Leveraging emails For Consultation

It must be accepted that we cannot stay away from the advancing technology. Newer methods of communication and sophisticated modes of sending data and images are now available in everyone’s pockets. It is only natural that the general public would use this to deal with other people around them, which naturally include doctors as well.

Hello there!

Until two decades ago, the patient could speak to the doctor either when the latter is at home or at the clinic. At all other places the doc remained unreachable and therefore, undisturbed! Today with the cell phone boom, it is easy to reach the doctor anywhere including the wash room! So what do the patients want next?

Today patients are not satisfied with the land line telephone number. They want his mobile number and ‘WhatsApp” (for those who are not aware, it is a mobile application for instant text-audio-video communication) details so as to post skin images for instant treatment. “Doc, I have this patch of hair loss, pleaaase opine,” or “my lip is swollen like this, is it serious?” While some emergency situations are understandable, especially for old ‘follow up’ patients, such a method of seeking advice may not only be incorrect but sometimes downright dangerous.

There may be some situations for a dermatologist to ask for the image and then decide whether immediate attention is required or not. It could be a fast spreading or intensely disturbing disease like Erysipelas or Herpes zoster. Or it could be the post operative condition or an urgent blood report based on which to decide whether hospitalization is necessary or not.

“When ECG tracings can be forwarded online to a cardiologist and immediate opinion elicited what’s wrong in sending a picture of the skin lesion to a dermatologist?” is the current generation’s thought process.

Doctor, welcome aboard!

Doctors should get onto internet and mobile networks and use these technologies to their advantage. Just because you decide not to join the network it does not mean that the rest of the patients and one’s colleagues will stay away from it. Moreover, with the fast paced evolution of newer technology, not getting on board soon will make it harder to learn later on.

To begin with, let patients’ send email to you for better connectivity. There is a lurking fear in the minds of most dermatologists about how this move will turn out. The following questions commonly arise: Will the patient continuously bombard me with emails and expect instant replies? Will people stop coming to the clinic if they get replies on email? Will they pay for email advice?

Here are the answers:

Benefits to patient and doc

· Email access helps patients remain connected with dermatologist during office hours as well as when the doctor is on tour. Also when the patient is unable to come for follow up visits when he is away at work or secures university admission far away from home or when the patient is away on holiday.

· The basic and the greatest advantage in these situations is that they need not find a new doc in a strange country/city/village

For patients who are in town, it helps save their time in visiting and waiting just showing test

· reports and get confirmation on continuing same Rx. This is especially true for dermatologists who have a long line of waiting patients.

· Lesions which appear occasionally (e.g. Urticaria) and which do not appear when the patient consults in the clinic can be clicked and emailed to the doctor.

· Elderly patients and disabled who cannot be brought for consultation often can be helped if their family emails clinical progress to the dermatologist.

· In the case of conjugal dermatoses and the spouse does not wish to consult out of embarrassment, an image sent by mail to the doctor may help in the diagnosis.

· Sudden setbacks in lesion can be communicated instantly to doctor for reassurance or alternative advice.

· When an opinion of another doctor is sought (either from same specialty or a different branch) the findings can be communicated to keep dermatologist informed.

Doctor’s convenience

· With patients sending email of investigation reports there could be less crowding in clinic

· This becomes another parallel channel of consultation

· Small suggestions can be easily given to pt without wastage of time. e.g. Questions like: Doc, can I take the tablets with milk instead of water? … “Is it ok if I meet you two days later while continuing the medicines? …can be answered easily.

Pitfalls

Allowing patients to send emails will mean that the dermatologist has to check his email inbox at least once every day. It is yet another commitment of time which may not be easy for a less computer savvy clinician.

Email consultation can never replace regular consultation. It can only be used both by the dermatologist as well as his patient as an alternative mode of communication. It cannot be a method of consultation for a new patient who has not visited the doctor before.

Some of its significant drawbacks should always be borne in mind whenever the dermatologist offers to guide someone through online advice. A few of common limitations is as follows:

· As the patient walks in to a clinic and takes a seat, the doctor automatically observes his appearance, general health, gait, speech, social skills etc. This detail provides preliminary data which assists in the final diagnosis. In online consultation, this vital information is missing.

· There are medico legal issues if patient does not follow advice accurately and later complains against the doctor. Although the charges may not stick to the doctor, it can spoil his reputation.

· There is a risk of a disobedient patient repeatedly sending emails and not coming for follow up visits even when advised

· Non payment of consultation fees

· A doctor could have many patients with a similar name. He may misinterpret Ashok Savla as Ashok Surve if he has not met the patient for a long time. Very often plenty of time is wasted in searching email and identifying patient.

· If the patient is not computer savvy, and follow up emails are not sent in serial sequence the earlier prescription may not be accurately recalled by doctor while suggesting further treatment.

Create systems

While a dermatologist would be willing to help patients via email, there are some technical difficulties which may not be obvious to him till he actually starts the process. In order to make the procedure easy for the patient and convenient for the doctor he should make a perfect protocol that the patient should follow while sending email. Such a system allows the dermatologist to promptly respond to emails without any ambiguity. Here are some useful tips:

· A different email id should be maintained by the doctor for receiving his consultation mails so that it does not get cluttered with personal or ‘friendly’ emails.

· While sending mails patient should be instructed to mention their name right on top and the date of last consultation

· Preferably, the snapshot of the patients’ face and the lesion as well as the scan of the prescription should be attached for quick reference.

· Subsequent pictures should be sent along with the earlier ones and each should be appropriately dated.

· If there are two different skin disorders, both should be separately mentioned with serial numbers.

· Use the same email ‘thread’ for follow up emails so that the dermatologist can easily see what he has prescribed the previous month.

· A disclaimer should be clearly mentioned in each mail stating that any medication advised is only a guideline and that it should be consumed or applied ONLY after confirming with a local doctor, if the patient is in another town. The disclaimer should appear both above and below the medicines advised.

· Follow up visits should be clearly defined even when suggestions are given on emails so as to prevent misuse and misguidance. Email consultation should be discontinued if the patient fails to attend the clinic as advised or if appropriate reports are not sent.

· Payments can either be collected through family members visiting the clinic or through online payment systems by providing account details. In this case please provide a case number to the patient and instruct the patient to mention this number in an email specifically with the details of the paying bank, time and date of amount transfer.

In conclusion, it must be remembered that prescriptions and advice through emails should only be used as an adjunct to regular clinic consultation. Under Indian laws there is yet no clear description on how online consultations can be carried out. For websites that exclusively provide online consultation as a service it is necessary that all prescriptions should carry a secure digital signature for which a specific procedure is to be followed as provided under the Information Technology Act 2000.

What Got You Here Won’t Get You There Part – 2

What is the need of this part of article?

The points which we discussed in Dermatalk is over and above the basic things so the basic remains the same – that’s one thing. Second thing is, “NOTHING FAILS LIKE SUCCESS, BECAUSE OVER A PERIOD OF TIME AFTER GETTING THE SUCCESS WE USUALLY FORGET OR IGNORE THE FUNDAMENTAL THINGS WHICH HELPED US TO GET THE SUCCES IN THE FIRST PLACE AND THAT RESULTS IN FAILURE.”

So here the question comes what are the fundamental things in derma cosmetology clinic:

· Clinic’s atmosphere which makes patients waiting time more comfortable

· Thoroughly trained, polite & courteous staff

· Equally focusing on dermatology practice also

· Even after opening of many branches, same importance given to the main clinic

· Respect for all and good relationship with all people like chemists, GPs and pharma people

· Proper focus given to patients’ satisfaction and rather patients’ loyalty

· Timings of the clinic

Hope these guidelines will also help you to keep the command over both – the fundamentals as well as the transformation phase.

In next issue of Dermatalk, we will have different marketing subject.

Post below in the comment box which marketing related topics you would like to be covered in forthcoming issues, we value your comments, suggestions and feedbacks.

What Got You Here Won’t Get You There Part – 1

We are all on different stages of our life and career. As per explained by Marshall Goldsmith & Marc Reiter in their book named “WHAT GOT YOU HERE WON’T GET YOU THERE” in which they interestingly invent and explained the concept of our life and career. We require different set of skills and traits on different stages of our life and career and as we all know we have got mainly 4 stages of our life (Childhood, Youth, Middle Aged and Old Age) similar to this in our business, profession or any employment also we have got various stages. If we are aware of this concept and we can evaluate our position then we can work on that effort-fully and we can bang on that!!

The skills we require as a student are different than the skills we require to start the practice and clinic or business.

While before starting career we require to study and work long hours for education but while starting practice we need to have risk taking capabilities, when to start the practice, where to start the practice, may be we need to work on all rounder practice since we do not have much staff. Only one receptionist and the doctor – in many cases this is the scenario. Somehow we manage to do it. So this requires mainly risk taking nature, little plan and little of all your interpersonal skills.

The skills required for early success in the practice are different than the skills required for starting of the practice.

Once the business or practice has been started, we need to recruit more people but the challenge is on this stage the brand of the clinic is not so strong. At the same time budget is also low and we need somebody who is more of trustworthy rather than competent. So usually recruitment of some known person or some relative or some well-wisher is being done. At this stage because the brand is not so strong the competent people may or may not join. Here the skills required are patience, focus, hard work, utilization of all available resources, a bit of finance arrangement. Since the brand is new even the investors also reluctant from the investment.

The skills required for scaling up the practice are different than that of the skills required in early two stages.

Now the clinic, business or the profession has been set-up with good revenue. So now the question is of scaling up by having more number of patients, more branches, aggressive advertising budget, building a brand, collecting & keeping patients’ data base, taking follow-up of all those things, we need more efficient & competent people in this stage. The people who were there in first two stages may not be that much helpful for us in this stage unless we educate and develop them. Here lot many things are going on at a time. We are also overwhelmed. Now we are on our way to build a brand so lot of focus is required on quality & efficiency, creating PATIENTS’ WOW EXPERIENCE is our prime focus. Lot of systems and processes needs to be put so that the doctor can save on the time for small-small issues. If scaling up in terms of more number of patients then proper marketing is the key while scaling up through more number of patients as well as more number of branches then proper marketing as well as systems and processes play a major role along with team building. Here if your brand has become strong, more quality people will inclined to join you. Same way more bankers would be offering finance, vendors would be liberal with credit facilities and rates, etc.

The skills required for corporatization of your clinic and practice are different than the skills required in previous 3 stages.

After scaling up, the next stage is corporatization where optimum focus is on brand building and developing systems and processes so efficient that our business, clinic or practice works even in our absence. And this is the real game. Scaling up the practice up to the level that it becomes legacy and runs even for hundreds of years like McDonalds, CocaCola, Tata and Reliance. Here the skills required are willingness to decentralize the power and the authority and be ready to let your business or your practice/clinic go into the hands of the systems and processes. To reach to this level, the contribution of the team is very vital. So in process we also become a very good leader.

Now, if we see all above stages in context of “Dermatalk”, when we launched Dermatalk’s first issue the main concern was to launch it and to get enough articles and funds, then after gradually we increased the numbers of articles, then after we started on focusing on quality & content of articles to be more impressive and diversified to cover vast number of topics, then after we improvise the quality of printing & paper. Thus in every project of your business and in your practice above all stages play equally important role.

Still there is another side of the coin also, “AS WE SUCCEED, WE USED TO FORGET THE BASIC THINGS WHICH BROUGHT US HERE”. This article I have uploaded on our website, we welcome you to visit our website and go through the article to get the other part of the coin also.

Here is the link: www.ethicare.in/what-got-you

EVEN EAGLE NEEDS A PUSH : Being exposed to hundreds of books on marketing & management, I though to share those experiences with all the readers under this section, so in different issue various topics we would be covering under this section. While we love to receive your comments and suggestions or topics which you would like to be covered under this section, nevertheless as the title of this para says “even eagle needs a push” – your comments and suggestions would really be a truly needed encouragement for us. Feel free to write to me at [email protected]

Tips & Tricks For Using Botulinum Toxin Series 1: Upper Face

To learn the anatomy of the facial muscles and how they are affected by botulinum toxin.

1. The website artnatomia.net is a very useful resource.

2. Receive training from someone who is willing to give you hands-on experience, and adopt as a starting point whatever toxin and dilution they use.

3. Read and study the literature.

4. Visit experienced practitioners and watch their practice and flow.

5. Set-up a training day in your practice where you offer the treatment for cost to existing patients or staff family members, letting people know you are just starting out. Set up at least 5-10 cases, and ask for them to return after two weeks.

6. Repeat the hands-on training day at cost again after one month. The best way to become good at a procedure is to practice it, and the best way to acquire new patients to the practice is to offer a big discount.

In this series, I am sharing the tips & tricks from my private practice for the Upper Face, in the next series I shall cover the Lower face.

Glabellar Rhytides:

• 3 or 5 point injections

• Females: 20-25 units

• Males: 25-35 units

• Dilution: 2 – 2.5 mL most common

• Dilution with preserved saline

• Needle 30-32 gauge

TIP: Press with one finger inferior to the injection point. This help prevents pain and lessens bruising. The eyebrow should not be considered the landmark for placing injections because the brow itself may be ptotic, plucked, shaped, tattooed, dyed, and otherwise modified

• Beware of women who pluck or have had permanent tattooing of their eyebrows

• The peak of the arch should be located just above the lateral limbus of the iris of the eye

• The tail of the female eyebrow should lie on a horizontal plane 1–2 mm above the lowest point of its medial end.

• Pre-existing asymmetry of the brow and eyelids should be discussed with the patient before treatment

TRICK:

• Injections should remain medial to the mid-pupillary line

• Inject 0.5–1.0 cm above the supraorbital margin, placed deeply into the corrugator supercilii.

Frontal Lines:

• Typical injection uses about 5 – 12 units

• Do not treat the bottom line the first time you inject patient.

• Inject the lateral part of the orbicularis to get the depressor component.

• Inject higher with more dilution

• TIP: Before injecting the forehead the patient should be evaluated for brow and lid ptosis, which is especially important in elderly individuals. People with brow and lid ptosis try to correct and compensate the depressed position of their brow/lid by constant contraction of the frontalis. These patients should not be injected because any weakness of the frontalis may compromise their visual field.

• Identify and document brow or forehead asymmetries prior to treatment.

• Weaken the frontalis; do not paralyze it

TRICK:

· The recent trend is to inject the frontalis quite high (at least 2 cm above the orbital rim) to maintain some brow movement and avoid a frozen look. Use a more diluted Botox for better spread.

· Counteract brow ptosis and elevate the eyebrows by injecting the superficial fibers of the upper orbital portion of the orbicularis oculi with 1–2 units of low-volume BT injected into the medial and lateral aspects of the brow . Otherwise, brow ptosis will remain as long as the current BOTOX® treatment is effective.

Lateral brow Lift:

• Superior and lateral aspect of orbicularis oculi

• 4-6 units each side, with focal superficial placement at site of maximal orbicularis pull downward

TIP:

· Two common techniques for achieving an eyebrow lift are:

(i) injecting the glabella alone and

(ii) injecting the lateral orbicularis oculi (vertical fibers), lateral to the mid-pupillary line.

· Too medial injection diffusing to orbital septum area risks eyelid ptosis

· Too superior-medial injection diffusing to frontalis risks lateral brow drop and eyebrow ptosis

Orbicularis Oculi: / Crows Feet:

• This is a sheet like muscle that wraps the eye.

• Point needle away from eye.

• Superficial placement of needle, raise blebs

• Keep bevel up

• Typical injection is with 20 units (total)

TIPS:

· injections should be superficial (because the orbicularis is very thin and superficial), kept lateral (approximately 1–1.5 cm from the orbital rim) and directed ‘outside’ the orbital rim to avoid diffusion to extra-ocular muscles and palpebral portion of the orbicularis oculi which can cause strabismus and lid ptosis

CAUTION:

• Injecting the lateral canthus can produce upper lip asymmetry and cheek ptosis.

• Lower eyelid injections of BOTOX® produce a ‘wide-eyed’, actively youthful appearance.

• Older patients will have varying degrees of improvement, depending on the amount of photoaging, redundant skin, and static wrinkling present.

TRICK:

• Inject well above the superior margin of the zygoma

• Inject 1–1.5 cm lateral to the lateral canthus (bony orbital rim) to avoid diplopia.

• Inject only 1–2 U and no more than 3 U of BOTOX® into the lower dermis or the upper subcutaneous tissue in the pretarsal mid-pupillary line.

I hope this series was useful to practitioners of BOTOX..

I would love to hear from you on [email protected] / www.facebook.com/drchytraanand

And if you are interested in seeing the videos for these procedures, mail me and I shall send you the link.

Dietary Management in Psoriasis

Diet is a complex combination of foods from various groups and nutrients, and some nutrients are highly correlated. It is challenging to separate the effect of a single nutrient or food group from that of others in free-living populations.

Many studies have evaluated the role of individual nutrients on the development of psoriasis. Some of them are really fruitful during management of psoriasis. After searching more than 300 articles from PubMed with key word diet and psoriasis, here I am discussing about the diet and nutrients which can affect the chronic course of psoriasis.

Mediterranean diet

The Mediterranean diet is a healthy eating pattern, associated with reduced risk for metabolic, cardiovascular, and neoplastic diseases,that has consistently been shown to provide a degree of protection against chronic degenerative diseases. One of the most accredited hypothesis of this association is that the high content of different beneficial compounds, such as antioxidants and polyphenols, largely present in Mediterranean foods, such as plant foods, fruits and red wine, have anti-inflammatory properties. In particular, the monounsaturated fatty acids intake, whose major source is represented by extra virgin olive oil (EVOO), was found to be associated with a reduced prevalence of risk factors for major chronic inflammatory diseases. The Mediterranean diet it is characterized by a high intake of fruit and vegetables, legumes, grains and cereals, fish and seafood and nuts; a low intake of dairy products, meat and meat products; and a moderate ethanol intake mainly in the form of wine and during meals.

Fish Oil

Oils of cold water fish rich in omega-3 polyunsaturated fatty acids, eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA) have been considered for use in psoriasis treatment. Several uncontrolled, open studies have also shown that supplementation of fish oil, ranging from 0.54 to 13.5 grams EPA and 0 to 9.0 grams DHA daily for 6 weeks to 6 months, resulted in clinical improvement, measured by erythema, induration, and scaling. These studies have also demonstrated clinical improvement associated with inhibition of leukotriene B4 production in peripheral leukocytes in vitro, decreases in platelet malondialdehyde production, changes in abnormalities of erythrocyte lipid membrane pattern, and increase in leukotriene B5 to leukotriene B4 ratio in peripheral blood neutrophils. Consumption of omega-3 fatty acids from fish oil forms leukotrienes and prostaglandins that are of odd-number, such as prostaglandin E3 and leukotriene B5, which oppose the even-numbered inflammatory mediators, decreasing overall inflammation. A high consumption of omega-3 fatty acids is found in the populations of the West African countries, and this dietary intake of omega-3 has been linked to a low incidence of psoriasis in this region. The most common side effects of fish oil include nausea, which may be dose dependent, indigestion, diarrhea, and fishy taste in the mouth.

Vitamin D

Vitamin D deficiency associated with psoriasis has been reported. Vitamin D derivatives have been widely used as a treatment for psoriasis in topical form. Vitamin D has been found to be immune regulators that may benefit inflammatory diseases like psoriasis through its effects on T-lymphocytes type 1 (Th1) cells. Vitamin D3 acts through the vitamin D receptor, which activates transcription of genes that affect keratinocyte proliferation and differentiation. Genetic polymorphisms in the vitamin D receptor and vitamin D metabolic pathway may impact levels of circulating vitamin D3. Vitamin D has also been found to impair the capacity of human plasmacytoid dendritic cells to induce T-cell proliferation and secretion of the T helper 1 cytokine interferon-gamma. A brief exposure of sunlight to bare body is sufficient for the formation of endogenous vitamin D formation. The flesh of fatty fish (salmon, tuna and mackerel) and fish liver oils are among the best sources of dietary vitamin D supplementation. Mashrooms, cheese and egg yolks are also contain vitamin D. Possible side effects of oral vitamin D supplementation include hypercalcemia, hypercalciuria, and kidney stones. Long-term vitamin D overdose can also lead to bone demineralization.

Vitamin B12

Vitamin B12 deficiency associated with psoriasis has been reported. As this vitamin is animal derived so late onset psoriasis in vegetarian diet people are quite severe. Shellfish, organ meat (liver), crab, fortified soy products and cereals, swiss cheese and eggs contain higher amount of vitamin B12. Vitamin B12 has no common side effects reported. Rare side effects include hypersensitivity reaction, nausea, vomiting, myalgia and swelling.

Selenium

Selenium is an essential element with anti-proliferative and immunoregulatory properties. Selenium has been hypothesized to regulate immune processes in psoriasis by increasing the number of CD4+ T cells in the reticular dermis of plaques Several trials have assessed the role of selenium supplementation in psoriasis. Seafoods and organ meats are richest food sources of selenium. Pork, turkey, chicken, fish, shellfish and eggs contain high amounts of selenium. Some beans and nuts especially Brazil nuts, contain selenium. Side effects with selenium are quite uncommon and are observed at doses above 400 mcg/ day. They include nausea, vomiting, nail changes, loss of energy, and irritability. Long-term selenium toxicity can mimic arsenic poisoning and can include nail changes, nausea, vomiting, garlic breath, metallic taste, and hair loss.

Gluten-free Diet

It is well established that psoriasis patients are more likely to have concurrent autoimmune diseases, particularly those affecting the gastrointestinal tract such as Crohn’s disease and ulcerative colitis. Recent large study showing that psoriasis patients have 2.2 fold risk of being diagnosed with celiac disease compared to matched controls. Epidemiological and clinical studies suggest there is an association between psoriasis, celiac disease, and celiac disease markers. So switching to a gluten free diet may improve the psoriasis. Gluten free diets are beans, seeds, nuts, fresh eggs, meats and fish, fruits and vegetables and dairy products. Suspected psoriasis patient with celiac disease must avoid barley, rye, triticale and wheat.

Pepper

An experimental study showed that consumption of red pepper produced exfoliation and nitrosation of the intestinal epithelium of rats because it has nitrophenols, resulting in chronic inflammatory bowel disease with neutrophil infiltrate and transepithelial neutrophil migration as markers. Evidence shows that induction of IL8 in the intestinal epithelium acts as a trigger factor for neutrophil recruitment in several types of inflammation, including colitis and psoriasis. Studies of the colonic mucosa in rats showed that, under the action of capsaicin, there was increased expression of transforming growth factor (TGF). The transforming growth factor TGF-alpha is a polypeptide produced by keratinocytes whereas the epidermal growth factor is produced anywhere in the body. Both bind to the same active receptor tyrosine kinase in the basal and immediately suprabasal epidermis to stimulate cell proliferation. In psoriasis, the keratinocyte intensely participates in the multicellular and multimolecular activation of the network coordinated by cytokines.

Caffeine (1,2,7 trimethylxanthine)

Caffeine is quickly and completely absorbed in the digestive tract, being distributed to all body tissues. It has a half-life of 2.5 to 10 hours. Plasma concentrations are reached within one hour. Metabolism occurs mainly in the liver; 95% of its transformation occurs in cytochrome P 450, originating more than 25 metabolites, while the remaining 5% are excreted in urine. The main mechanism of action of caffeine is due to its structural similarity with the adenosine molecule, being able to bind to its receptors (A1, A2A), blocking them and, therefore, having a stimulating action. Caffeine has pro-inflammatory effects when administered in the presence of an acute inflammatory process in rats, increasing tissue damage evidenced by increased mRNA levels of TNF-alpha, TNF-beta, lymphotoxin-beta, IL-6 and IFN-gamma in the spleen and increased IFN-gamma in peripheral blood. Cytokines such as IFN-gamma act as mitogens for keratinocytes in psoriasis.

The caffeine and chlorogenic acid present in coffee contribute to increased homocysteine, which is a risk factor for cardiovascular disease. Homocysteine requires folic acid, vitamin B12 and vitamin B6, which act as cofactors for its metabolism. In psoriasis, plasma homocysteine is increased and correlates directly with the PASI score and inversely with folic acid levels; there is probably an increase in consumption or a decrease in absorption.

At least half of the world population consumes tea. Prepared from the leaves of Thea sinensis, tea contains caffeine, theobromine and theophylline. 13 Theophylline has the ability to enhance epidermal keratinization, possibly by restricting the activity of the gene associated with proliferation, and to strengthen activities related to the maturation and cell differentiation of normal or psoriatic epidermis.

Smoked food and barbecue

These foods lead to functional and morphological alterations in polymorphonuclear leukocytes and it can also cause a higher release of chemotactic factors, with an increase of interleukin 1 B, TNF-alpha and transforming growth factor-beta, which have been associated with the severity of psoriasis.

Cooking methods that use high temperatures and low humidity (frying, roasting, grilling), especially food high in lipids, contribute to the high dietary content of AGEs-Advanced glycated-End Products, which damage cells and bind to specific receptors, causing the production of inflammatory cytokines and growth factors.

Miscellaneous

High fiber diets may reduce circulating endotoxins. Elevated endotoxins are positively associated with psoriasis.

Fruits and vegetables (especially carrots) may alleviate psoriasis.

One clinical observation is that psoriasis patients given a rice diet showed a dramatic reduction in or disappearance of their skin lesions.

The skin lesions in four cases of long- standing psoriasis cleared strikingly when the patients were placed on a low-tryptophan diet. In three of the four patients the lesions cleared completely.

The last but not the least one is that concomitant use of curcumin with methotrexate decreases the hematological side effects of methotrexate during treatment of psoriasis.

ACKNOWLEDGEMENT

I pay my sincere thanks to Dr. Rashmi Gupta consultant “Pearl-The Skin & Cosmetic Clinic” for her efforts in preparing the article.

BIBLIOGRAPHY

1. Barrea L , Macchia PE , Tarantino G , Di Somma C , Pane E , Balato N , Napolitano M , Colao A,Savastano S. Nutrition: a key environmental dietary factor in clinical severity and cardiometabolic risk in psoriatic male patients evaluated by 7-day food-frequency questionnaire. J Transl Med. 2015 Sep 16;13:303.

2. Luigi Barrea, Nicola Balato, Carolina Di Somma, Paolo Emidio Macchia, Maddalena Napolitano, Maria Cristina Savanelli, Katherine Esposito, Annamaria Colao5 and Silvia Savastano. Nutrition and psoriasis: is there any association between the severity of the disease and adherence to the Mediterranean diet? Journal of Translational Medicine (2015) 13:18.

3. SI QIN, JU WEN, XIAO-CHUN BAI, TIAN-YU CHEN, RONG-CHANG ZHENG, GUI‑BIN ZHOU, JING MA, JIE-YING FENG, BI-LING ZHONG, YI-MING LI. Endogenous n-3 polyunsaturated fatty acids protect against imiquimod-induced psoriasis-like inflammation via the IL-17/IL-23 axis. MOLECULAR MEDICINE REPORTS 9: 2097-2104,2014.

4. Jillian W. Millsop, Bhavnit K. Bhatia, Maya Debbaneh, John Koo, Wilson Liao. Diet and Psoriasis: Part 3. Role of Nutritional Supplements. J Am Acad Dermatol. 2014 September ; 71(3): 561–569.

5. Moira Festugato. Pilot study on which foods should be avoided by patients with psoriasis. An. Bras. Dermatol. vol.86 no.6 Rio de Janeiro Nov./Dec. 2011.

6. Harry Spiera, Albert M. Lefkovits. REMISSION OF PSORIASIS WITH LOW DIETARY TRYPTOPHAN. The Lancet, Vol.290 (7507):137–139, July 1967.

7. Nazıroğlu M , Yıldız K, Tamtürk B, Erturan İ, Flores-Arce M. Selenium and psoriasis. Biol Trace Elem Res. 2012 Dec;150(1-3):3-9.

How Cosmetic Patients are Not Really Patients??

Introduction

When I was studying Masters in Dermatology in one of the best institutes in India, KMC Manipal, I used to often wonder whether I would spend my whole life consulting patients with itches, ulcers, scabies, leprosy and fungal infections. However when I started my own practice as a dermatologist, focused on treating cosmetic problems, I came across many patients who spoke about their bad experiences with their previous dermatologists. Some of the common complains that caught my attention were:

“My previous dermatologist did not spend more than 2 minutes consulting me. She was always in hurry whenever I went to her clinic for treatment”
“Doc she burnt my skin with laser and when I showed her my face, she did not even bother to look at it. What kind of doctor is she?”
“ She was not soft-spoken and never assured me of flawless skin after the treatment”

I realized that these patients were different and needed to be treated in a different manner. Many questions cropped up in my mind, like:

Should I spread red carpet for them. Make each and every one of them feel special whenever they walk in my clinic?
Should I wish them on their birthdays and anniversaries?
Should I address them by their names and pay attention to every individual
Should I invite my loyal customers for get-together and know them better?

After pondering for quite a time, the one answer that came up for all these questions was YES. Since then my whole focus has been to be their special doctor.

Understanding My Patients and Creating a Special Bond with them

I have always maintained that patients seeking cosmetic treatment are very demanding and expect a solution for their every cosmetic concern. This puts lot of pressure on me to satisfy them, because a NO can deeply disturb them.

Every patient has his or her set of questions or problems. Their questions can be as simple as, “Doc I have an oily skin, then why should I use moisturizer?” or as bizarre as “I have heard that laser hair removal causes cancer later in life. Is it true?” Though this can be irritating and sound stupid, dealing with such queries is part of my daily cosmetic practice.

As a skin specialist you need to have flawless skin because your patients treat you as your role model and want to imitate you. In other words, you inspire them and they feel that they are in the right hand. Many of my patients say to me, “You have flawless skin and I want mine to be like you”

I have been in cosmetic practice for more than a decade now and I love my profession. I have created a special bond with patients and they like the way I speak to them, assuring that they too will have a flawless skin. Hence they wait for months to get an appointment. It is very satisfying for me to see smile on their faces and I do not mind seeing 100 to 140 patients a day.

The Typical Profile of Cosmetic Patients is very different

Patients don’t mind waiting, provided it’s worth it. However I try my best to arrange the appointments in such a way to cut down their waiting time to minimal. However factors like traffic jams, long distance to travel in a city like Mumbai; and some cases that require longer consultation can extend the waiting period. However my staff usually engages them in complimentary treatment, paying attention to their needs.

Patients Seek Honesty

Patients don’t expect perfection, but honesty. As a dermatologist, I often come across chronic, recurrent conditions of varying aetiology like freckles, acne, melisma, which have various internal as well as external unknown causes and triggers. Treating them with lasers gives them a feeling being under the magic wand that will erase all their skin blemishes. However I am honest to them and discuss all the possibilities of recurrence and treatment failure with them before starting any treatment. This is the backbone of my practice.

They Have High Expectations

Practicing in a 5-star clinic with lasers and all modern updated technology raises the expectation of my patients and they ask me question like “Even with laser, you mean melasma will not go away permanently? “ I have to explain them that laser is not a magic and just an external treatment for resistant cases. There may be an internal cause that triggers the skin problem and hence no permanent cure to such a problem. I patiently explain them and they agree to sign up for temporary treatment because that is the best solution they can have. At the end I frequently hear them say, “Oh our previous dermatologist never said that. He said your skin blemishes will go!!”

Willing to Pay through their Nose

Cosmetic patients have deep pockets and I am often surprised, when average looking patient readily pays for expensive Botox and laser treatment. I remember one such patient, a 62 years old lady who had taken a bank loan to do skin treatments like Botox and fillers. When I asked her why she did so, she said, “Doc my skin is the only thing that I will take with me when I die. Rest all the diamonds and properties that I own, will be left with my family. My skin is my priciest possession”.

Patient Trust You only

Patients Insist on seeing only YOU. Well that is at times pretty frustrating. They know that doctors aren’t omniscient; they just want them to share what they know. Sometimes I wish I could clone myself. Hey wait I cannot clone myself, but I can do something similar. Train and educate my assistant doctors and teach them to deal with my patients in the same way as I would. For that I conduct regular training sessions for all my staff so that they can understand patient problems and solve them independently.

They Like You if You accept your Faults

Once your patients trust you, it is bond of lifetime. Uncertainty is fine, as long as they are told the truth. Also they accept that doctors are human and that medical errors occur. They don’t aim for retribution, but they want doctor to acknowledge it and sincerely address it. Have I never burnt any patient with lasers? Yes I have and I am sure most of my successful colleagues would agree with me. Have I apologized to my clients? Yes many times. And that only wins their trust. They know I am human.

Patients are Surprised if You offer them Options

They need an option: People don’t know that they have options, especially when it comes to saying no. They are used to doctors telling them what they need; they are surprised when I mention that they have a choice to “NOT get a test” or “NOT take medications”. However I discuss why they should and what will happen if they don’t. However I always say that “If you don’t do dermaroller, you won’t die!!”

Worried about Side-effects

They are very scared of side effects. Almost every patient walking through my door is on self- medication like multivitamins and calcium. They pop pills like peanuts and when I ask them why they are taking calcium, the answers are hilarious. “My gym friend advised me”, “Am I not supposed to, I am 41. It strengthens my bones” and the best one is “for the white patches on my face” or “my son has white spots on nails which is due to calcium deficiency”. I always end up lecturing them on the need for good nutrition and not depending solely on supplements. No one thinks that these supplements could also have side effects. However when I have to prescribe an antibiotic or a topical lightening agent, I have to face so many questions. But that is how some of my patients are.

Patients are Looking for Role Model

They are looking for a life coach and a role model. People aren’t just looking for a paper prescription or a doctor eager to inject Botox into their faces. They want a doctor who is good listener and adviser on all aspects. Because most of us don’t spend time discussing about lifestyle changes, most people don’t want to go to their doctor at all, and prefer to find ways to improve their lifestyle and prevent disease. None of us can undermine the effect of good nutrition and balanced lifestyle on skin. People crave connection and caring. They want face-to-face interaction with “their” doctor. They want to be listened to, heard and be told. Knowing their medical history is only the start; they also want their doctors to understand and connect with them emotionally, physically, and spiritually.

A Five-Star Environment that Attracts Patients :5- Star Hospitality is a key to a successful cosmetic practice: Over the years, my dad and brother were always amazed at the amount I spent on beautifying my clinics. They could never understand why I would take bank loans and decorate the clinic. After all they are in business too. And I never could explain well. When I had a menu card for the choice of refreshments in my clinic, my dad frowned “have you started a restaurant here?” Don’t we all like to put our best face forward? That’s all what I want to do. Since I am in the business of beauty, I believe in creating a luxurious environment in my clinic, what is wrong with it? You can’t call yourself a cosmetic dermatologist and have a shabby, falling, dull and dead place. I want my clients to look forward to an excuse to drop by at the clinic.