Dermatology Pearls for Primary Care: Lessons from ACD ASM 2026

Welcome everyone. Um, welcome to those joining us online tonight and welcome to those who will be watching this at a later date. My name is Annelise. I'm one of the co-chairs of the Dermatology Special Interest Group for Wonca. Just before we get started, a little bit of housekeeping. First of all, just checking everyone's in the right place. We are having a discussion tonight on pearls and wisdom and reflections from this year's Australian College of Dermatologists annual scientific meeting, which was held in Melbourne recently. Just before we begin, a couple of housekeeping points. Um, please keep yourself muted. Um, I'm just going to keep adding people while we're going. Please keep yourself muted when you're not speaking. Feel free to pop questions into the chat throughout the session. I'll be monitoring this and will leave some time for discussion at the end. And what we're doing this time is this is intended to be quite a relaxed and conversational session rather than a formal lecture. Um, I am really excited about the night that we have ahead of us, particularly as I am an Australian-based um, special interest GP. And I am I am I'm really looking forward to hearing about these reflections from the conference. Given I am based on Australian land and so is Rochelle, it is customary for us to start with what we call an acknowledgement of country. And through this, what I want to do is just acknowledge the lands from which I am presenting today, which is the um, lands of the Wurundjeri people from the Kulin nation, as I am based in Melbourne and extend my respects to um, any First Nations um, clinicians who might be joining us today and acknowledge my um, pay my respects to elders both past and present. Rochelle, I believe that you are presenting from, is it Gadigal land? Um And if anyone Fantastic. And if anyone else is um based in Australia or in countries around the world where this is a a custom, I would encourage you to add these details into the chat where and we can know where everyone is presenting from. I am also quite interested where everyone's joining us from today. So, if you'd like to um say hi in the chat and just introduce yourself and say where you are zooming in from today, that would be fantastic. So, um what I might do is I might actually formally introduce Rachelle. Now, Rachelle, I may butcher the pronunciation, but I seem to remember you are Dr. Rachelle O'Hayon Hicks. Is that correct? Fantastic. >> That's correct. >> So, Rachelle is a first-year dermatology trainee, but will be known to many joining us as have it as coming from a general practice background until very recently. Um she is one of our um I've gone blank on the word. A What is it? Key members of founding members of the special interest group in dermatology. Um and she's a fellow of the Royal Australian College of General Practitioners. Rachelle is passionate about education, collaborative care, and improving access to dermatologic care across Australia. And I might even say and across the world, particularly in regional and rural communities. Rachelle has previously been involved with RACGP, so the Royal Australian College of General Practitioners, as both a GP supervisor, so supervising trainees, and with the University of New South Wales as a conjoint associate lecturer. Alongside clinical practice, she's involved in clinical research with the University of Sydney and has contributed to advisory committees for the Kids Research Institute in WA and the National Centre for Immunisation Research and Surveillance. And she's particularly passionate about uh strengthening partnerships between dermatologists and primary care, such as general practice workforce, to improve dermatological care, health literacy health literacy, and patient outcomes. So, we we feel incredible well, we the royal we feel incredibly lucky to have one of our members go on to become a dermatologist in training. I think I'm I think one of the reasons I'm so excited about this is I think historically there have been some silos, so almost some separation between I guess primary care and dermatology care, and I really see Rochelle as starting to bridge that gap as she continues to work through her training. So, I am so excited. So, I might we're going to start with a couple of questions for Rochelle, and then Rochelle is going to share some slides on what she's learned. And as anyone has any chats while we're we're going. Oh, and I can see uh I am struggling to see a few things. Oh, so we've got Janelle from Ireland, WA. We've got Carl and Theet Theeta in Orange. Fantastic. Okay. So, Rochelle, can you start by explaining for those of us who haven't attended before, what actually is the Australian College of Dermatologists annual scientific meeting? >> Well, firstly, thank you so much for the warm welcome, Annelise, and for inviting me to come and speak to everyone tonight. And thank you for joining us. I know we've got a small group, but hopefully it means that we can have a nice conversation and chat. So, basically, as you've explained, Annelise, it's the College of Dermatologists annual conference, basically. And so, it takes place on Friday, normally we have workshops, and then Saturday, Sunday, Monday are full of great talks and presentations from speakers from mostly Australia, but around the world. >> Fantastic. And I was wondering, um how many people attend the conference? Is it quite a small one or relatively large? >> This was actually the biggest turnout we've had so far, apparently. Um so, we had 1,800 people there, which is very exciting. Um there's also a conference that takes place at the same time for all of the dermatology nurses um from around Australia, as well. >> Cool. And I'm really curious. Um having attended a lot of I've I've attended a online version of of the conference during COVID, which I'm sure is quite different to in-person, but I have also attended a lot of general practice um and medical educator conferences. I'm just curious, how how is a dermatology conference different to, for example, a Wonca conference or general practice conference? >> That's an excellent question, and I may not actually be the best person to answer that, cuz unfortunately, I haven't managed to attend a Wonca conference, although I would love to in the future. Um but I think they would be very similar. Um I think, you know, there's lots of sessions that are run um often concurrently, and people can pick and choose what interests them. Um there's also often lots of great food, so morning tea, lunch, afternoon tea, and so there are really good breaks and lots of coffee and tea for people in between. Um one of the big differences might be we have a really big exhibition hall at the dermatology conferences, uh where there are, obviously, lots of brands from around the world um selling prod- or trying to promote their products or devices to doctors and nurses. So, that might be one of the slight differences. But, I think on the whole maybe the other difference would be different target audience for content. So, very much focused at maybe practicing dermatologists and not even necessarily at registrars such as myself. >> Um. And I think just I think totally one of the things I've noticed attending some of these conferences is with general practice conferences I've noticed that um often people are very casually dressed. I remember a few conferences in Australia people have been wearing flip flops around and wearing like board shorts and and t-shirts. Whereas, my experiences with the my small experiences everyone has been really a little bit more dressed up and and well put together. Was that Is that perhaps accurate everyone looks quite Is usually wearing something kind of clinical practice like? >> Yeah, definitely more professional work clothes probably. Except maybe on Sunday people might rock up in jeans and kind of smart casual. >> Sure. Sure. And I was just wondering what was the overall mood or direction of this year's meeting? >> So, there was a really big focus on I guess some of the key issues being faced around the world particularly in the I guess dermatology space. So, there was a lot of focus on photo protection especially for those coming from Australia. A lot of people would know that there's a lot of misinformation around sunscreens in particular. And so, that was one of the big focuses of the conference. And another big topic was improving access to dermatologic care for the rest of the world and particularly underserved populations. So there was a big focus on skin of color as well. >> Fantastic. I'm looking forward to asking you a few more questions about that later. Um so we might shift over just to some some more kind of general questions to start with. Um having just attended I think this was Was this your first time attending this particular type of conference? >> Second. >> Um were there any um was there anything that really surprised you um that either in terms of emerging evidence or shifts in expert opinion? >> Mm. I think um one of the amazing things about um a lot of the dermatologists that spoke is a lot of them are speaking from personal experience or um more anecdotal experience. And so um a lot of them were sharing tips and tricks that have worked for them in their clinical practice, but they might not yet be well-established or published yet. Um so that was quite interesting um hearing some of their insights and just seeing how um creative and innovative a lot of the um specialists are. And I think that would probably go with lots of the lots of the different um doctors around the world as well. >> Yeah, cool. Can you think of any I might be putting you on the spot, but can you think of any example? >> Um so there was in particular um ooh, pityriasis rubra pilaris. Um >> Yeah. >> We I don't I might have said that wrong. Uh I might have said the condition wrong. I've been learning a lot of different terms of lots of different um conditions. Um but they there's been some trials of the use of sirolimus topically for the treatment of this condition. Um so together with using um quite strong pulses of laser some of the dermatologists were saying that using sirolimus topically had actually improved the appearance of the flushing that often comes with this condition. Um I think it's actually keratosis pilaris rubra I think is the condition. Yeah. Um so that was quite interesting. >> I actually do know a little bit about sirolimus. Um a number of years ago I worked in a organ transplant clinic alongside a number of dermatologists and a lot of our patients were on sirolimus or tacrolimus. And from putting my general practice hat on for a moment I have come across requests for sirolimus um with the um the push for longevity or anti-aging medications. It's not something I feel comfortable prescribing for anti-aging but I know that there are other GPs who do prescribe it for that reason. So very interesting space at the moment. And >> Yes, absolutely. >> Now was there a particular talk or session that really stood out to you that really changed the way that you think about your clinical practice? >> I think in particular I I was really struck by the clinical pearls given by some of the really well-established dermatologists just sharing kind of some of their um thoughts and uh that was quite inspiring for me hearing from people that have been in the field for a really long time. So learning some of their tips and tricks was wonderful. Um, one of the dermatologists, Dr. Belinda Welsh, in particular, she showed a picture. Yeah, Belinda's one well wonderful um educator. Um, she showed a photo of one of her patients' necks. Um, in particular, she the patient was concerned about poikiloderma of Civatte, which often, I guess, we see um sort of blotchy pigmentation and um vessel damage, so telangiectasia. And um this lady also had a big goiter, which the patient actually wasn't concerned about and hadn't really thought much about. So, when uh Dr. Welsh mentioned it, the patient thought, "Oh, I just thought my neck was getting a little bit fat." Um and that was a really good reminder that we're doctors first and foremost. So, no matter where um or what um your practice looks like. So, I know that many of us are family practitioners um or GPs, um but some of us might be kind of more specialized in a certain area, but we're still doctors first and foremost. So, I thought that was a really good tip for me and to not ever lose the GP in me. >> Oh, fantastic. Cool. And um I know I think you're going to go through some slides in a little bit, but I was wondering if there was any updates that you think are particularly important for GPs to know about? >> Yes, absolutely. So, one of the things that I'm really looking forward to seeing maybe change in the next little while, it hasn't yet been published fully, um but there's been a lot of talk about potentially downgrading the guidelines for management of melanoma. Um, so as many of you would be aware, currently, um the guidelines are often for something like melanoma in situ to do a wide local excision of sort of 5 to 10 mm. Um or, you know, if if it's a little bit more invasive, think about sort of 1 to 2 cm margins. Um there's now a bit of talk about whether or not the recurrence rates actually change or whether when we go back for those wider re-excisions, whether there's actually any cells left. Um and so, in the next little while, there might be a change that we're actually just thinking clearance and not going back for wide local excisions. So, that's something that will actually I guess improve our workflow that we might not need to bring patients back as much. They won't need to go through a bigger excision or a a second excision, and that will also have savings for healthcare as well. >> Oh, fantastic. That's really interesting. And just so I understand it better and and maybe for anyone joining us this online, um when you're saying clearance, are we talking just clear of margins? Like to the nth part of a millimeter or like a 1 or 2 mm margin? Or is it just still being discussed? >> That's a really good question. So, I guess normally when if we are trying to do something like an excision biopsy, we try and recommend doing like a 2 mm margin. So, something like that would probably be appropriate and not trying to get sort of 5 to 7 mm clearance. >> Cool. And moving on to another question, you touched on skin of color and photoprotection as being recurring themes. I was wondering if you could tell us a little bit more about these and why you think these conversations are becoming increasingly important for for discussion in conferences such as these. >> Mm. Mhm. I think in particular the photo protection we're seeing um that I guess it's becoming a bit of a health a public health issue um particularly with lots of misinformation out there um people being concerned about sunscreens being toxic um but also emerging evidence um which I'll talk about shortly um about the role of uh long UVA and visible light in conditions such as melasma um and pigmentation as well as um a causing photoaging changes. Um so I think that's one of the reasons that photo protection probably came up a lot. We also had the benefit of having Professor Henry Lim who is one of the leading experts in photo protection um and he's based in the US. So that was probably another reason that we um focused quite a bit on photo protection. Um we were also really fortunate that a lot of the organizers of the ISM um play a special role in the International League of Dermatological Societies. So Professor Lim is the current president of the ILDS um and uh Associate Professor Michelle Rodriguez was one of the conference organizers um and you would be familiar with um Michelle Annelise but she um I guess had a very keen interest in ensuring that um we improve education um around dermatological conditions particularly in skin of color because often patients with um skin of color are underrepresented in textbooks and teaching. So I think that was kind of something that we um that the conference aimed to improve. >> Fantastic. Um I I can't I think we might have had a conversation recently. Um I teach medical students at Melbourne University and I teach them about primary care dermatology, and um I show a whole lot of different pictures on my slides, and one of the pictures I show is I show one of um uh chronic plaque psoriasis um in in a skin phototype. I think it's a four I think it's a five. And then I show a picture of a slide of someone with impetigo in a um skin phototype six. And I think eventually someone will get the the psoriasis one, a couple in the room of 50 or 60 students, but almost never does anyone get the impetigo diagnosis right. And it And I show a quite a classical I I say textbook, but I realize that we don't show these types of cases in textbooks, but I show a a kind of discrete lesion with a golden crust on an ankle in a patient who's come in for an ultrasound guided steroid injection to the ankle with all of this impetigo there. And the Yeah, it's it's been really interesting um hearing from the students as they reflect we like I know impetigo, but I had no idea that was how it presented on that skin type. So, I think it's really great that we're starting to make inroads in this area. Now, I might hand over to you to share your slides at this stage, but I'm just wondering from those who have joined us, do we have any questions at this stage, or shall we ask a few more questions later on? We've got no hands going up, so I might let you um I might let you share your slides now, and I'm going to mute myself, and I'm going to disappear into the background. >> And very happy at any point if anyone has a question to um raise their hands or unmute themselves. Um so, let me see if I can share my screen. Okay. Can everyone see that? Hopefully people can. >> Yes, we can. >> Wonderful. Thanks, Annelise. Okay. So, basically tonight thanks, Carl. Just wanting to share some of the key clinical pearls for primary care physicians. So, hopefully this will be relevant for all of you. Um So, just a few disclosures. So, I am a fellow of the Royal Australian College of General Practitioners and I'm a first-year advanced trainee. Um so, basically just wanting to um share that this is a summary of what I learned from leading experts and I myself am not the expert. Um So, I'm still learning and hopefully you can learn with me, too. So, today I'll be um going through a couple of updates. I think we've just had another join us, so welcome. Um so, just wanting to share a couple of updates about photo protection, psoriasis, skin of color, rosacea, dermatitis, and social media. And I'll also be sharing some tips and tricks in particular focusing on biologics and immunotherapy and basically what the primary care physician needs to know and some other clinical pearls. And then we can have some time hopefully for some question and answer at the end, but please feel free to ask during the webinar at any stage as well. So, a little bit about photo protection. As many of you would already be familiar with, the role of UVA and UVB is very well established. However, there's sort of more emerging evidence suggesting that long UVA sort of between 240 to 400 nanometers in wavelength is playing more of a role, particularly in tanning, photo-aging, and photocarcinogenesis. And that applies to actually all skin types. And there's a little bit more evidence nowadays that visible light, um, approximately between 400 to 700 nanometers is playing quite a big role in, um, producing erythema in all skin types as well as tanning, um, for, um, skin phototypes 4 to 6. So, that's quite an interesting thing cuz often when we think about sunscreens, we're often thinking about UVA and UVB, mostly UVB being covered in SPF, um, and then the UVA being covered in the broad spectrum. Um, so I guess that this is something that's a little bit new and we'll be seeing more of in the future. >> Rochelle, could I >> Oh, you're already >> Yeah. >> Oh, no, you're I might just quickly touch base for a moment. I, um, I did think explain phototypes before. Would you mind just briefly explaining what we mean by skin phototypes? Um, >> Yeah, absolutely. Um, so when we are talking about skin phototypes, it's also known as Fitzpatrick skin types. Um, so we have sort of, um, one to six. Um, I do actually have a diagram coming up shortly, but, um, so hopefully that will make sense, um, shortly. But one normally we're talking about really fair skin types, often people with, um, red hair and blue eyes might be often what we see or green eyes. And then it kind of, um, it's based on how someone also reacts to sunlight. So, um, normally, um, a Fitzpatrick skin type 2 might be someone with blonde hair or light brown hair and they often can sort of maybe when they get sun exposure, they might turn a little bit red or, um, and go back to being fair, or they may sometimes tan, but very rarely. Um, whereas Fitzpatrick skin type one would be someone who um, burns pretty much instantly and will never ever tan. And that kind of goes down to um, Fitzpatrick skin type um, six. And that might be someone with um, African-American background, um, who normally when they get exposed to the sun might not actually um, ever get burnt. But um, someone with sort of type three skin, um, often would be someone who can tan quite gradually. So, I've got a diagram coming up soon, but that's a great question, Annelise, and um, it is definitely something useful for us to be familiar with, particularly when we're assessing people's risk. Um, so that's kind of more assessing someone's actual response to sun. Um, and often we do associate it with maybe someone's phenotype or what they look like. Um, but that's also another topic that came up in skin of color. So, um, happy to answer more questions on that shortly. Um, so in particular with UVA1 or this long UVA and visible light, we can see that it plays a large role, especially in skin types four to six. Um, so looking at this diagram, you can see that with UVA1, there is actually a little bit of color change. Um, and with visible light as well, we see a little bit of color change. Less so with Fitzpatrick uh, or skin type two in this case. So, often visible light maybe plays less of a role um, in lighter skin types. Um, and this is especially important, the role of UVA1 and visible light in pigmentary disorders like melasma. Um, in particular, we um, some research um, done by uh, Professor um, Henry Lim, or actually presented in your slides and done by another team colleague et al, um, demonstrated that there's a synergistic effect between visible light and UVA1, or this long UVA. You can see here that the color change that's actually, um, produced all this sort of, um, darkening and pigmentation is actually, um, heightened when there's the effect of both UVA1 and visible light. And so this brings us to, I guess, some emerging technology, um, pretty or new filters in sunscreens being used, um, that are particularly targeted at visible light and UVA1, um, and there are actually some new sunscreen filters that target blue light as well, which has been shown to, um, increase photoaging. So, often when we're thinking about blocking visible light and UVA1, um, many of you might be familiar that tint, um, in the form of iron oxide is often used in sunscreens, but that's not always, um, sort of, um, aesthetically acceptable for people, and so there's this some newer filters including, um, a filter by La Roche-Posay called Mexoryl 400. So, um, this is an exciting time and there will be some, sort of, newer, uh, filters emerging. Now, onto skin of color, and this is where you can see the Fitzpatrick scale. So, as I mentioned, um, there is this type one skin that we often talk about, and that's normally someone who always burns and never really tans, and, um, just to highlight that, I guess, the, uh, Fitzpatrick skin type, or the, um, uh, when we talk about this, this is actually talking about their response to sun, um, and to UV radiation. So, often it might be associated with, um, what someone's skin looks like, but actually it's mostly highlighting someone's response to UV radiation. So, this is particularly important in skin of color. So, when we actually talk about skin of color, um, Professor Rodriguez mentioned that this term kind of is an umbrella term for all skin that is non-white or non-Caucasian. Um, and so often we use it interchangeably with something like the Fitzpatrick skin type. Um, in order to describe what someone's skin might look like. However, this is, like I mentioned, just a tool to assess response to UV light exposure. And I'll be talking about a different, um, tool that might be more useful for us to actually think about how we describe someone's, um, skin color. So, as, um, we discussed, um, there is a gross lack of representation in textbooks as well as medical education, as Analisa has highlighted. And also an underrepresentation of patients with skin of color in clinical trials. So, this is the newer tool, um, that has been, um, sort of, uh, developed by Ellis Monk, who's actually a sociologist, um, and adopted by Google AI. So, they've developed something called the Monk Skin Tone Scale, um, and this is actually kind of, um, shows 10 different categories of skin tone. Um, and this might be a better, um, tool for us to actually categorize people's skin color. Um, this is now uh, being available in different swatches, and, um, you can actually put it up against patient's skin to assess which skin type or skin tone someone has. And I didn't get to check out the website too much myself, but there's a link here, um, and I believe you can actually figure out your skin tone online. So, that's a new cool thing that Google AI has developed. Um So, now for those amongst us who um might be using lasers for patients in skin of color um or treating patients in skin of color. I'm not sure if anyone here actually does any laser treatments, but it's especially important for us to consider the risk of post-inflammatory hyperpigmentation or otherwise known as PIH. Um and in particular, one of the tips that Professor Rodriguez shared was um being able to look at the palmar creases. Um and so, in particular, we can see here um that there's actually quite a difference between the color of the palmar creases and the surrounding skin. And this actually is a marker of um or um can be used as a risk predictor for whether someone might develop post-inflammatory hyperpigmentation and then being extra careful if someone is doing any treatments um and particularly also, I guess, for um thinking about how we assess someone's risk. Um and so, really important when we're um seeing a patient that we take a history about what happens when someone scars, whether or not they're prone to hyperpigmentation, asking about UV exposure and tanning and what happens to their skin, as well as ask about medications and prior treatment and outcomes. Um and so, this is really helpful. Um you can see there's a four-point visual scale and then it evaluates pigmentation contrast between palmar creases and surrounding skin. So, if there's no difference, um then that's low risk, as well as if they're scoring one or two. Um and then scoring two or three kind of indicates that they might be a higher risk of developing post-inflammatory hyperpigmentation. Um and then moving on to psoriasis. So, this kind of also touches on the topic of skin of color, but we talked about how psoriasis presents in diverse skin types. Um So, in particular I guess um something that was really helpful is that psoriasis occurs in 1 to 3% of the world's population. So, 3.7% white, 2% black, and 1.7% Hispanic. Um and in skin of color, it actually um there's evidence that shows that it's that patients are four times more likely to require a biopsy to get a diagnosis, and it often takes them three times longer to get a diagnosis. Um some research also showed that um when dermatologists were surveyed, only about 60 or about 66% said they weren't really comfortable diagnosing skin conditions in patients with skin of color. So, that's quite interesting. Um So, some of the diagnostic challenges, particularly for diagnosing psoriasis, is that there's a lot less erythema. Um there's also increased hyperpigmentation post inflammation. Often um they have thicker, more scaly plaques and more scalp involvement. In particular, um we spoke about the contribution of hair care regimens and um especially in afro-textured hair. So, often afro-textured hair is um a lot more fragile and um and that might mean that people wash their hair a lot less frequently frequently. And so, we have to think about really carefully when we prescribe different medications for the scalp um about what might be acceptable for our patients if, in particular, they're washing their hair less frequently or their hair is a lot more fragile. Um so one of the tips that um Professor Rodriguez gave was thinking about the base in which we put our actives. Um so there are lots of different um medications that can be compounded such as um putting betamethasone dipropionate in olive oil. Um and so thinking about how we can actually make treatments more accessible um and acceptable for our patients is helpful as well. >> Just to interrupt for a moment, putting on my educator hat for a moment, with afro-textured hair, I presume that we're talking about quite um I know a little bit about hair types, but I I'm guessing that a lot of people watching this won't. With um afro-textured hair, I understand that they I always get them mixed up. They're quite flat when you look at them under the microscope, and therefore they curl a lot more, I think. We're talking about quite curly hair generally, is that correct? >> Yes. Yes. >> Yes. >> And really prone to knots as well. >> Yeah. Fantastic. Sorry to interrupt, I just want to make sure I'm following correctly. >> No, thanks Annelise. Um so as Annelise was talking about um how she often puts up um photos for her medical students, these are some photos um just of what psoriasis might look like in skin of color. So often uh we might see that psoriatic lesions are characterized by a purple or lilac um tint, um and more often gray as well. Um and that there might be thicker plaques as well as extensive scaling and hypo- or hyperpigmentation. Um in particular um one of the examples that Professor Rodriguez gave was that um often people might present with hyperpigmentation around the scalp region, um and they might be referred in with vitiligo, but actually it could be that there was some hypopigmentation after having psoriasis, which is quite interesting. Um So, when we think about psoriasis in skin of color, so on the um left side, we've got sort of um two different types of psoriasis in um what we deem as skin of color. Um and what one of the tips that um Michelle Rodriguez gave was thinking about replacing that purple or gray with pink or red, and then that's when we get our classic-looking psoriasis that we're often taught about in textbooks. Um that um coral-colored um arrow was courtesy of my nephew who was helping me. Um he's eight, and he said that I needed to put the um pink coral um arrow to help hone in that that's what we're replacing the gray and that violaceous um tint with. So, um also something that I found really interesting and probably have only um learned more about lately. Um some of you may know this already, but psoriasis is also particularly important in managing other comorbidities. Um so, in particular, interleukin 23 is one of the pro-inflammatory pathways that drive psoriatic skin inflammation and atherosclerosis. And that psoriasis is actually an independent risk factor for cardiovascular disease. Um and so, really I guess when we're thinking about psoriasis, it's not just a skin condition. It actually does have um impacts for the patient's overall health. So, thinking about how, you know, if someone presents with psoriasis, thinking about how we can manage their other um risk factors such as um their cholesterol, um their sugar levels, um if they're a smoker thinking about their pack years. Um and in particular, it's not something that in Australia is commonly or routinely done, but it um there is um some discussion around whether or not this should actually be added into our regular screening is testing for lipoprotein A. Um so in particular um people of Southeast Asian descent, Indians, and Sri Lankans actually have um evidence that um so they're positive for lipoprotein A, and that can actually increase um their cardiovascular risk. So that's just something to think about especially in our patients who have psoriasis. Then we're going to um move on to psoriasis in children. Um and I found this actually very interesting. Um so psoriasis affects 0.1% of children worldwide. And often when we're um thinking about psoriasis, it's really um helpful to think about uh the history of the patient in front of us or the child in front of us. So often cradle cap is the first presentation of psoriasis in a lot of patients. Um and it's often correlated with a nappy rash um which often presents as really bright red. Um so often I guess recurrent nappy rashes in kids is associated with psoriasis. Um and there are other associations um with psoriasis in children including obesity, sleep disturbance, mental health issues, joint issues, and bullying. And and interestingly, obesity is often correlated with severity of psoriasis in children. Um another thing to ask about on history taking is about family history. So 30 to 50% of children have a first-degree relative with psoriasis. On examination, um often it can appear quite a lot like atopic dermatitis or eczema. And there are often thinner or softer plaques. It's often not as well demarcated as psoriasis in adults. And there's often less scale and less erythema than in adults as well. It's also not classically that extensive surface, so normally I guess in classic psoriasis we think about, you know, backs of elbows, backs of knees, or on the front of knees. Um but actually often more facial and flexural involvement as well as scalp and peri-auricular regions are often involved. Um and pruritus is often very common, so really itchy skin. Um Koebnerization is also quite common, so um for those of you who might not um completely understand the term Koebnerization, what that refers to is the occurrence of new lesions on previously unaffected skin. And that normally is following an injury of any kind, so it could be after a surgery or a surgical site scar, or it could be a graze or a cut. Um that sometimes then new psoriatic plaques can form. Um and um often does involve about 30% 38% um have nail involvement as well. And the most common morphological type for kids is plaque psoriasis. Um and then guttate psoriasis. And pustular psoriasis is actually quite rare in children. Hi Jackson, thanks for joining us. Um so now a little bit about rosacea. So um back in 2017, so a little bit um ago, there has been a rosacea consensus, otherwise known as ROSCO. Um and it's kind of moved it's um something that's helpful for us to actually think about how we diagnose rosacea and given that it's often a clinical diagnosis. So this was something that I actually wasn't very familiar with. So I thought this might be helpful to share. But looking at sort of having one diagnostic feature of either fine matrix changes so that classic sort of rhinophyma that people develop or is associated with rosacea. Or persistent centrofacial erythema with transient flushing. As well as two of these four major features. So papules and pustules, flushing which is often frequent and prolonged, telangiectasia which are these little fine vessels, and ocular manifestations. So that could involve lid margin telangiectasia, blepharitis, keratitis, conjunctivitis, sclerokeratitis, or anterior uveitis. And that someone might also have some minor features, but this isn't necessary for the diagnosis. So burning or stinging of the skin, edema, or dry sensation of the skin. This was one of the talks that was all part part of some of the clinical pearls provided by Professor Adrian Lee. And this was about her approach to dermatitis. So often thinking about sort of the timing whether it's more immediate or delayed when we're thinking about contact urticaria or allergic contact dermatitis or allergic irritant contact dermatitis. We also think about the pattern and distribution of in which the dermatitis occurs. So whether it's on hands, face, eyelids, or neck. Particularly important to ask about occupation. So I guess hairdressers is a really common um occupation that presents with um hand dermatitis um as well as um healthcare workers um and that might be to different soaps around the hospital or sanitizers. Um thinking about exposure, so you know, how long ago were they exposed to a um some sort of irritant or allergen. And then um per se Adrian Lee sort of gave a different list of some various irritants and allergens to be aware of. So methylisothiazolinone um is one of the really common things that's often in shampoos or conditioners. So um people might present with kind of um some dermatitis around their forehead or ears kind of from when they're washing their scalp that it's sort of contacting those areas. Um perfumes are also a big one. Um nail cosmetics particularly for um eyelids. Um so a lot of people might present with eyelid dermatitis and often that's um due to contact. So um in particular um acrylic shellac um SNS nail polish and nail hardeners are some of the biggest culprits and so important to ask about those. Um hair dyes airborne, so that could be, you know, pollens or dust in the air can sometimes present as sort of an airborne dermatitis um and sunscreens uh that can also cause some um irritation and dermatitis. With um sunscreens, it's quite tricky um to work out um I guess which ingredient might be causing it. Often it's not really the filters themselves, but might be some of the other um preservatives or fragrances added in. Um but it's very hard to test for patients and so often it is sort of trial and error and working out if there's a common ingredient in some various sunscreens. And the management often involves avoidance, um potentially desensitization if it's a more immediate allergy, um or um avoiding for a minimum of 6 weeks, and then reintroducing one at a time. And then if wanting to do some further investigations, um you might do an IGE if you're thinking about an allergy, um or a RAST. Um and then patch testing would be if you're looking at particular irritants and can't identify a cause, and that's more in the allergic contact dermatitis, so the delayed dermatitis. Sorry, this clicker is not working. Um so, in terms of um approach, um management often is uh using topical corticosteroids to calm down the inflammation, um and then can consider calcineurin inhibitors later on, but obviously avoidance is a really big thing if you can identify the cause. Um there are also quite a few new apps that have come out which can help patients identify ingredients in um different cosmetic products. So, there's InciDecoder, CosDNA, and the Cosmia app. Um and the Cosmia app I believe is um has been established by um a dermatologist from the Australasian College of Dermatologists. Um and so, that's helpful for patients if they're trying to work out what ingredients and what um products they can continue using if they've been diagnosed with um some sort of allergic contact dermatitis. Um now, this is um a topic that's quite close to my heart, um and I had the pleasure of presenting in this session. Um so, we for the um had a presentation in particular on social media, the good, the bad, and the ugly. Um so, many of you might be aware that um disinformation is the intentional spread of misinformation and that this is um becoming a big problem um particularly on social media and the WHO has now um classified um misinformation as a public health issue. Um, it does have real effects for um and particularly I guess um might be politically driven um it's causing increases in infectious diseases um and some people are um doing it for money and power um and that it's actually posing a risk to science and public health. Um so we've seen a re-emergence of things like diphtheria, whooping cough and measles particularly with anti-vaccination movements um and that it's actually have we're having the worst vaccine coverage in the past decade. Um so it's now at less than 90% um and in order to have herd immunity we need a minimum of 95%. Um one of the things that was highlighted highlighted is that um misinformation actually creates distrust in the health system and in establishments um and that the solution is systemic but also at an individual level. Um so one of the key points is that we as health professionals are part of the solution and that we need to help promote discernment in our patients. Um meet people where they're at and teach them um about what is actually correct and what is evidence-based. Um and that we might be able to do some of that through mobilizing social networks and friends um and that we actually do need trusted health professionals to help build trust um again. And so one of the things that can be quite helpful is pre-bunking misinformation so actually spreading um the right information and teaching our um patients about what is correct. So, for example, if you know, one of the things that I like to do is tell people about sunscreens and that they actually don't um one of the big myths online currently is that sunscreens cause cancer. And so, actually telling them that the research shows that they actually prevent skin cancer. So, I think it's helpful to use our roles as clinicians to help combat some of that misinformation. Um many of you might also be online whether in more of a public profile or just as people who use social media, but it is actually really important for us to be aware of what is being spread online in order to facilitate dialogue with our patients and engage with them with the things that they're seeing online as well. Um it is also really important and this is what I spoke about was that we need to be aware of our own legal and professional responsibilities and that it's actually different in every country. So, this will be an interesting um space to watch in the future. Now, um Annalise, let me know how we're going for time, but I've got a couple more sort of updates. Um >> I'm really enjoying and I'm learning a lot. Um do you think we'd be ready for questions in the next 5 minutes or so or 5 to 7 minutes? Would that work? >> Yes, I will speed through this stuff and feel free to ask me at the end if I went over anything too quickly. So, this is very briefly biologics kind of what primary care physicians need to know. So, biologics is definitely a space that I'm very new to um, haven't been doing much of up until, um, learning about it recently as a trainee. Um, but basically biologics, um, target specific immune pathways in order to, um, bring about precise immune modulation. Um, the monoclonal antibodies used are a Y-shaped protein with a variable binding site. Um, and with the names, just so that guys are aware, um, the umabs are 100% human, the zumabs are greater than 95% human, and the zimabs are chimeric, so, um, approximately 65% human and, um, partially mouse. Um, and so commonly they're being used in atopic dermatitis, psoriasis, hidradenitis suppurativa, and chronic spontaneous urticaria. And there's, um, lots of, um, emerging uses sort of coming up and, um, lots of exciting things happening in the biologic space. Um, but other things that, um, useful for primary care physicians to know is that often they need to be commenced by a rheumatologist, immunologist, or dermatologist. Um, but in many countries, um, a primary care physicians play a role in continuing these managements and so prescribing ongoingly. Um, so screening is often performed, um, initially at, um, before commencing, um, treatment. Um, screening done is around infections, so tuberculosis, hepatitis B, hepatitis C, HIV, and strongyloides. Um, often it's important to check someone's vaccinations are up to date. So all live vaccines need to be completed at least 4 weeks before starting treatment. Um, and no live vaccines are to be given during treatment. Um, baseline bloods include sort of full blood count, EUC, LFTs, and these are often repeated, depending on which agent is commenced. And sometimes an autoimmune screen might be performed, particularly if, um, wanting if there's a history of autoimmune conditions or joint involvement in psoriasis. Um importantly, counseling should be done regarding the risk of infection awareness, pregnancy planning, and malignancy history. This should be done by the prescriber, but GPs and family um physicians do play a really important role in ensuring that these things don't get missed. So, um if you have a patient that he has been commenced on a biologic, it might just be worth flagging this and making sure that it has been discussed. Um other things to be aware of, sometimes these patients will be um well, these patients will be assessed at 12 to 16 weeks post initiation, and then every 24 weeks for continuation. Um but, as primary care physicians, patients might present to you in the meantime in between their checkups. And so, it is really important to monitor for any adverse effects um and you might um be able to um to perform some repeat bloods if required. So, in particular, I like to think about um local, ocular um infections, skin-related adverse effects, laboratory adverse effects, or um changes um on blood tests, and then the more serious um reactions that can occur, including um anaphylaxis um or allergic reactions um ocular eye pain and visual disturbance. Um sometimes there's also new-onset psoriasis um and um often musculoskeletal issues. So, always just good to be aware of sort of that um these treatments can cause various adverse effects and that you might be seeing them before they follow up with their specialist. Um so, this I'll just very briefly touch on, but some people might um see this term biosimilar. Um so, sometimes uh that might be changed over to something called a biosimilar, which are basically identical copies of an original biologic and they're assessed as safe and effective. Um, they don't go through quite the same rigorous testing um, as initial biologics, um, but often they can be used very effectively to continue treating various conditions and they're often a lot cheaper. Um. So, in terms of immunotherapy and what primary care physicians um, need to know, um, I guess one of the big things is that you might see patients um, with cutaneous toxicities. Um, so often immunotherapy, um, I guess sometimes used in things like managing melanoma, um, or other cutaneous malignancies. Um, people come in with things like eczema, lichenoid reactions, morbilliform eruptions, so it will often look like measles, pruritus, itch, um, acneiform eruptions, so things that look like acne or folliculitis, um, fungal skin infections, psoriasis-form dermatitis, rosacea, bullous disease, or cutaneous T-cell lymphoma. Basically, with immunotherapy, any treatment that affects the immune system, patients can get any kind of condition and so that's just something to be aware of um, when your patients might be on immunotherapy and um, feeling free to reach out to um, their oncologist or dermatologist or whoever has initiated the immunotherapy if your patient is experiencing any odd um, side effects from treatment. Um, I'm going to very um, rapidly um, go through some of the tips and tricks that I learned from um, some of the amazing dermatologists that spoke. Um, so in particular in the consultation, um, Professor Delova um, from South Africa talked about um, asking patients how their condition makes them feel. So, um she had these um nouns written on little pebbles and stones that she collected um from various places. Um and just being able to give her patients the words to describe how they're feeling when they might not be able to find it in their own vocabulary. Um she highlighted that it only really takes us 1 minute, but it can be really helpful for us to understand um the impact that um someone's condition has on them, not just skin, but other conditions. Um and it can be helpful um in follow-up as well when um a patient um it can actually show that they're feeling so much better um in and of themselves. And so this was one of her patients that actually is an artist and created her um some um special stones which had all the various nouns on them. Um Other see tips and tricks is um just thinking about medical gaslighting. Um so, there are really high rates particular in um Ehlers-Danlos syndrome and um endometriosis. Um and one of the tips that was given to us was um thinking about how we explain to them the symptoms that they've got, the symptoms that they don't have, and the diagnostic criteria that they might need in order to reach a certain diagnosis. Um and that we actually as physicians need to give patients an honest and grounded alternative diagnosis. So, rather than telling them that they're um that their condition is made up or it's all in their head to actually think about, "Well, I don't know if you actually do have Ehlers-Danlos, but you might have hypermobility." Um and kind of thinking about how we um don't strip away a patient's identity if that's kind of where they've been putting their hope um in. And so I think that's really helpful for us just thinking about um the person as a whole um even if they might not present with all of the classic criteria for a diagnosis. Um other things to think about is um how we look at equality and equity. Um so this was really important for me. I've often kind of maybe thought they were the same thing, but that equality does not equal equity. Um so equity is about fair access, opportunity, and support, and how we can um ensure that people around the world in particular are able to access um and have equitable access to health care. Um when we think about referrals, um something that I probably felt as a um general practitioner was feeling that I had to have failed all possible treatments before referring on to a specialist um or to the dermatologist, for example, and thrown lots of different creams at patients, um but really that we don't actually have to have completely tried everything or fixed our patient at any point if you're um not really sure what the patient might have to think about referring on or discussing with um a specialist to kind of run a case past them, think about whether, you know, there might be any feedback for um us as clinicians and how we can improve our practice in the future. I guess also being aware that some conditions actually um have better outcomes if they're treated early, such as vitiligo, for example. So referring on early actually um often ends up with a better prognosis for patients, as well. Um I've been triaging quite a lot of referrals to my dermatology department, and it's really helpful um when um family um physicians and general practitioners provide as much information as possible to facilitate triage. So, for example, if you're able to biopsy lesions, um, that helps us, um, especially cuz wait times can be quite long. So, if there's anything you're particularly concerned about, and it comes back as positive for melanoma or squamous cell cancer, it means that we can get them in a lot more rapidly. Um, actually using some of those morphological terms that we were taught in medical school of how to describe rashes can be really helpful, as well. Um, and providing photos, if consent has been given by the patient. Um, it's also very helpful to tell, um, the treating team or, um, specialist what your main concern is. For example, if you're worried that a spot looks like a melanoma, um, that's a lot more helpful than, um, "Please assess for lesions of concern," um, particularly when we're trying to triage someone quite urgently. Um, now this was more about the, so tips and tricks for the procedure room. Um, this was a artwork or a video, um, done by Maria Kojic, who is an artist, and she gathered, or asked the surgeons to gather all the waste from her operation after being diagnosed with breast cancer in 2019. Um, and this is just, um, how much waste was actually produced, um, during that operation. So, um, surgery, interestingly, accounts for 30 to 70% of hospital waste. Um, I'm sure that many of you do procedures in your, um, clinics or practices, or some of you might even be hospital based. Um, and so there was a interesting review done by Farooq et al., which demonstrated that there was no difference in, um, surgical site infection, length of stay, complications, or mortality using just disposable gloves. Um, so clean gloves are actually seven times cheaper and 10 times less carbon intensive than sterile gloves. Um, and so there's a bit of a move towards just using um, clean uh, disposable gloves rather than sterile gloves. Um, there's also a tip of using a buffering local anesthetic with sodium bicarb. So sometimes just 10% um, sodium bicarb, which saves costs but also uses less local anesthetic. Um, and interesting the nice um, nice has come out with a guideline on using soap and water at the start of the procedure and then alcohol gel afterwards, which obviously saves on water. Um, some other tips and tricks post-op, um, particularly for those of us who um, perform procedures, that um, applying a Tegaderm um, post-op for um, 3 months afterwards can improve hypertrophic scarring and keloid scarring, as well as um, stop the scar from stretching as often scars remodel um, for up to sort of 12 week 12 weeks after a procedure. Um, it's helpful for use in young patients um, re-excisions of hypertrophic scars, previous history of um, in patients with previous history of hypertrophic or keloid scars and high tension areas like the back or chest. Um, you can also use paper tape, Hypafix, or silicone dressings. Um, and thank you for bearing with me. I definitely feel like the best part of the ASM um, other than all of the amazing learning was actually learning from and meeting so many inspiring colleagues in the field. So definitely would recommend people thinking about attending um, in the future and please let me know if you're going um, to any of the ASMs in the future. And just a special thank you to um, some of uh, the amazing professors and dermatologists who shared some of their slides with me. Questions. Sorry, that was like rapid fire, but um >> That was fantastic. >> people found that useful. >> Um I was wondering if anyone had any questions at this stage. Feel free to unmute yourself and ask, or you can just pop it into the chat. I have two questions, so I'm I'm going to jump Oh, we've got one in the chat already. Oh, Janelle, such a helpful talk. Yes, Janelle, I was thinking exactly the same thing. I thought this um I was really sad I couldn't make it to the conference, and I feel like I've learned so much tonight. It's fantastic. Um So I um have a lot of patients who are using red light masks, and I do not I am not a cosmetic doctor, and I know we've got red lights, blue light, and infrared, and I know that from my limited education about cosmetics, I understand that a lot of dermal therapists are using blue light for acne management. And I'm wondering, does that seem to be heading out the door? Um that particular use, or is there Was there concern across infrared like infrared saunas that patients are using, or red light masks as well? I don't know if you can answer that, but I'm just really curious. >> Yeah, that's a great question. Unfortunately, I didn't um hear any talks on this specific topic, um but uh Professor Lim did highlight that blue light does actually um cause photoaging. Um so I guess that's something to just be aware of it for those who are using blue light for acne management. Um Other things that we do know from um previous discussions that I've had with other dermatologists is that infrared, I guess that heat can actually worsen pigmentary disorders, particularly for that darker skin types. So, for people who are prone to melasma, the heat in infrared saunas can actually worsen those things and pigmentation. So, I think some of those things need to be used in like with caution when people have particular conditions. But, um yeah, I I unfortunately I don't know too much about all the other evidence around red light masks. >> No worries. I was putting you on the spot there. Um I have one other question and I'm thinking we'll wind up in the next couple of minutes and across a number of patients with allergic contact dermatitis over the years and one of the questions I always get asked, especially when we're thinking about sunscreen allergies, what should I use? And I was wondering, do you have and I know you can't promote any particular brands, but I'm just wondering if would you use like a zinc-based sunscreen as an example or or you can mention just some names you might mention if if that's help if if you can think of any. >> Yeah, yeah. So, that's a really good question. So, one of the great things that Professor Lim talked about was changing the way that we think about sunscreens. So, there's often people will talk about chemical versus physical sunscreens, but the proper name should be really for chemical should be organic sunscreens and inorganic sunscreens. And when we talk about organic, it's mostly those chemical filters. So, like previously oxybenzone, avobenzone, those sorts of or now like the Mexoryl 400s that La Roche-Posay has come out with. And then when we're talking about the inorganic um, filters, they're often considered the more physical blockers. So, titanium dioxide, zinc um, oxide. Um, so often there is some discussion about whether um, those more physical or the inorganic might sit on top of the skin more often and cause less irritation. So, particularly I guess when people have breaks in the skin, um, people might prefer to use more of those zinc-based sunscreens. Um, but often they're not as cosmetically appealing. So, um, they're using now nanoparticle-sized zinc, um, which there's previously been some um, I guess uh, often people talk about the um, inorganic sunscreens or those physical blockers um, reflecting and scattering UV radiation instead of absorbing, which is how chemical sunscreens work. Um, however, what we actually know is that about 60% of um, those physical sunscreens actually use absorption now. So, um, we Yeah, I guess it's kind of people might need to do a bit of trial and error to figure out what sunscreens work for them. Um, there's definitely sort of pros and cons in terms of um, ease of application for more of those nanoparticle-sized um, zinc-based or titanium-based sunscreens. Um, but it really depends I guess on what someone um, would like to use as well as um, yeah, whether they've got underlying skin conditions. So, I think um, what Professor Lim said was um, you know, sometimes he would recommend the sort of more inorganic sunscreens or those physical sunscreens if someone has eczema or broken skin. >> Fantastic. I I gave you a bit of a curly question then. Um, I I think that's all the questions from me. Now that I have put Rochelle on the spot, does anyone else have any questions from that presentation? Well, we might wrap up there. I I think I can speak for everyone here that that was absolutely fantastic and um I was really looking forward to hearing your thoughts and I um really learned a lot and um I may have taken some sneaky screenshots that I'm looking forward to putting in my notes for my learning for later and um and I I really particularly love that slide on um approach to um your kind of contact dermatitis' and and looking at timing and but um different testing and things like that and that was a really helpful reminder for me. So, let's wind up there um and um thank you so much for your time. We really appreciate it. Fantastic. Awesome. I will leave you all to wash night and um thank you for joining us everyone. See you later. Awesome. Bye. >> Thanks for joining us everyone. Bye.