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Atopic Dermatitis Provider Toolkit

Adult Immunization Provider Toolkit

Dermatology Hot Topics

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A 5-year-old boy with a history of atopic dermatitis since 6 weeks of age, presents with a rash around his mouth that has been present for approximately 1 year. The patient’s mother reports that desonide topical cream was applied to the affected area for about 5 days, which initially resulted in improvement, however the rash returned after this medication was discontinued. The rash also recently improved after the patient took amoxicillin for an infection. She also notes that the patient has been licking his lips more frequently.

On examination there is an erythematous papulopustular eruption restricted to the perioral region, with sparing of the vermillion border. Mild hyperpigmentation is noted on the patient’s neck. There is no active involvement of other areas of the body.

The eruption has been present for 1 year and is restricted to the perioral region. What is included in your differential? 

Clinical Topics

Rash Around the Mouth of a 5-year-old Child

This relatively small (1 cm), pigmented nodule of uncertain duration was noticed on the left arm of a 57-year-old man with a history of skin cancer.

This relatively small (1 cm), pigmented nodule of uncertain duration was noticed on the left arm of a 57-year-old man with a history of skin cancer. What do you suspect here?

Nodule With Dark Black Pigmentation: Your Dx?

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. She has a history of multiple non-melanoma skin cancers.

Squamous cell carcinoma in situ (Bowen  disease)

Lichenoid keratosis (an inflammatory variant of seborrheic keratosis)

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. What does this look like to you?

What's This "Red Spot"?

The mother of a 10-year-old boy brings him in for evaluation of his moles (which are all benign). During the visit, the mother asks about the lesions on the first 2 knuckles of his right hand; she initially noticed them several months earlier. The boy is otherwise healthy.

White Knuckles

Monu Khanna, MD, offers tips on creating pain management plans for obesity patients, with a focus on dosing challenges, metabolic issues, and potential complications from medications like acetaminophen.

Monu Khanna, MD: Practical Pain Management Tips for Patients with Obesity

Managing pain in patients with obesity can be particularly challenging for clinicians, requiring more than just addressing the pain itself. It also involves understanding the broader metabolic and physiological factors that these patients often deal with. In a recent interview with 

Monu Khanna, MD, a board-certified obesity medicine and internal medicine expert, discussed how to approach pain management in this patient group.

Patients with obesity often have additional health concerns, like diabetes, cardiovascular disease, and airway issues, which can complicate pain treatment. Dr Khanna emphasized the need for caution when adjusting medication dosages. While increasing doses may seem like a straightforward solution, it can come with a higher risk of complications, including respiratory problems and liver damage. Patients with obesity may also metabolize drugs differently, which means that the typical dosing guidelines might not always apply.

Take acetaminophen, for example. It is commonly used for pain relief, and the usual guideline is to limit the dose to no more than 3 or 4 grams per day. But in patients with obesity, this amount might not be effective for pain management. This can lead clinicians to inadvertently increase the dose, which raises the risk of liver toxicity and gastrointestinal side effects. Research into how acetaminophen behaves in patients with obesity has shown that the drug’s metabolism can be altered, leading to concerns about appropriate dosing.

Pain management for these patients requires careful consideration of both medication options and non-drug treatments. Physicians should keep a close eye on potential side effects, be mindful of medication overuse, and account for the individual health factors that each patient brings to the table.

For primary care physicians, understanding the complexities of managing pain in patients with obesity is crucial. With the rise in obesity rates, these challenges are only going to become more common.

In the video above, Dr Khanna offers practical advice on how to navigate pain management in patients with obesity, emphasizing individualized treatment plans and safe medication practices.

The following transcript has been edited for clarity, flow, and style. 

What advice would you give to clinicians when developing pain management plans for patients with obesity?

 It’s very tricky because you don’t want to under-treat the pain, but at the same time, you have to be careful. Patients with obesity often have other metabolic issues, such as diabetes or heart disease. As you increase their medication doses, you have to consider that individuals with obesity might also have underlying airway issues. This makes them more prone to complications, such as respiratory compromise, due to the accumulation of high doses of medication. Additionally, we’re not always aware of how drugs metabolize in people who have excess fat stores.

On top of that, we lack accurate guidelines for dosing medications in these patients. We're constantly faced with a higher chance of complications. Take acetaminophen, for example. The usual guideline recommends no more than three or four grams a day as a safe dosage. However, in patients with obesity, it can be difficult to manage this. At that level, acetaminophen may not provide adequate pain relief, so clinicians may be tempted to increase the dose. But this can lead to liver damage, gastrointestinal side effects, or other issues.

O'Brien, KD, et al. Pharmacokinetics and Pharmacodynamics of Acetaminophen in Obesity: Implications for Pain Management. 

Wadden, T.A., et al. "Obesity and Pain: A Comprehensive Review." 

Dr Khanna discusses dosing challenges, metabolic issues, and potential complications from medications like acetaminophen. 

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Hard Purple Nodules: Your Dx?

Leo Robert

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