kind of, "Oh, and by the way, what should I do about this? What does that look like? Should I see a dermatologist?" So, I'm really happy we're going to dive into some of that tonight.

Dr. Temitayo Ogunleye: Yes.

Host: Are there specific dermatology pearls, let's say, like these little, small, but very important pieces of knowledge that you think are really helpful for those of us in primary care to know when we're seeing patients day in and day out who invariably have questions about their skin?

Dr. Temitayo Ogunleye: I think from the perspective it probably would come in different buckets. One bucket would be sunscreen. I think there are a lot of myths about sunscreen. People read about the fact that, "Oh, you only need an SPF of 30, and there's no difference between an SPF of 30 and an SPF of 100," which is true.

In the lab, the difference between an SPF of 30 and an SPF of 100 is 7% more coverage, which doesn't sound like a lot. But the truth is that most of us don't put on the amount of sunscreen that you need to get what is advertised on the bottle. And so, when I counsel my patients, I usually tell them to use a minimum of SPF 30. But that if the 50 or the 70 or the 100 is the same price, they should be using as high as they can get.

The example that I give to patients is that, on average, if you're going to the beach and you're on the beach for some number of hours, for every application of sunscreen on your body, you should be using about one to two ounces, which would mean that a bottle of sunscreen, which should last you maybe two or three days if you're at the beach. And most people have a bottle of sunscreen that lasts them the entire summer, sometimes multiple summers. And so, none of us are applying enough sunscreen to get what's advertised. So, there is value to using a higher SPF.

The other kind of sunscreen myth is how long does sunscreen work or how long can you apply it? People think that they're fine applying it in the morning and then not thinking about it for the rest of the day. And the truth is that sunscreen usually only lasts for about an hour or two, and you really do need to reapply, particularly if you're getting in and out of water, particularly if you're, you know, sweating or outside for a period of time. So, reapplication is very important in order to maintain efficacy.

And then, the other myth, and it's not really a myth, but the concern is really about the safety of sunscreens. You know, I have a lot of patients who are hesitant to use chemical sunscreens particularly, because the FDA removed kind of like the safety label on chemical sunscreens.

And usually, what I have to do from a myth-busting perspective for that for patients is just to let them know chemical sunscreens are considered safe. There's no evidence that they cause cancer. There is not strong evidence that they are endocrine disruptors or anything in that category where, you know, patients may have a lot of concern.

But what has happened recently with the FDA is that the truth is that when they measured how much of it was, you know, measurable in the blood, it was measurable in the blood and it was measurable in some cases above what the FDA set as a set point. And the issue with that just because it's above what they consider like a minimum level doesn't mean that it's in a level that it causes toxicity. For most patients, what I have to tell them is that I still wear chemical sunscreen, because chemical sunscreens exist because they're elegant. They go on clear. If you're darker skinned, that is the type of sunscreen for most people that's going to give you that kind of elegant non-gray, non-purple kind of hue. But if you're worried about chemical sunscreens, you can always try mineral sunscreens with the idea that you may have to do a little bit of trial and error to find one that will go on in a more elegant manner. And there are definitely brands that will do that, but it may be a little bit more effort.

Host: That's all really helpful information about sunscreen. Maybe it would be helpful just to describe ingredient-wise, just to inform our viewers. So when you say chemical sunscreen, you know, what are those specific ingredients versus the mineral?

Dr. Temitayo Ogunleye: From an ingredient standpoint, so physical agents are going to be zinc oxide, titanium dioxide, and iron oxide. And then, for chemical ingredients, you're going to have avobenzone, there's octinoxate, oxybenzone, there's a number of other ones. The most recently approved chemical sunscreen is bimatrizanol. And that was recently approved by the FDA. It's photostable. It's transparent as most of the other chemical sunscreens are. And most importantly, it has, like, about two decades of data that prove its, like, safety, which is why it actually has received this label by the FDA as safe. It was recently approved maybe about two or three months ago. So by the end of this year, we should be seeing some of the sunscreens that are on the shelf with bimatrizanol.

Host: And this is, like, the one that we've heard is like it's been approved in Europe and now we're going to get our hands on it?

Dr. Temitayo Ogunleye: Exactly. It's been in Europe and some Asian countries probably for the last 20 years.

Host: Well, that's exciting news, as someone that is pale and freckled, which actually leads perfectly into my next question for you, which is about skin cancer. This is definitely something that we see a lot of in primary care, not just the actual diagnosis of the skin cancer, but patients will come in and say, "Can you look at this? Is this something that you're worried about? Should I see a dermatologist? Should I get a skin check? How often do I need to be getting skin checks?"

So, maybe we could talk a little bit about how you approach evaluating moles. I mean, I would assume that most of our audience is pretty familiar with the A-B-C-D-E method. You know, is something symmetric? Is there irregularity, the border irregularity? Is the color varied at all? Diameter, the pencil eraser, you know, six millimeter is the ideal size that you want something below, and then evolving for like change. But beyond those really basic and actually not terribly descriptive parameters, are there certain things that you really want us in primary care to be thinking of in terms of red flags or other ways to approach skin checks?

Dr. Temitayo Ogunleye: So, the rule that I like to discuss with both patients and clinicians is the ugly duckling rule, and I think that is actually more helpful than the ABCDE rule generally. And the ugly duckling rule is that everybody creates the certain types of growths.

And so, when you're looking at somebody's skin or when a patient's looking at their own skin, they really want to be looking for the ugly duckling, which is something that, it sticks out in terms of appearance. So, does it look different than everything else that you have on your skin? Or is it different in terms of symptoms? So, is it acting differently than everything else that you have on your skin? So, is it growing? Is it itching? Is it bleeding? Is it changing in color? All of those things may be concerning. Or if you have a spot and you can't find another spot that looks somewhat similar, whether it be in size or shape or color, then something may be wrong with that spot as well.

And so when we're doing skin exams, you know, obviously, we have dermatoscopes and we're looking at each lesion. But generally, what we're looking for is we're looking for patterns, right? And so, I'm scanning, and I'm looking for something that sticks out from the pattern of that person's skin. And what may be something normal on one person's skin or within their normal group or family of lesions may be completely different than in someone else. And so, that's why I think you have to really look at each person as an individual and look for something that like kind of sticks out as the ugly duckling.

Host: That makes so much sense, also because I think it also helps frame the discussion a bit when we're dealing with different skin types, different skin colors. So, we can't just make a blanket statement, you know, "Oh, if it's this color, then you should be worried," because obviously we have all different colored skin. So, that I think makes a lot of sense to think about it in context of what else we see on the patient's body.

Dr. Temitayo Ogunleye: Absolutely.

Host: Oh, that's great. Are there any kinds of lesions that you think really should not be biopsied in a primary care office? Like, are there certain things that we should be looking out for that would give us pause if we were thinking about doing a biopsy or a certain kind of biopsy?

Dr. Temitayo Ogunleye: I wouldn't say that there are certain lesions that shouldn't be biopsied in a primary care office from, like, a purely lesion perspective. But I think that you have to take into context the safety of doing a biopsy. So, if something looks like a vascular lesion, do you have some type of electrocautery or Hyfrecator or something present to stop bleeding? Because there's some lesions that will bleed profusely. So, that is something that I would think about.

I also think about area that you would be biopsying. Can you biopsy safely on the face? Yes. Do you have to be careful about the type of biopsy that you choose? Yes. Considering punch biopsy versus shave biopsy and what's going to give the best kind of cosmetic result.

Considering the purpose for the biopsy. Whenever I kind of talk or teach about biopsies, I think that you have to think about, like, why are you biopsying? Are you biopsying for the purpose of removing a lesion in its entirety or are you biopsying for diagnostic purposes?

And if you're biopsying for diagnostic purposes, do you need to remove the entire lesion, in order to get that diagnosis? Sometimes, maybe in the case of a melanoma. But if you're thinking about a squamous cell or a basal cell, you can certainly just take a small piece of that biopsy. So, first of all, if you find out that it isn't a skin cancer so that you haven't, like, left a patient with some unsightly scar. But secondly, because again, you don't need that much tissue to make that diagnosis.

Host: That's a great point. Yeah. I really stay away from the face, to be honest. It makes me very worried about doing anything on the face, because I know the cosmetic aspect is important to most people, even when people's—you know, I'm thinking about skin tags or things like that. I really, really don't want to go on the face.

Dr. Temitayo Ogunleye: And I always think that you should do what you're comfortable, right? So if you look at a spot and you think twice about doing it, don't do it.

Host: Yeah. That's good advice in general for life, I would say. I would love to touch on a condition that we see a lot of in primary care. I'm sure you see a lot of it, but atopic dermatitis. And I work in a primary care office where we see everything from newborns to people 90 years old plus. So, we see atopic dermatitis in different ages, different skin colors. I would love to talk a little bit about stepwise therapy, meaning there is, I think, sometimes a misunderstanding that people other than dermatologists will just, you know, let's just put a steroid on it and be done and walk away. And that is not our approach, generally speaking. I think most people are wise to the fact that steroids are not something to be taken lightly.

But in terms of a general approach to someone with atopic dermatitis, how do you start to think through how intensive a therapy does this person need, and when would you potentially advance their therapy?

Dr. Temitayo Ogunleye: It's partially based on symptoms and how much it's affecting the patient, and also total body surface area involvement. We usually say that if you have less than 10% total body surface area involvement, then you can usually get away with topical therapy. But once you get above 10%, it becomes a little bit more onerous, a little bit more difficult to do, topical therapy reliably.

And then, I would say, as I said, the other part is how much it's affecting a patient. So for instance, a patient could have very little body surface area involvement, but have involvement on the face or have involvement in the hands where it's affecting functioning, affecting, you know, their quality of life, and we might be more aggressive with therapy in that perspective.

For atopic dermatitis, I consider moisturization and your form of cleansing, as part of your treatment regimen, and that's like that first rung on that kind of step stepwise ladder of treatment. When I speak to my patients, I always talk to my patients about using mild cleansers, and there are differences between cleansers and soaps.

When you're thinking about cleansers, cleansers will leave the skin with a little bit of moisture. Usually, they have moisturizing agents in it to actually provide additional moisture. And there are a number of brands that we may kind of recommend, things like Dove, Aveeno, Cetaphil, CeraVe, all of these things that are more cleansers.

And then, there are soaps. And the funny thing is that a lot of people use soaps because they feel cleaner, right? My husband actually calls Dove soap greasy soap because it leaves you with a film, and people don't like that idea of leaving a film on the skin. What I have to kind of really discuss with my patients who have atopic dermatitis is that you have to get past this idea of feeling like your skin has to be squeaky clean. If your skin is squeaky clean, you have removed the oils from your skin, and that may contribute to worsening of your atopic dermatitis.

Once we've discussed cleansers, then I also discuss kind of moisturizers. And the way that I discuss moisturizers with my patients is that I usually ask them whether they're using a moisturizer where they can pump it out of a bottle or whether they're scooping it out of a jar. And that's really the easiest way to solidify that kind of, like, understanding of what kind of moisturizer they should use. Because everybody's using something that pumps out of the bottle because people use lotions, right? Lotions are the most common kind of moisturizer that you're going to find over the counter. But if you have atopic dermatitis, you really need something thicker. You need something that's going to last on the skin. So, I usually recommend that patients are using either creams or ointments. The easiest way to describe that is by using something that they can scoop out of a jar.

When you're thinking about younger children, I think it's really easy. You know, I just tell them they should be slipping and sliding, right? So they should be, like, super greasy. I don't care what they're using that's greasy, but they should be sliding off their beds, right? And so, that could be even as simple as, for patients, in the past, I used to tell patients that they can use lard, right? They can use something that's very inexpensive, very easy to use, as long as it's providing that longer kind of lasting moisture. I discourage the use of oils because everybody thinks that oils are moisturizing, but oils are moisturizing for two minutes. The moisture, it just doesn't last long enough. And particularly, in atopic dermatitis patients, it doesn't last, it's not useful for them at all.

We also discussed showering, right? And the kind of, like, what to do from a bathing perspective, what to do from a showering perspective, temperature of water to use. Now, I personally have eczema and, you know, the dermatologist recommendation is that people should be taking lukewarm baths and showers, which I think is fine for a child. I think that from an adult perspective, I don't particularly enjoy lukewarm showers. So, I don't recommend them. But it is, you know, something that is on the list of things that can be recommended. But I think that if you're using a good moisturizer, if you're using a mild cleanser, you can overcome any dryness that you may see from taking a hotter shower if you want to.

Speaking of myths, there are myths about kind of, like, the frequency of showering that is necessary. Again, I think that that differs on age. You know, when you're dealing with an infant with atopic dermatitis or a toddler, you can get away with having them, bathe maybe every other day because, again, they're not usually getting very sweaty. They don't have a lot of odor, and that's fine. But for adults or, you know, older children or teenagers with atopic dermatitis, I think it's fine to shower daily. Again, keeping in mind that moisturization component of things. That would be the kind of like that first rung.

Second rung would be topical steroids. And, you know, usually we think about topical steroids in terms of their strength, where you're either having, like, kind of low potency, medium potency, or high potency topical steroids. And I usually recommend medium potency topical steroids for adults, lower potency topical steroids for children.

And for topical steroid use, it's really about consistency. What I find that people do when they're using a topical steroid is they use it for a couple of days, things start to improve, and then they stop early. And then, their atopic dermatitis starts to flare again. So, it really is important, use it for the full period of time. We're using it twice a day for two weeks, maybe three weeks if you need to, depending on the body surface area. And honestly, I tell patients to use it for a couple days after they think it's gone. Because again, a lot of people discontinue it early and then have more frequent flares.

Host: That makes a lot of sense. I think that's really smart. And then, you may be getting to this, but I think the other question I have about steroids is similar to what you were saying about moisturizers, which is this idea of a lotion is the thinnest, cream is in the middle, ointment is the thickest, and really, you know, forms that barrier against the skin. How do you think about that when it comes to which steroid to prescribe apart from the potency?

Dr. Temitayo Ogunleye: We almost always will err on the side of doing ointments. Ointments do work better. They have a little bit higher potency compared to creams or lotions or gels or foams or anything else or solutions. I will make exceptions because I prefer to give a patient something that they're going to use.

For children you can get away with almost—you know, they're not particular about what you're doing to their skin. So, for children, I almost always will go ointment because again, it's going to work a little bit better. Even if you're using hydrocortisone within the same medication, ointment works better than cream.

For adults, again, I still will recommend ointments. But, again, a lot of people don't enjoy being greasy. They don't enjoy that kind of tacky feeling. And so, you know, I will ask patients what their preference is and if they prefer a cream, I'll give them a cream in that situation. I mean, there is a difference between cream and ointment, but not enough to kind of overcome the fact that they're probably going to use an ointment less frequently, because they don't enjoy the feeling of it.

Host: Yeah, that seems to be the biggest barrier, I would say, in terms of patient use, right? You don't want to put an ointment on and then that puts a stain on your clothing and then you don't want to use the medication.

Dr. Temitayo Ogunleye: Exactly. And you won't use it. So, I will give you something that you will use rather than giving you something that maybe works slightly better that you won't use, right? So, I think that's important.

And then, you know, for the other forms of topical steroids that are available, like the solutions, the gels, the foams, those I usually will, you know, kind of consider when somebody has eczema on the scalp, right? And so, in those areas, you want something that's lighter that you can apply more easily so that it doesn't weigh the hair down or cause some residue or buildup.

Host: Well, on a somewhat related note, I guess I want to just throw in a question about psoriasis really quickly while we're on the scalp, but then I do have another question about eczema. But I think sometimes I've found that when I'm looking at the scalp, it can be challenging to know, is this eczema? I mean, presumably there's a history of eczema. Or are we actually talking about psoriasis? Because psoriasis, in terms of similarity with eczema, I mean, there are certain parts of the body that are favored. And the appearance should be different, but how do you approach that?

Dr. Temitayo Ogunleye: When thinking about, like, psoriasis, atopic dermatitis or eczema, and even seborrheic dermatitis, which you're going to see much more commonly on the scalp, initially, I don't think it makes that much of a difference to differentiate because the treatment is the same for most of them, right? You're going to do a topical steroid. Maybe you'll choose one of these nonsteroidal kind of creams or foams that are available. But most of those nonsteroidal creams and the steroidal creams have broad efficacy for all three.

So, I think initially if you have questions of whether it's psoriasis versus atopic dermatitis versus seborrheic dermatitis, and you don't have evidence elsewhere on the body to help you make that differentiation, where like, you know, they don't have nail pitting, they don't have psoriasis, they don't have a history of atopic dermatitis, at least initially, I don't think it's important to make that differentiation. I think that you can treat and then you can decide based on response to treatment. So if you have something that's not responding to treatment, it may be more important to consider doing a biopsy to try to figure out what the actual diagnosis is.

Host: Is there any other way I would suppose I'm kind of thinking about like would you say that maybe you might see psoriasis more commonly along the hairline versus in the center of the scalp versus eczema or seborrheic dermatitis? Is there any kind of distribution that might be helpful for us to think about?

Dr. Temitayo Ogunleye: Distribution, not always. But appearance, yes. So, typically for psoriasis, it's going to be a little bit thicker. And psoriasis, you know, we always describe it as well-demarcated. So oftentimes psoriasis, if you're going to have a plaque or a thin patch of psoriasis on the scalp, you're going to see a border that's kind of very well-demarcated. And that's going to be in comparison to either atopic dermatitis or seborrheic dermatitis, where it usually is a much more poorly demarcated, like, eruption, where you'll see some redness, you'll have some scale, but it'll just be scattered in different places, rather than having a spot where you could almost draw out the border of a psoriatic plaque or patch.

So, that would be probably one of the major differences. Oftentimes you're much more likely to see plaques with psoriasis where you have thicker areas of involvement. You're much more apt to have maybe thicker scale, where it's a little bit more of that what we call micaceous scale, which is kind of looking more of like a silvery scale. And interestingly enough, psoriasis is more likely not to be itchy. So, definitely people with scalp psoriasis can have itching, but there are definitely people with psoriasis on their scalp that have very minimal symptoms. So if you see someone with kind of a rash on their scalp and it's not that itchy, I might consider that it'd be more likely to be psoriasis compared to atopic dermatitis or seborrheic dermatitis, which is usually itchy.

Host: That makes a lot of sense. Yeah. Just to go back to eczema or atopic dermatitis for a moment, I am curious if you ever recommend bleach baths for kids. Because every now and then, I talk about this with patients, and they give me a look like they can't believe I'm telling them to do this. Maybe I'm out of date, so I would love to hear your thoughts on that.

Dr. Temitayo Ogunleye: You are not out of date. We do recommend bleach baths for both children and adults. So, usually, we're recommending bleach baths in patients, who have a history of repeated secondary infections, because that's really what the bleach baths are most helpful for. They really aren't helpful necessarily for the primary treatment of eczema, but really for the secondary kind of downstream effects where people are getting infections.

So if I have a patient who's repeatedly getting kind of like, you know, staph infections secondarily or is requiring, like, antibiotic, whether it's topical or oral treatment, I will recommend bleach baths in that situation. And yes, when you talk about bleach baths, you have to be, like, very specific because as you mentioned, people are going to look at you like you're crazy when you say, "Why don't you take bleach baths two or three times a week," right? I always tell patients it's like a swimming pool. You're not bathing in bleach. You should only be using, you know, three to four capfuls in a tub full of water. It should not smell like bleach when you're in there, you know. And obviously then, you do your soaking for anywhere from, like, 15 to 30 minutes.

Host: Thank you. Okay. That's very validating. And to move back towards psoriasis and then also seborrheic dermatitis. Let's say we see something, we're not completely sure what we're treating. We try a steroid, and maybe there's some efficacy but not complete. What then would you recommend in terms of the next step in evaluation? I know not every office has a microscope. But in theory, you might have one handy. when is that helpful? Is it helpful, or are there other things that we might be thinking about to really differentiate what we're dealing with?

Dr. Temitayo Ogunleye: In terms of differentiating psoriasis and seborrheic dermatitis, there are no in-office procedures that are going to be helpful from that perspective. Oftentimes, you're going to end up having to just do a punch biopsy of the scalp in order to make that differentiation. And interestingly, there is also a condition that we call sebopsoriasis, which is this, like, overlap between the two, where there's features of seborrheic dermatitis and features of psoriasis.

But where it may be helpful to have an in-office procedure, for instance, of doing a scraping, would be if you're considering a tinea infection. Obviously, there are patients that will come in with a tinea capitis infection. It may look like seborrheic dermatitis initially. It may have been treated as seborrheic dermatitis initially. But as you mentioned, maybe they're not getting better or maybe they're even getting worse with treatment. And in those situations, doing a KOH in office can be helpful, where you can either, you know, kind of just take some of the scale and scrape that onto a slide and add the KOH, or you can actually pull some of the hair follicles in the infected area out, or infected/affected area. And then, also put that on a slide and use the KOH. In that, you can sometimes see the hyphal kind of spores on the outside of the hair follicle or sometimes actually within the hair follicle as well.

Host: Oh, that's a great tip. I was not aware of that. That's often where we are in primary care. You know, we can recognize or speaking for myself, I certainly feel like I recognize what I'm treating. But then, if what I think I'm treating is not responding to what I think is the appropriate treatment, then the next question is, "Where do I go from here?

And I think sometimes it can be challenging because you don't necessarily want to leave people in limbo with a rash or a patch that's uncomfortable. And also, I don't want to slap immediately a steroid and antifungal on top of something. And then, if it gets better, I have no idea what's what. So, that is a challenge that I've often come across.

Dr. Temitayo Ogunleye: Yeah. I mean, I agree. I think, first of all, there are situations where scalp psoriasis doesn't get better, right? Like, just scalp psoriasis can be very resistant. You can do all the appropriate treatments and still not get the appropriate response. But those are situations where if you have access, I mean thankfully, even though our wait time is long, there is access to dermatology at Penn. So, you know, I think referral in those situations are completely appropriate. And it's funny how the myths are coming up as we're speaking, but dermatologists very rarely will treat, it depends. But we try not to treat with both a topical steroid and an antifungal at the same time if we can help it, especially in situations where the diagnosis is ambiguous because, as you mentioned, you just don't know what's helped, right? Now, you could make the argument if the patient is better, then it doesn't matter. And I think that's a fair argument, but I usually will try one or the other, right?

And so, if you are strongly concerned that it may be a fungal infection, you try an antifungal for a period of time and see if it helps. And then, the idea of leaving a patient in limbo, I think patients feel in limbo when nothing is done. But I think if you're making an attempt where you're treating in some way, I mean I think that's fair.

Host: And while we're in the conversation here about steroids and antifungals, then guess the condition that I do think about using both, albeit maybe in slightly different forms, is seborrheic dermatitis, right? So in that case, you may have a patient that is using an antifungal product maybe in a shampoo form and then using a steroid. So, I'd love to hear how you counsel patients. Let's say they have the diagnosis of seborrheic dermatitis, and you know that they will use both products. How do you counsel them about how to use those?

Dr. Temitayo Ogunleye: So for seborrheic dermatitis, usually, what I counsel my patient on is that we're treating two different pathways when we're treating seborrheic dermatitis. None of us really understand, no one understands completely why seborrheic dermatitis occurs, but part of the thought process is that that yeast that live on the skin are either overproducing or overreplicating, or people are particularly sensitive to the yeast that are on the skin. And so, what you need to do is decrease the burden of yeast, and then you're also decreasing the inflammatory response by using a topical steroid.

And so for anti-dandruff or kind of antifungal shampoos, I do think that there are some nuances to use, and those nuances can vary based on hair type as well. What I usually ask patients is how often are they washing their hair at baseline, so that you can pick a frequency that is somewhat in line with what they're already doing. So if a patient's washing their hair three or four times a week, then they can use the antifungal shampoo two or three times a week. Antifungal shampoos are very drying. They're not great hair shampoos. I tell people that they are scalp shampoos. So, you want to make sure that they're applying it just to the scalp, letting it lather, sit for a minute or two, and then rinsing it out. I usually tell patients to wash the shaft of their hair with their shampoo of choice. For patients who may wash their hair less frequently, if, let's say, they're washing their hair once a week or once every two weeks, then I will have them use the shampoo at that frequency.

So, what happens, and actually for both dermatologists and I think probably also for primary care physicians, is that the automatic recommendation for antifungal shampoo is to use it two or three times per week. But if somebody doesn't wash their hair at that frequency, what may potentially result in that patient is that they start washing their hair every two to three times per week. Now, their hair is breaking. Now, they're having other issues downstream. So, I do think it's important to ask patients about the frequency with which they wash their hair, and then recommend something that's in line with that. The only caveat to that for me is if a patient's washing their hair less frequently than every, like, two to three weeks. If they're going longer than three weeks without washing, then there are very few medications that are going to get their seborrheic dermatitis under control, and they really just need to wash a little bit more frequently. And so in those situations, I usually try to have my patients wash preferably every two weeks, no longer than every three weeks.

And so once they have that on board, oftentimes, particularly if patients have symptoms like itching or scaling, they're going to need that topical steroid in addition. If they have very severe symptoms, I'll have them use a topical steroid daily for about a week or two, again, to get them to this maintenance point where they can then use it maybe just one to three times a week if they need it for itching or scaling.

Another trick that I do with my patients once they are doing their wash for the week, I'll have them apply the topical steroid after to the scalp. And I do that from a preventative perspective, because it's much easier to prevent or kind of delay the time where the scaling and/or itching kind of starts to occur as opposed to having the scaling and itching already being there and then trying to get ahead of it.

Host: That makes a lot of sense. So, almost like, yeah, maintenance of a normal healthy scalp so that it doesn't evolve. That makes a lot of sense. Yeah, I think that you bring up a really great point about the frequency of shampooing. I think that is something that I think those of us that treat people of color, people with different hair types, we want to think about that, right? You have to give directions that fit with the patient's normal daily routine. And for many people, myself included, that does not include shampooing or conditioning your hair. So, I really think that makes a lot of sense with like the minimum of once every two weeks. And then, to go back to what you said earlier with the steroid then in terms of the form it's going to take is most likely going to be like a solution or a lotion or how would you—for the scalp specifically, right, how would you approach that?

Dr. Temitayo Ogunleye: For the scalp specifically, it depends on their hair type and what they do, right? So, I would say for most people, most people will prefer something like a solution or a foam because it's light, it doesn't leave that much of a residue. But the caveat that will be, first of all, there are some people who are used to greasing their scalp and they may prefer something that has a little bit more body, so ointment may be preferred.

And then, the other caveat to that is that people who heat straighten their hair. So if you straighten your hair with heat, using anything that's liquid-based is just going to revert the hair at the root. You know, if they're paying for their hair to be done, their hairstyle won't last as long. It's not going to be something that's going to be easy for them to use on a daily basis initially and then kind of like taper down.

So, for a patient who use heat styling, I usually actually will recommend that they use a cream or an ointment, because then they won't have like that liquid base that may be kind of reverting or shortening the length of their style.

But oftentimes, honestly, I just ask patients, right? And I tell patients like, "Look, we have these five versions. We have a gel, we have a foam, we have a solution, we have a cream, we have an ointment, ointments like Vaseline. What do you prefer? What do you think is going to work best for your lifestyle?"

Host: That's great. I think that's really helpful information. And a shout-out to Vaseline. I'm a big fan. I'll put Vaseline on almost anything.

Dr. Temitayo Ogunleye: Absolutely. Same.

Host: To go back, I suppose, because you did touch briefly on tinea and, certainly, I mean, you can see that in any age, but for those of us that treat younger patients and then their family members, we do tend to see a fair number of fungal infections. So, any specific tips in terms of delineating what's what when it comes to tinea infections, or are there certain things that we should be thinking about potentially not recommending that patients use or that they use in a specific way when we're trying to treat a tinea infection?

Dr. Temitayo Ogunleye: if you're trying to delineate between like tinea corporis and tinea capitis, I think about those two different ways as far as like what are the active signs that will kind of help you make that diagnosis. For tinea corporis or, I mean, I guess anywhere else, any other form of tinea that's happening on the body, we always talk about this active border. An active border to us means that there's more inflammation on the border, or on the periphery of the lesion as opposed to in the center of the lesion. And that's, you know, partly because your immune system is getting rid of the fungus, right? It's partially treating the area, and then as that fungus kind of moves outward, that's where the most active or like the least immune touched area is.

And so, most people will confuse tinea corporis with nummular dermatitis. So, that's really your kind of like your differential diagnosis that you're trying to distinguish between. And so, you're looking for an active border. And that active border can be redness, it can be increased scaling at the border. It can be blisters or pustules at the border of the lesion. Those are all signs that can be helpful to help you make that distinction.

Also, even in the absence of a particularly notable active border, usually within a tinea corporis patch, you'll still see areas that it's a patchy patch. So for, you know, nummular eczema, usually it's like a patch of scale that's very uniform. But in tinea infections, it does tend to be like less uniform. Those are probably some of the main factors that I'll utilize or kind of that I use to kind of distinguish between the two.

But from a treatment perspective, I always say that if you have any question, you know, first of all, and let's say you're in a situation where you don't have the time to do a KOH or you just choose not to do a KOH, I always will lean on the side of doing or using a topical antifungal if I'm questioning the diagnosis of nummular dermatitis versus tinea. And that's because, when you apply a topical steroid to tinea, then you run into the situation where potentially the infection gets worse, it spreads. And, you know, in worst cases, it actually doesn't only spread outwardly, but it spreads downward into the hair follicle. And then, you're in a situation where you have to treat the patient with an oral antifungal as opposed to just treating them topically. Worst case scenario, if you treat nummular dermatitis with a topical antifungal, the worst thing that's going to happen is that it won't completely go away.

But even in the situations where it's just mild nummular dermatitis, a topical antifungal may have some effect because it's still a moisturizer. You're still getting kind of some moisture directed in that area.

Host: That makes a lot of sense.

Dr. Temitayo Ogunleye: And then, for tinea capitis, the things that you want to look at, you know, if you're trying to distinguish between seborrheic dermatitis, you're trying to distinguish between eczema, maybe you're just trying to distinguish between other forms of hair loss, because tinea capitis oftentimes causes, like, localized hair loss. You're looking for the broken hairs in the area. Oftentimes if you look closely in patches of alopecia that are caused by tinea, you'll see broken hairs in that area. You'll see scaling in that area. And in children particularly, children are susceptible to getting a lymphadenopathy either occipitally or on the posterior cervical chain along with that infection

Host: Yeah. Kids can have some really impressive reactions to tinea, unfortunately. So, I would love to save a little bit of the time we have remaining to touch on acne and maybe rosacea too, because sometimes speaking of diagnoses that can be difficult to make, sometimes acne looks like rosacea, and sometimes rosacea looks like acne. And then, there's acne rosacea. So, that can be confusing.

But I am curious, if you were to recommend a first-line treatment for folks in primary care to be recommending for mild acne, let's say. And when I say mild acne, I mean, I know there are a lot of terms that can go along with diagnosing acne, but let's say mild acne meaning whiteheads, blackheads, to use like the colloquial, and then maybe some small mildly inflamed papules. Is there an approach that you typically tell patients like, "Hey, you know, maybe you can get away with these over-the-counter products before using any prescription medication"?

Dr. Temitayo Ogunleye: So from a over-the-counter perspective, benzoyl peroxide is our mainstay for treatment of acne. It's available over the counter. It's relatively inexpensive. Main thing to look out for benzoyl peroxide is that sometimes it can be a little bit irritating to the skin, and that it bleaches towels and clothing. So, people have to be careful to either use white towels or towels that they don't care about. So, that's one thing that, you know, I usually recommend over the counter.

The second thing is always a topical retinoid. Thankfully, there is one topical retinoid that's available over the counter, and that's adapalene in the form of Differin, the brand Differin. Particularly for people who have blackheads, whiteheads. Even for people who have, like, just small or mild inflammatory lesions, topical retinoids are a mainstay for treatment of acne. And so if I'm being honest, even before, if a patient wanted to choose one thing that they were going to use, that one thing that I would recommend would be a topical retinoid.

Host: Can we go back to the benzoyl peroxide? Because this is something that I am always confused by. Why are there so many different percentages available, and is there actually any benefit to using a higher percentage over-the-counter product?

Dr. Temitayo Ogunleye: I am unsure why there's so many different percentages outside of it probably being a marketing ploy that has now fallen out of patent and is now just available over the counter and maintain that. But I will say that the lower percentages are less irritating. So if usually you'll see like 2%, 5%, 10%, I believe 10% is its highest that I think that you can get over the counter. And so, 10% definitely can be more drying. So, 5%, the 2.5%, those are generally less irritating. And for patients, for instance, who have eczema, patients who have, sensitive skin overall, I usually will recommend using the lower percentage.

And looking at efficacy, I don't actually think that there's that much of a difference between the 2% and 2.5% and the 5% and the 10%. And I usually will tell patients to just get whatever they can find most easily. But from an irritation standpoint, lower percentages are less irritating.

Host: Yeah, that makes a lot of sense. And then, if people are game to use both or feel like they really do need both, is there an ideal way to apply them? Should they be separating them in different times of day, or what's your counseling in terms of application?

Dr. Temitayo Ogunleye: So, I usually recommend benzoyl peroxide wash. I know that benzoyl peroxide is also available as a cream, it's also available as a gel. Most dermatologists, we don't tend to recommend the types that stay on the skin just because you're going to have a higher likelihood of getting irritation. So, the wash, you wash it off, it's great. We usually recommend using the wash in the morning and then using the tretinoin in the evening before bedtime.

And from an application standpoint, you know, when talking about acne, I think acne, it's always important to be very clear about application processes because people are very highly motivated to get rid of their acne, and people will do almost anything to get rid of their acne, including using medications in a very aggressive manner.

So from a retinoid perspective, I always tell patients more is not better, you know? Less is more in this situation from a efficacy standpoint, but particularly from an irritation standpoint. So, I always tell patients very clearly you want to do just a pea-sized amount. That pea-sized amount is for your entire face because the other thing is, particularly for retinoid treatments, retinoid can have preventative properties as well. So, it can prevent blackheads, it can prevent whiteheads, and so you don't only want to use it in the affected areas. It's helpful to use it kind of just as full face at nighttime. You start it out every other night. And we usually recommend that people start it out every other night because the main potential side effect is the dryness. And that dryness is something that their skin can get acclimated to a retinoid if started on kind of like slowly and then generally ramped up.

So, they do it every other night. They do that for two to four weeks. And then, if they're noticing that their skin is doing fine, they're not getting any irritation, they can increase the frequency of use. And the rule that I usually give patients is that they can skip a night if they ever feel like they're getting too dry or too tight. So, some patients may skip one night a week, some patients may skip two nights a week. And then, because of TikTok and all the like, there are lots of methods to kind of improve the tolerance of topical retinoids, and that could include using a moisturizer to base your skin before using a topical retinoid or sandwiching the topical retinoid where you're using a moisturizer to base the skin, applying the topical retinoid, and then applying a moisturizer on top of that.

Host: I think those are great points. I think that is something that is so hard to get ahead of when I'm counseling patients about acne treatment because what I want to say to them is, "Your skin is going to get really irritated. I can almost guarantee it if we go full speed ahead with this." And I say that totally acknowledging that you would like this acne gone in the next 24 hours. But we're going to do harm if we don't talk about how to try and minimize irritation. I think can be really tough to avoid it altogether. But I think the tip about the moisturizing before application and potentially sandwiching it is great. I really hope people take that to heart.

And I think what you're saying about the retinoids as being preventive is really important too, but because of that, it's a waiting game with acne treatment, right? I mean, it's tough to think about waiting weeks to start to see any response, but patience. Patience is the name of the game with acne.

Dr. Temitayo Ogunleye: It is. And I mean, I think it just generally in dermatology because people can see their condition, like they're much more impatient about seeing results. And so I, I think managing expectations is so important when treating any type of derm condition, but I mean, I think particularly acne. So, I am very clear with my patients that this is going to take six to eight weeks for you to even begin to see an improvement, and that I'm not really expecting to see improvement until three to four months. And if you stop the treatment before then, then I'm not going to consider it a treatment failure. I'm just going to send you back on the same thing.

Host: We could probably do an entire episode on acne, so I will pause there because it's a much larger conversation. But I'm curious, I mean, in relation to acne or just even speaking more broadly about skin, are there certain ingredients or certain products that you tell most people, "Hey, listen, you may want to avoid this, because even though it may sound like it's really helpful, it can be very irritating to most skin types?

Dr. Temitayo Ogunleye: Generally, what I tell patients is that obviously if you're looking for moisturizers, you want to look for a moisturizer that specifically says that it's non-comedogenic, because that imply that they've done testing to prove that it doesn't clog pores and worsen acne.

You also want to think about things that are generally occlusive to the skin. So, I don't recommend thicker ointments on the skin. So, Vaseline, you know, may not be the best thing for someone with acne. There have been different fads that have gone out like beef tallow and things like that. All of those things can potentially be irritating to the skin and/or worsen acne. Those are probably the main things.

I would say also when even looking at sunscreens, I would make sure that patients with acne are using sunscreens that are specifically made for the face because those are also ones that are also likely to be non-comedogenic as well.

Host: Yeah, that's a really good tip. I think that's an easy thing to forget because we get so comfortable with whatever kind of sunscreen we're using that we just want to put it everywhere.

Dr. Temitayo Ogunleye: Absolutely.

Host: And then just last, I know we only have a few minutes, but I'm curious. So, rosacea can sometimes overlap a bit in terms of appearance with acne. So, do you have any tips for maybe if it's a history that we're getting or if we're in that in-between area between those two diagnoses, any tips for how to think about diagnosis or initial treatment?

Dr. Temitayo Ogunleye: Absolutely. So for acne versus rosacea, usually with acne you're almost always going to have comedones, right? So, they're going to either have whiteheads, blackheads. So if they have whiteheads or blackheads, it's more likely to be acne than rosacea. But as you mentioned, there are sometimes people who have an overlap at both, or an overlap of both.

The good thing about acne and rosacea is that the treatments are similar. When you're thinking about you can use a benzoyl peroxide for both, you can use topical antibiotics for both, you can use oral antibiotics for both. we don't typically use retinoids in rosacea, but, like, using a retinoid in rosacea also isn't harmful.

So from, like, a treatment perspective, like, you know, most things that you would initially think about pursuing may also help rosacea as well. Rosacea patients also tend to have background redness, right? So, they kind of have those rosy cheeks even before they start to form that papular pustular form of rosacea where they're getting bumps that look like acne.

They typically will have a history of having kind of like chronic redness on the face, along with the symptoms that you think of when you think about rosacea, such as easy flushing or blushing, and easy flushing or blushing that lasts longer than would be considered normal. You know, it's not like, "Oh, I'm embarrassed. I blush for five minutes and it goes away." These are people who are blushing for 30 minutes, an hour after drinking alcohol, after being outside in the cold, after being exposed to some other type of trigger. And then, when patients are complaining of, like, very sensitive skin, that might also be a clue that they may have rosacea as well.

From a treatment perspective, like, I think that if you are, in between, let's say, you know, like, maybe they have a comedone or two, but you're not quite sure whether it's rosacea versus acne. And I should actually say that the last point would be location. Rosacea very often is going to be on the cheeks and maybe on the nose, whereas it's unlikely to be kind of on the jawline, on the forehead. So if people have involvement on the forehead or they have involvement on the lower cheeks or the jawline, that's much more likely to be acne as opposed to rosacea.

From a treatment perspective, I think you can always start with a topical antimicrobial, so whether that be clindamycin, you can use metronidazole. If I have some question, I always err on the side of using something that works for both. So, clindamycin tends to be my go-to for something like that. And then, if you're considering an oral antibiotic, the good thing is, actually, all of the oral antibiotics that are utilized for acne also have efficacy in rosacea as well.

Host: So, I think we can wrap up, but are there any things that you haven't yet told us that you think would be really helpful for those of us in primary care to know either about evaluation or treatment or even when to refer?

Dr. Temitayo Ogunleye: I'd say when to refer, think we mentioned it earlier, if there are conditions that you are uncomfortable with, obviously, I always recommend referral, you know, biopsies that you're concerned with. And I think that, when making referrals, it's also kind of thinking about the urgency with which you think the patient needs to be seen, right? So if you are very concerned about a melanoma, that might be something where you make that referral a little bit more urgently as opposed to someone with seborrheic dermatitis or eczema.

And then, I think, in the situations where patients have more severe cases of conditions, like you have a very severe case of psoriasis, a very severe case of atopic dermatitis, where we kind of went, just took that second rung of that ladder where we're starting with topical steroids, but obviously there are a lot of things above that ladder which, you know, include systemic therapies, that if you think that a patient has a disease state that is severe enough to require systemic therapy, those will also be the patients that I would recommend referring to dermatology so that we can start treatment, you know, as early as possible.

And, you know, there's at least some research kind of looking into that, this idea of like, that there probably is this like depot of patients who have moderate to severe disease that are seeing their primary care physicians but don't have a pathway to seeing dermatology easily. You know, I think that if we can get to the point where we,dermatologists are seeing fewer mild cases, right? And then, we can just kind of focus on seeing patients with more moderate to severe disease, we'd be able to kind of create more access for patients that way as well.

Host: Yeah, that's true. That makes a lot of sense. And it's interesting, I mean, because there is so much of this that does tend to run in families, I mean, I would say almost everything we talked about today there is some genetic piece, I always find it really interesting that there's actually a lot of knowledge within families that I see, especially when it comes to atopic dermatitis, right? Mom says or dad says, you know, "Oh, I had this when I was a kid, so we're already doing this," or "I know these products work for me, then they're going to work for my child." So, it's great to tap into family knowledge, certainly when starting with treatments.

Dr. Temitayo Ogunleye: Absolutely.

Host: Well, thank you so much for coming on tonight.This was like a great derm potpourri. we might need to have you back again. I think, acne is something that we see so much of in primary care. And to your point just a minute ago, there is a lot that we can do in primary care to treat acne. So, I think it would be a great episode to really delve into everything that we can be doing in primary care so that hopefully not that many people necessarily need a dermatology referral unless we're talking about Accutane, and that's a whole other box. But thank you so much.

Dr. Temitayo Ogunleye: Thank you for having me, and I would love to come back for part two.

Host: Great.