DEPARTMENT OF DERMATOLOGY
Faculty Administration Research Dermatology and
Luis A. Diaz, MD, Emma Beckham
The C.E. Wheeler Jr. Distinguished Associate Chair
Laboratories Skin Cancer Center
Professor & Chair Suite 405, CB 7287 Appointments
Mary Ellen Jones Building 919-966-2485
Robert A. Briggaman, MD, Emeritus Phone: 919-843-6756
405 Mary Ellen Jones Building
Craig N. Burkhart, MD University of North Carolina Southern Village
Donna Culton, MD, PhD Chapel Hill, N.C. 27599-7287 Immunodermatology 410 Market Street, Suite 400
Amy W. Fox, MD Phone: 919-966-0785 Luis A. Diaz, MD Chapel Hill, N.C. 27516
Lowell A. Goldsmith, MD, MPH, Emeritus Fax: 919-966-3898 Donna Culton, MD, PhD Fax: 919-966-6460
Puneet Jolly, MD, PhD http://med.unc.edu/derm Phone: 919-843-5401
Ning Li, PhD Fax: 919-843-5766
Zhi Liu, PhD
Aida Lugo-Somolinos, MD Dermatopathology
Patricia Mauro, MD Daniel Zedek, MD
Bradley Merritt, MD 414 Mary Ellen Jones Building
Dean S. Morrell, MD University of North Carolina
James B. Patterson, MD, PhD, Emeritus Chapel Hill, NC 27599-7287
Ye Qian, PhD Phone: 919-966-0786
David S. Rubenstein, MD, PhD Fax: 919-843-2530
Susan R. Runge, MD
Nancy E. Thomas, MD, PhD
Rajat Varma, MD
Welcome to UNC Pediatric Dermatology
The primary objectives of your experience include:
1. learn effective management of pediatric atopic dermatitis
2. learn effective management of acne vulgaris
3. learn the appropriate classification and management of pediatric vascular lesions
4. learn the appropriate classification and management of pediatric melanocytic nevi
5. learn the appropriate management of cutaneous infections including impetiginization, molluscum
contagiosum, verrucae, herpes simplex, etc
6. appreciate the role of a dermatologist in your care of patients
You will be a member of our team which can include dermatology, pediatric, and family medicine residents.
As a team, our goal is to provide timely, courteous, safe, and appropriate care to the patients. While we work,
we all aim to learn from each other (residents are always teaching faculty) and have fun.
You will be expected to see patients after the nurses have appropriately checked the patient into a room. We
use google Docs to keep track of patients once they are checked in. To access this document, go to gmail
and login under the username “uncdermclinic” with password “tarheels1”. Select the “drive” heading (at the
top of the page) and select the file “DO NOT CLOSE”. Once open, you will see the names of the attending
physicians who are having clinic that day. There are three columns for each clinic; the left-most column is
the room number, the middle column is the patient’s initials and first three numbers of their MR and the
right-most column is where you put your initials to signal that you are going to see this patient. You will
know that the patient has been checked in by nursing and ready for you when a room number appears in the
Once you are signed up for a patient and the room number is present beside that patient, grab that chart, see
the patient, and return to the resident’s room to present the patient to the attending. Remember that there
may be a queue for presenting to the attending so ask your fellow residents working the same clinic if they
are waiting to present.
As some of our patients are new to an academic setting, please introduce yourself and begin similar to:
“Hello, I am Dr. Smith. I am working with Dr. Morrell. I will start collecting information and exam
you/child’s name, then bring in Dr. Morrell.”
Obtain a problem focused history and find out the evolution and potential treatments previously utilized.
Perform an examination to the degree that you feel comfortable. Return to the “write-up” area and wait to
present to Drs. Morrell or Burkhart. In your presentation, focus on primary lesions and generate a differential
list. Don’t fear being incorrect; in medicine we always will miss diagnoses during and after our training.
After the resident/attending team has decided on management and follow-up, you’ll exit the room and enter
prescriptions and diagnoses into Webcis. Allow the attending physician to complete the coding sheet. As
you leave the room, make sure that the patient knows to wait for the nurse to bring them their
Please enter any medications that the patients require into Webcis but do not send it to the pharmacy unless
your attending physician requests that you do so. Most of us prefer to send it from our account so that any
questions/refill requests are clearly linked to our clinic.
Please also enter the patient’s diagnoses into “problems” in Webcis and then finalize the clinical summary.
Edit the clinical summary to include only the diagnoses that we have directly addressed during the visit and
only the medications that we are managing as a result of those diagnoses.
Once you have entered the patient’s medications, diagnoses and finalized the clinical summary, place the
blue summary sheet (filled out with when to return to clinic and any specific instructions for the patient) that
comes in each patient folder in the file holder on the nursing desk counter. This will let the nurses know to
print the patient’s clinical summary and discharge them from the room.
If the patient is going to follow up in 2 months or less time, detach the white top copy of the billing sheet and
place it with the blue sheet at the nursing desk. If their follow up is more than two months, place both the
yellow and the white copy together in the “completed encounters” cubby in the work room (ask someone to
help you find it).
Once you have placed the blue sheet at the nursing desk, enter your initials into the googledocs spreadsheet
to see the next available patient.
At the end of clinic (or between patients if we are not busy and there are no patients waiting), dictate a clinic
note using clinic phones and the 843-4000 escription number. You will need your physician code, patient’s
medical record number, and a code for the clinic visit. Document any prescriptions given on the clinic note,
making sure to record strength and vehicle (cream, gel, ointment, etc). You can also directly enter the notes
into Webcis if you prefer.
New patients: 321901
Return patients: 321902
When you proofread the notes on Webcis, please add any follow-up information (biopsy results, lab results,
etc can be “copied and pasted” as an addendum) at the end of the note. Use the “Ctrl + C” keys to copy and
“Ctrl + V” keys to paste.
If at any time you receive calls from patients or pharmacists regarding patients that you have seen in the
dermatology clinic, please forward those calls to the clinic phone line at 919-966-2485. Simply tell the
patient or pharmacist that you are no longer in that clinic and Dr. Morrell/Burkhart needs to be aware of the
We appreciate your involvement in our clinic and hope that it will be an informative experience. Your
Residency Coordinator will have a couple articles regarding common conditions for your reading. Please
utilize our textbooks and dermatology residents as sources of information and/or guidance. Included in this
introduction is our therapeutic approach to atopic dermatitis and acne, frequently asked questions, and a brief
Dermatology Residency Coordinator (Cherie Ezuka) 843-5539
Dermatology Clinic front Desk 966-2485
Dermatology Write-up room (for physicians only) 966-2483
Dean Morrell’s pager 969-0441
Clinic Appointments 966-2485
Dermatology consults (In-patient) 216-6360
Commonly asked questions
What do I need for clinic?
The most important thing you need is a WEBCIS account (physician number and password). Without
this, you will be unable to dictate, check lab/pathology results or sign your clinic notes.
Optional (but useful): pocket calculator, penlight, magnifying glass, digital camera
How do I go about seeing patients?
After you grab a chart, first see if they are a new patient or follow-up. If they’re a follow-up, review
prior notes on WebCis.
If the patient is a follow-up, note the date of the last visit, take a quick look through the HPI, and review
the assessment/plan. When you see the patient, review that they followed the plan as instructed. Inquire
if their condition is better/worse/same. If they’re on systemic meds, ask about pertinent ROS to check
for adverse reactions. If they have a skin cancer history, ask about new/concerning lesions.
For new patients, in addition to the HPI, you’ll also need to ask about PMH, meds, allergy, SH, FH, and
ROS. We collect pertinent parts of this history with the new patient intake sheet (pink) included in the
chart so that you can review it and follow up on things as needed. If the patient has been referred from
another clinic, get the info on the referring doctor so we can send a note to the appropriate
physician/clinic and include this information in the HPI.
Examine the patient as appropriate. Then tell the patient that you will return with the attending, that the
attending will examine them too (otherwise, they may get dressed), and that diagnosis and management
will be discussed at that time.
IMPOTANT NOTE: Ask the patient at this point whether it’s OK for medical students/visiting
physicians to come in.
What general advice do you have about the patient interview?
For a new patient, after you introduce yourself, it’s a good idea to let them know that you’re working
with the attending. Otherwise, they’re often confused and think they’re seeing you instead of the
Ask everyone about amount of sun exposure (outdoor work/hobbies, tanning beds, or sunbathing),
sunscreen use, and use of wide-brimmed hats. This is the preventive medicine obligation for our field.
For patients with a history of skin cancer, ask about new, changing, or concerning lesions. If there are
concerns, ask about noted changes, itching, burning, bleeding or crusting.
PMH and medications are especially important to review if you think their complaint could be a
manifestation of systemic disease or due to drug reaction.
Always confirm the patient’s drug allergies.
Social history: Find out how far away patients live because this influences management/follow-up.
Family history: Ask about history of melanoma and non-melanomatous skin cancer; for suspected atopic
dermatitis, ask about FH of atopy, asthma, and hayfever. Family history can also be important for
suspected autoimmune dermatoses and obviously, genodermatoses.
ROS: Especially important for patients with history of melanoma and patients being treated with
What should I keep in mind during the physical exam?
A full body exam will usually not include breasts and genitalia unless the patient has specific complaints
about these areas (ask them). If you need to examine these areas in an older kid, ask for chaperone from
the staff. You can use your own good judgment for these situations but when in doubt, it’s always safer
to have a chaperone especially if parents are not present.
If it’s scaly, consider scraping it for KOH.
Check hair, nails, and oral mucosa as appropriate.
Check lymph nodes for patients with history of melanoma, evaluation of tinea capitis, or suspicion of
When checking for pigmented lesions, remember to look in scalp, on soles of feet, and between toes.
When checking for non-melanomatous skin cancers around the head and neck, look carefully in all the
“nooks and crannies” (behind ears, within the auricle, corners of eyes/nose/mouth).
Wear gloves as appropriate (HIV+; exam of genitals, axillary/inguinal lymph nodes, mouth; potential
We need to check labs. What do I do?
Laboratory order sheets are in the patient rooms and also at the nurses’ station. Check off the labs you
need and place the patient sticker on the order sheet. Have the attending you are working with sign the
sheet and place their MD code at the bottom so that the lab results will be sent to them.
Place this order sheet at the nursing station at the end of the visit with the blue sheet.
Tell the patient that the nurse will send them to the lab when she/he comes back with their summary
sheet. Our lab for blood draws is at our checkout.
Any tips for writing out prescriptions?
Always make sure you prescribe the appropriate quantity and make sure you ask the attending how much
to give if you are unsure. We usually specify the number of grams of creams/gels/ointments that we
want the pharmacy to dispense. Without this information the pharmacy will often dispense the smallest
tube possible and it is insufficient for most of our patients.
Specify the location (hands/face/arms) whenever possible in the instructions for topical medications.
Give appropriate number of refills to at least cover the interval until their next visit.
When do I dictate/enter my clinic notes?
It depends on the flow of clinic and the type of patients you end up seeing (new vs. established;
complicated vs. simple). Sometimes, you won’t have time to dictate any notes until the end of clinic if you’re
doing many procedures, the attending is seeing patients quickly, and all the patients show up. At other times,
you’ll be able to dictate some notes during clinic if there’s a queue to present to the attending or patients are
not showing for their visit.
How do I dictate the clinic note?
Everyone has their own style and you’ll develop you own after enough repetition, but here are the basic
instructions to get you started:
Enter the first 5 digits of your physician code and press #
Enter 321901 for new/consult patient or 321902 for established patient and press #
Enter the patient medical record number (without the check digit) and press #
Begin dictating. As an example:
“This is resident _______ dictating a clinic visit note for patient Jane Doe, medical record #123-45-67.
The date of visit was ______ and the attending was Dr. _____. The reason for the visit: ______ (ex.
new patient with complaint of rash; follow-up of acne treated with Accutane). History of the present
illness: The patient is a ___ year old female whose last visit was _____ weeks/months/years ago on
______.” Use the last clinic note and any notes you jotted down to finish the HPI.
For a consult visit, dictate the referring physician information prior to the reason for visit. Also, the
consult must be acknowledged in the reason for visit or HPI section of the clinic note. As an example:
“The patient is a ___ year old female seen in consultation at the request of Dr. _____ (or clinic/practice)
by Dr. _____ for evaluation of _____.”
Dictate PMH, meds, allergy, SH, FH, ROS. For new patients/consults, it’s best to be more complete
with these details since it’s also necessary for coding. For follow-up patients, it’s OK to use the term
“reviewed and updated” for PMH and meds. Try to always dictate the drug allergies. Also, try to re-
dictate SH and FH info from the last clinic note so it gets passed along because your note will become
the last visit note being pulled for the next follow-up.
Dictate the physical exam. As an example:
“General: Well developed, well nourished, alert and oriented, pleasant, black female, in no acute
Skin: Exam of the scalp, head, neck, back, chest, abdomen, upper and lower extremities was performed
and remarkable for…..(address all complaints you’ve dictated in the HPI; note that you don’t have to
dictate into the HPI every single complaint the patient reports if the complaints are about numerous
Lymph nodes: negative for lymphadenopathy
Laboratory data: KOH positive for hyphae
Vitals: (if recording weight, temperature, BP)”
Dictate the assessment and plan. As an example:
“1. Acne vulgaris: Will continue current regimen of ----------, or discontinue AAAAA and add BBBBBB.
2. Warts: 6 lesions treated with liquid nitrogen.
3. Follow-up in 2-3 months for re-evaluation.”
Press 8 if you have more notes to dictate, or press 5 if you’re finished dictating. In either case, you will
receive a confirmation number. Record this on the second page (body part pictures) of the clinic template
sheets, then sign and date that sheet. You can keep the pink copy for reference if you would like.
If you are using direct entry, adhere to the same general note outline described above.
The biops/laby results are back. What do I do?
The Attending will call the patient and give them the results. When you proof and sign your notes on
Webcis, copy and paste an addendum at the end of the note regarding lab or biopsy results. Use the “Ctrl
+ C” keys to copy and ““Ctrl + V” keys to paste.
How do I handle prescription refill requests?
Direct the patient or pharmacist to call the Derm Clinic at 966-2485.
How do I refer a patient other subspecialties?
Fill out a form for referral request and place in the appropriate cubby in the write-up room. Ask where it is
and we will tell you.
Treatment of Molluscum Contagiosum
Body: Cantharidin for younger patients and Cantharidin or liquid nitrogen for older patients. Cantharidin
needs to be washed off in 4 hours or whenever a blister forms (whichever comes first).
Face and groin: Aldara cream three times per week.
Treatment of Hemangiomas (Rapidly growing/ulcerating/deforming)
Oral propranolol 2-3mg/kg divided BID. We usually start at 2mg/kg and then see them back on one
month to increase toward 3mg/kg if all is going well. Therapy is ideally started in the first three months
of life and continued to 9-12 months age.
Acne, Topical Antibiotics/Antiseptic
Typically no insurance coverage but many OTC formulations are available (wash, gel, creams, etc).
Sodium sulfacetamide (Klaron)
10% Lotion (59 ml)
Clindamycin/BPO (Benzaclin, Duac)
1% clinda/5% BPO gel (25 gm- Benzaclin, 45 gm Duac)
Clindamycin (Cleocin T)
1% soln (30, 60 ml)
lotion (60 ml)
gel (30, 60 gm)
2% oint (25 gm)
soln (60 ml)
Metronidazole (Metro –cream, -gel, -lotion)
0.75% cream (45 gm)
gel (30, 45 gm)
lotion (60 ml)
2% oint (1, 15, 30 gm)
4% cleanser (15, 120, 240, 480, 960, 3840 ml)
Retinoids (Topical): In order of increasing strength
0.025% cream, gel (20, 45 gm)
0.1% cream, gel (15, 45 gm)
0.025%, 0.05%, 0.1% cream (20, 45 gm)
0.01%, 0.025% gel (15, 45 gm)
(Retin-A Microgel) Tretinoin
0.04%. 0.1% gel (20, 45 gm)
0.05%, 0.1% cream (15, 30, 60 gm)
0.05%, 0.1% gel (30, 100 gm)
Ciclopirox (Penlac for nails)
8% soln (3.3 ml)
1% cream (15, 30, 45 gm); OTC (12, 24 gm)
1% cream (15, 30, 85 gm)
2% cream (15, 30, 60 gm)
2% shampoo (120 ml)
1% cream (30 gm)
Cream (30 gm)
Powder (15 gm)
Terbinafine (Lamisil AT)
1% cream OTC (12, 24 gm)
Anti-histamines, Anti-puritic (Oral)
Tabs (5, 10 mg); adult 5-10 mg qd
Syrup (5mg/5ml); kids 0.5-1 tsp po qd
Caps (10, 25, 50, 75, 100, 150 mg); adult start 25mg qhs
Concentrate (10mg/ml); kids take 1cc po qhs
Tabs (30, 60, 180 mg), Caps (60 mg); adult 60mg bid or 180mg qd
Tabs (10, 25, 50 mg), Caps (25, 50, 100 mg); adult 10-100 mg qd-qid
Syrup (10mg/5ml); kids 2mg/kg/d divided tid
Tabs (10 mg); adult 10mg qd
Aluminum Cl hexahydrate (Drysol)
20% soln (35, 37.5, 60 ml); apply qhs
Talc/microporous cellulose (Zeasorb)
Powder (70.9, 312 gm)
Hydroquinone 2%, OTC (Porcelana, Palmer’s, Ambi)
Hydroquinone 4% with sunscreen (Solaquin Forte)
Tri-Luma (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%)
Lactic Acid (Lac-Hydrin)
5% lotion OTC
12% lotion (225, 400 ml)
12% cream (280 gm)
10% lotion OTC
20% cream OTC
40% cream Rx
Lactic acid/Urea (Eucerin Plus)
2.5% Lac/10% U cream OTC
5% Lac/5% U lotion OTC
Tab (1 mg); 1 mg qd
2%, 5% soln OTC (60 ml)
Eflornithine HCl (Vaniqa)
13.9% cream (30 gm)
Pigmenting Agents/Cosmetic Cover-up (Vitiligo, Alopecia)
Chromelin, (Summer Labs)
Dermablend cosmetics (Loreal)
Toppik alopecia cover-up (Spencer-Forrest)
Zinc oxide (Desitin)
10% cream (420 gm)
40% oint (30, 60, 90, 120, 240, 240, 480 gm)
Zinc oxide/Corn startch
25% paste (30, 480 gm)
Coal Tar (T/Gel)
1% shampoo OTC
1% shampoo OTC (Nizoral A-D)
2% shamppo (120 ml)
Salicyclic acid (T/Sal)
3% shampoo OTC
1% shampoo OTC (Head & Shoulders Intensive Care, Selsun Blue)
2.5% shampoo (120 ml)
16% soln OTC (Compound W)
17% soln, gel OTC (Duofilm)
40% plasters OTC (Mediplast, Compound W one-step)
0.1 cc per wart to max 1cc in patient per visit
Protocol in clinic
Aluminum Acetate Solution (Burow’s)
Domeboro powder (12, 100 pkts/box)
Domeboro tablets (12, 100, 100 tablets/box)
[1 pkt/tablet per pint of water = 1:40 solution]
Therapeutic Approach to Acne
Dean Morrell, MD
a. Microcomedo formation
b. Androgen stimulation of sebaceous glands
c. Normal cutaneous bacteria
d. Immunogenic stimulators
e. Inflammatory response
2. Types of acne
a. Superficial (comedones)
i. Topical retinoids qhs
ii. My retinoid therapeutic ladder
“Comedo buster”, potential for irritation Tazorac gel 0.05%, 0.1%
Tazorac cream 0.05%, 0.1%
Retin-A Microgel 0.1%
Retin-A Microgel 0.04%, Differin 0.3% gel
My entry level for all patients Tretinoin 0.025% cream, Differin 0.1% cream
Differin 0.1% cream
Least irritating, least effective Avita cream
Can add topical benzoyl peroxide qam if needed or topical dapsone (Aczone gel)
Face only: gel
Torso + face: wash
OTC (Panoxyl), Triaz (3,6, or 9%), or Brevoxyl (4, 8, 10%)
b. Deep and inflammatory (papules, pustules, cysts, nodules)
i. Topical retinoids qhs
ii. Topical Combo products qam to face
1. Duac gel (Clinda/benzoyl peroxide)
2. Benzaclin gel (Clinda/benzoyl peroxide)
3. EpiDuo (retinoid/benzoyl peroxide)
iii. Oral antibiotics (tetracycline family)
Agent Dosing Issues
Tetracycline 500 mg BID Empty stomach
Doxycyxline 20-100mg qd-BID Sun sensitivity
Minocycline 50-100mg qd-BID Lupus, autoimmune hepatitis,
bluish discoloration (all if
used > 1year)
1. 1-2 mg/kg/day, 5-7 months
2. Monitor pregnancy, LFTs, lipids
Dean Morrell, MD
a. Control vs Cure
b. Daily bathing
c. Mild to no soap
d. Cotton clothing; fragrance-free products; no dryer sheets or fabric softener
a. White petrolatum after bathing
b. Cetaphil cream next acceptable
a. Staph aureus (cephalexin 125mg/5ml or 250mg/5ml, 30-50 mg/kg/d divided tid; clindamycin
75mg/5ml, 10-30 mg/kg/d divided tid)
b. HSV (eczema herpeticum)
a. Unwarranted fear of topical steroids
b. Always use the weakest possible to establish control in one week
c. Only use ointments
d. Intermittent pulses to clear in 3-5 days
e. Moisturize clear/controlled areas without steroids
f. First sign of return of inflammation:
i. Repeat topical steroid pulse
g. If steroid doesn’t clear in 1-2 weeks, go to stronger agent (knees, elbows, hands, and feet
commonly need a step up from rest of body)
h. My therapeutic ladder (There are many more options; below are my workhorses. Generic
forms are acceptable and effective.)
Class 1 Clobetasol, Halobetasol
3 Triamcinolone 0.1%
4 Synalar 0.025%
6 Hydrocortisone 2.5%
7 Hydrocortisone 0.5, 1%
(These are guidelines based upon the type of patient referred to our Pediatric Dermatology clinic. If
weaker steroids establish good control in 5-10 days, then go with that specific agent.)
Location Mild Moderate/Severe
Face Westcort Triamcinolone 0.1
Body Triamcinolone 0.1 Clobetasol
a. In infants and young children, good control of skin activity usually results in discontinued
b. Older kids and chronic scratchers may need oral antihistamines
i. Zyrtec qam (if not sedating in patient)
ii. Hydroxyzine (10mg/5ml, 2mg/kg/day divided TID) given qhs
iii. For recalcitrant pruritus, doxepin (10mg/1ml, 1ml NOT tsp qhs)