Dermatology in Older Adults (GeriDerm): Daniel Butler and Eleni Linos

Eric 00:24

This is Eric Widera.

Alex 00:48

This is Alex Smith.

Eric 00:49

And Alex, today we’re doing GeriDerm — geriatric dermatology. Who do we have with us today?

Alex 00:54

We’re just delighted to welcome Eleni Linos, who is a dermatologist and researcher at Stanford. She’s associate dean of research at the Stanford School of Medicine and also leads the center for Digital Health. Welcome to the GeriPal Podcast. Long overdue.

Eleni 01:11

Thank you so much for having me. It’s so nice to be with you both.

Alex 01:15

And we’re delighted to welcome Daniel Butler, who’s a dermatologist and researcher at the University of Arizona, Tucson, and he’s married to a geriatrician. Daniel, welcome to GeriPal.

Daniel 01:28

Thanks for having me, guys.

Eric 01:30

So we’ve got a lot to cover on geriatric dermatology, including…I got this mole right here that I just wanted to…It’s probably like…you’re probably sick of that joke, right? [laughter] So we have a lot to cover. But, Daniel, I think you have a song request for Alex. Is that right?

Daniel 01:44

I do.

Eric 01:45

What’s the song?

Daniel 01:47

I’ve Got You Under My Skin by Frank Sinatra.

Eric 01:53

Do I dare ask, why did you choose this song?

Daniel 01:56

Tough, tough to say. It just came to me. [laughter]

Alex 02:01

All right, all right, here’s a little bit.

Alex 02:06

(singing)

Eric 03:17

That was great.

Alex 03:19

I love singing Frank Sinatra. Thank you, Daniel. That’s a great one. Thanks.

Eric 03:24

All right, before we dive into the big topics of geriatric dermatology, I just love to hear from both of you briefly how you got interested in this as a topic. Daniel, I’m going to start off with you. Is it because you married a geriatrician or is this pre, pre existing?

Daniel 03:41

This is, this was a pre existing condition. You know, I, I thought I was going to be a geriatrician. I, I had a, a little bit of a circuitous route in medical school. I kind of liked everything. And I was actually in geriatrics clinic with Mindy Fain, who’s a famous geriatrician. And, you know, I was there and I was really interested in, in, in focusing care on older adults. And everybody there was concerned about their skin. You know, they would have these, you know, more mortal conditions like heart disease or, or, or cognitive impairment.

And, and then they would ask about the itching or the spot on their skin. And so as a student, I started to, to get interested in who was looking at that, and there weren’t many people. So I said, hey, that’s a, that’s a big grassy field to run in. And the other one that makes me interested in it and I would, I, I have to mention now is I had four of the greatest grandparents that anybody could ever, ever want, and I just lost my last one about three weeks ago.

But they really showed me that aging is a something to be honored and is, is a sort of a really unique practice. And I know dermatology has a complex relationship with aging because we talk a lot about anti aging, but I felt like it would be really fun to, to talk about that, that honoring of aging and being part of that journey.

Eric 04:58

Oh, that’s wonderful. And the, the U of A folks, University of Arizona geriatricians are just so marvelous. Just a big shout out to them. Yeah. Elena, how about for you?

Eleni 05:10

For me, it was probably a combination of what Daniel says of having role models who are older. I grew up in Greece, where again, older people are really valued and respected, and then also going through residency as a dermatologist and realizing that a huge proportion of our patients are older, but yet we didn’t seem to have any tailored approaches or even thinking even a subspecialty.

The words geriatric dermatology, you know, weren’t heard a lot together. But pediatric dermatology is a subspecialty with a fellowship. And so I was really lucky to come to UCSF and meet Meg Kren, who’s also married to a geriatrician who,

Eric 05:53

you know, that’s a theme right there.

Eleni 05:56

So when, yeah, when, when dermatology and, and geriatrics collide, I think it just inspired a lot of, a lot of much needed work at this intersection. And so, yeah, that’s how, that’s how my journey to geriatric dermatology started.

Eric 06:11

So I can imagine with peds, like the, it’s, you know, you treated things differently potentially, and there’s different diseases and. Jerry Durham, is it, is it that different how you think we should treat some of these more common major issues?

Eleni 06:26

I think so, for sure. I mean, there’s so many different issues, and there’s a parallel to pediatric dermatology. So the role of the parent in some cases is equivalent to the role of the caregiver or, you know, polypharmacy is a unique issue for older adults. Mobility issues and transportation, the social issues and who you interact with. I mean, there’s several unique issues for older adults that affect how we treat their skin in addition to the biological issues, like skin. Older skin is just more, more fragile, more frail, healing is slower. So, yeah, I would argue for sure it’s, it’s, it deserves its own attention as a, as a subfield.

Eric 07:09

Yeah, I’ll go ahead, Daniel.

Daniel 07:11

I’ll just add really quickly to that, Eric. The hesitation in our field, though, of really adopting this has been that dermatology, and I think this is probably true for a lot of specialties, is really disease focused. You know, the, the infrastructure of research and program development is really like melanoma clinics, lupus clinics, psoriasis clinics, and even for pediatric dermatology, they didn’t really take off until they had their own diseases, which were, were things like hemangiomas, which were birth defects of the skin and atopic dermatitis.

And the problem with geriatric dermatology, and it’s not a real problem, but something that’s perceived is that it’s, it’s everywhere. It’s, it’s every general dermatology practice. And so without these exclusive diseases, it’s been a little bit of a harder adaptation, but nevertheless, still really important for all those reasons that Eleni brought up.

Eric 08:02

I’m going to start off with, actually, I’m going to take a big step back as we think about, like, the aging skin. I think probably all of our listeners want to know what things should we be doing now to help with the fragility that comes with kind of aging skin.

Daniel 08:18

If that’s true, I’ll take a shot at that one, because I get it, you know, about 100 times a week.

Eric 08:24

Yeah, you live in Tucson, so I can imagine there’s this big glowing ball that most dermatologists, like, hide themselves from.

Daniel 08:32

Exactly. Well, so that’s the key answer is just stay inside and never do anything. I say that jokingly, and I want to be very clear. I think sometimes dermatologists, you know, sort of lose the message. UV or the sun is certainly a cause of, you know, morbidity, mortality, but really it is the cause of most of the aging of our skin that we see. So making sure that you’re well protected from the sun, you should still be out in the sun, which is a very clear recommendation.

You should be out running, you should be out playing. You should be doing things particularly, you know, in. In. In really nice places like San Francisco. Be out and about, but be vigilant when you’re out. And then the other easy piece to that is just make sure that your skin is well moisturized and taken care of. You know, we do a lot of things in this world that harm our skin barrier. You know, the pollution outside, harsh soaps, really fragrant things. You know, all of these in some sort of moderation, are not going to cause overall damage.

But the more we can think of our skin as sort of an active participant in our lives. So you want to make sure that it’s active, hydrated. Just like we go out and we take care of our muscles by exercising or our hair by shampooing, you want to make sure that you’re moisturizing as well. And those are sort of my skin longevity pearls. Obviously, there’s plenty of other things. And if you’re on, you know, social media for two seconds, you’re going to get bombarded with the thousand other things to do that are going to lead to skin.

Eric 09:56

Do I have to spend a lot of money on the hydration stuff, or can I just, like, get the cheapest thing at Walgreens? And what. What would that be?

Daniel 10:04

Yeah, my recommendation is not product specific. If you want a good hydrator, get it in a tub that you can scoop out and make sure it’s not fragrant. Doesn’t matter the product name. Those two are my easy recommendations. You don’t need to spend a ton of money.

Eleni 10:20

You told us we can argue with each other.

Eric 10:21

Yeah, go ahead.

Eleni 10:23

I’ve known Daniel for a long time, and so I can say this, but for not now that we’re not talking for older adults, but for the general public. There’s also a do nothing until you need to do something approach. Like, you don’t. That’s my approach to moisturize. Like, my approach want to say that, like, we, you know, unless there’s a problem, you could also just live your life and not do anything to your skin and, you know, just shower and shampoo your hair. Like, you don’t have to use a moisturizer every day and you don’t have to use sunscreen to sun protect. So I just want to make that clarification.

You can protect yourself from sunburn by simply not going outside on midday and like doing your runs in the morning or the evening or wearing a hat or wearing sunglasses. So I think there is a big industry that promotes spending a lot of money and buying products. But I just. Yeah, Daniel and I are friends. But that’s not. Doesn’t. You don’t have to do any of that.

Daniel 11:24

I think that’s a great recommendation and I think that’s really important for people to hear too. Mine is coming from when someone asks, you know, when someone asks us in clinic, they’re like, hey, what do I. Like, what should I be buying? And like, that’s sort of a low fruit. But Eleni’s totally right. And you know, I think sometimes simplicity is absolutely the way to go. And, and you know, your risk for sun exposure related things and xerotic changes or dry skin changes, those are very different for very different people. So I totally agree with Eleni there.

Alex 11:55

Now, while we’re on the subject, this is great. We’re getting so, so many questions. Okay, I’ve got some friends who I hike with and they’re like, you know, hippie Berkeley types. They’re like friends from med school. And they, they were like shocked that I was using this, you know, sunblock that wasn’t like a barrier protected sunblock. It was one of those old types of sunblocks, whatever those are. Do you know what I’m talking about?

Eric 12:19

Yeah.

Alex 12:19

Like, is that. Should we really be concerned? I don’t. What. I don’t know what the name is for those other. The old type of sunblocks, as opposed to the zinc or whatever, the barrier types of sunblock. Is that a real deal or is that overblown?

Eleni 12:32

Yeah, Daniel and I may disagree on this too, but there’s nothing wrong with using sunblock or sunscreen at times when you need to use it. Right. So I obviously, I use it on my kids and on myself when I’m about to go swimming if you’re on vacation and you’re out in the sun a lot, if you’re going to be out midday sun, so that there is a time and a place to use it for areas you can’t cover. And it does prevent sunburn. It does work.

But at the same time, there’s so many other ways to protect yourself from sunburn. Including, you know, the, the ways I just mentioned, like long sleeves. Long sleeves that I think sometimes we fall into this pattern of just assuming that the only way of sun protecting is. Is this chemical sunscreen. But in terms of the, you know, the ingredients, you’re right, Alex. There’s a huge, huge concern with some of them, both for ocean of planetary health reasons, but also for endocrine metabolism’s reasons. We’re actually doing a study right now where we’re measuring microplastics in these sunscreens as well. And so it’s super interesting.

But for me, I, I would say as long as you are sun protecting in moderation, you know, and using all these other methods, areas, you don’t actually need to use that much of any particular.

Alex 13:53

When we’re in Sierras and we’re hiking, we hit these through hikers, and they don’t use any of it. They just cover up because they’re like. I would have to put. If you. I’d have to bring like three gallons with me.

Eric 14:06

There was a meme going around about a dermatology conference in Hawaii, and you just saw all the dermatologists on the ocean just fully covered in clothes.

Eleni 14:15

That’s how we roll.

Eric 14:18

Daniel, your thoughts?

Daniel 14:20

Yeah, I mean, I think Eleni hits on a lot of good points there. I think, you know, the debate of the chemical sunscreens versus the physical blocking sunscreens, Alex, which is the sort of balance that you’re using. You know, it’s hard, and it kind of is a microchasm of a lot of the places we are in medicine where, you know, sort of pop culture and minor risk factors, you know, get potentially blown out of proportion of like, hey, if you use a chemical sunscreen, all of a sudden, you know you’re doing something wrong. I think the balancing act is exactly what Eleni said, which is like, you find the way to protect sun, that works the best for you.

There’s some people who barely need to do it whatsoever, and there’s some people who are out in the sun for two seconds and they’re going to burn. And so the, the, the needs for those people are going to be different. But back to your exact question is we do typically recommend the. The zinc and titanium, which are the physical blockers, because they are more effective and they’re. They’re less likely to get into your system. And there were. That the chemical blockers can get into your. Into your bloodstream.

And there was a study, I Wanna say, about 10 years ago, where it was at higher levels than was expected by the fda. But from an outcomes research standpoint, there hasn’t been a connection between the chemical sunscreens and any negative outcomes. So. So there’s a lot to fill in in the middle there. So that’s some of the debate. And I think it’s, you know, it’s interesting. But I will tell you what I do is I use physical blockers when I. When I need to, and I burn it like in two seconds. But they can be a little bit, you know, cakey and white on the skin, so you don’t love those. So if I need to, I’ll use a chemical sunscreen on my face when. When I’m going to be out and about. But I can’t look like a ghost, which I already kind of do, so it’s out of bounds.

Eleni 16:02

Yeah.

Eric 16:02

Okay. As Alex was walking up that. That Sierra and he saw the people without anything on, he noticed someone had a actinic keratosis on his skin. And they asked Alex, what should I do about this? And this goes to kind of the next section.

Alex 16:18

What can I give a real world?

Eric 16:20

Yeah.

Alex 16:21

My mom yesterday, she’s in her early 80s, and she says, I have these things on my skin. And my dermatologist says, don’t worry about them. They’ll just. They’re growing slowly. They’re nothing to worry about. And I said. And she said, maybe it’s a keratosis or something. And I said, okay, but. And then my mom says, but I want him out. I want him cut off, and I want them sent to the lab pathology, because I’m worried it’s cancer. I don’t know. Should she be worried? What?

Eric 16:49

Yeah, I was actually prepping for this podcast. I was looking at some older geriatrics books, and they give me these wide intervals of how often these AKs turn into something that we’re actually worried about. And then I look at newer stuff and it’s. It’s kind of all over the place. How worried are both of you around aks and how should we deal with it in keratosis?

Eleni 17:12

Should I start, Daniel, or.

Daniel 17:14

Yeah, go for it.

Eleni 17:15

So, first of all, Alex, I think your mom May have seborrheic keratoses because if the dermatologist told her not to worry, they slow grow and it might be a keratosis. In my mind, I think that’s probably what without seeing anything she might have. And in that case, truly she doesn’t need to worry. But, but I would say if she wants them removed, that’s totally okay and we can very easily do that. And I’m, I’m sure you can too. We can freeze them and they fall off. But in terms of actinic keratosis, it’s a really interesting question.

Eric 17:47

Sorry Lenny, can I ask you remind me what the difference between the two are versus actinic?

Eleni 17:54

Yeah, yeah, yeah. I wonder if I have time to screen share and show you pictures. Basically one is, you know, the brown round or oval kind of bumpy surface. They’re and bumpy and basically everyone has them after a certain age. And they’re on your back. Usually on the back or they can be on the face.

Eric 18:16

Yeah.

Eleni 18:17

The actinic keratosis is pink and scaly with kind of more of a white and usually smaller. They might only be, you know, 2 to 3 millimeters while the SKs are larger. Daniel, how, how would you rate my description? Perfect.

Alex 18:33

Perfect.

Daniel 18:34

You know, the, the, the brown, the brown velvety stuck on looking ones versus the rough, more, you know, poorly circumscribed red ones. That’s the difference. I thought you hit it right on the head.

Eric 18:46

That’s seborrheic versus actinic.

Daniel 18:48

Actinic, correct?

Eric 18:49

Yeah.

Alex 18:50

Okay.

Eleni 18:51

Ones are harmless. The actinic ones have a very, very, very low risk of progressing to a squamous cell carcinoma. And that’s why we pay attention to them.

Alex 19:01

And is that risk over time?

Eleni 19:04

Yeah, the, the latest statistic I remember, Daniel, I don’t know if you have more is like 2% will progress over the course of several years. Is that Marty Weinstock’s latest data or.

Daniel 19:15

Yeah, I think he’s. His was too. And I think that was one of the more, you know, from a single lesion that, that was the, the risk. And you know, most of the time if you have one, you’re going to have a handful around them. So that risk is, you know, someone you’re trying to sort of value. That risk can be challenging. But around, you know, I think anywhere between.01 to 2%, which is, you know, I think Eric, you hit it on the head, it’s kind of all over the place. You know, that risk.

Eric 19:42

Do you remove all of them or do you think about like prognosis and do you send them to pathology?

Daniel 19:51

Definitely don’t biopsy those. So that’s a really good distinction to make. So we don’t, we do not remove those, don’t biopsy those. I mean, traditionally, sometimes you’ll have some really big ones that you, you do biopsy, but those are the, those are the ones that you’re typically getting frozen. So when somebody, you know, hopefully, Alex, when your mom left, she didn’t leave with like a bunch of what looked like pock marks after.

But that’s a typical experience for a, you know, older adult coming into the dermatologist. And typically that means that they had a series of actinic keratoses frozen. And then the other treatment that’s a gold standard treatment is 5 fluorourouracil or Fudex, which you typically put on the skin for a couple weeks. Those are things that we definitely do use. But certainly there’s nuance for all people, but particularly in older adults, which. Happy to get into further.

Eric 20:39

Okay, well, is it okay if I’m, do you have any other questions on AKs? So I learned also something in my research. The most common cancer in the U.S. do you know what that is, Alex?

Alex 20:51

Basal cell.

Eric 20:52

If you add up all the other cancers that us adults get, it still isn’t as much as the basal cell carcinomas out there. So not only the most common skin cancer, the most common cancer. Do you treat basal cell any differently in younger adults and older adults?

Eleni 21:11

It’s a great question. My favorite question, because this, this is what the, the question that got me into geriatric dermatology. And it started with I, I still remember this patient so clearly. I was at the VA in Palo Alto as a resident and I was learning dermatology. And it was a, a frail elderly veteran who was being wheeled in by his daughter. And he had a basal cell on his, on his ear, right here on the helix. And you know, I was so proud that I diagnosed it and I biopsied it. And then we used to look at the slides in pathology under the microscope. And I called the patient and I brought him in for Mohs surgery to remove it.

And then he had a three month follow up. And then I found another one nearby and biopsied that same process. And this happened. He was in and out probably every couple of months between the follow ups and the mos. And when I called him to give him the update on the third time I biopsied him, I called and he had. He had passed away of unrelated causes. And that was the moment where I was like, what on earth did I do to this family for the last, like six months? You know, there was no reason, based on the speed of growth of basal cells, for me, as a very eager, attentive doctor, to cut, slowly cut pieces of his ears off and have him in and out and bring. So I.

Eric 22:38

What is the speed of growth? Like, does it. Are you worried about metastasis? Are you worried about local invasion? Like, what are you worried about?

Eleni 22:45

So typically, the vast majority of these grow very, very slowly over years. They don’t metastasize. And again, the vast majority of them, you know, like low risk prostate cancer are, are lesions that people don’t die of but may die with. And so the key for us as dermatologists is to balance the risk of that tumor growing and causing symptoms locally if it ulcerates or bleeds, versus the patient’s life expectancy and all the other health conditions they may need to prioritize. So this became an area of, you know, of research focus. And that’s where I was so lucky to meet many of the amazing geriatric researchers with you at ucsf.

Eric 23:30

And just a shout out, will I include a paper that you did on active surveillance? Was it, I think, jama Internal Medicine? Yeah, I forget. That was a while ago now. That was pre Covid, I think.

Eleni 23:42

Pre Covid, Yeah. It was very controversial among the dermatology surgeons Dan may remember.

Eric 23:48

Oh, is it still controversial?

Alex 23:50

Yeah. Can you say why?

Eleni 23:52

Yeah. So I think at the time, um, when, you know, with, with several colleagues, we published this idea that, you know, maybe we’re over treating, maybe we’re doing too many procedures. Like, let’s take a step back and think about what is appropriate and how do we balance the needs of an older adult with this slow rate of growth of these tumors and the potential side effects of surgery. I think that was the main, you know, the main concern.

I think the geriatrics community was very understanding because obviously you have many other examples of watchful waiting, of balancing procedures to the patient’s preferences and life expectancy. But the dermatology community wasn’t as ready, I’ll say. And yeah, people weren’t happy with me, but I don’t think it’s controversial anymore. I feel so lucky that now it’s in our. It’s in our textbooks, it’s in our guidelines. So I’m very impressed with our field’s acceptance of some of this research.

Eric 24:58

You feeling the same Way, Daniel.

Daniel 25:01

A hundred percent. And, I mean, I think we’re all lucky, and I was lucky to have Eleni as a mentor, but we’re lucky to have, really, the world expert Eleni on both basal cell natural history. I remember the trial you did or the study you did when you were in Greece, looking at the timing of a basal cell, which really no one had ever looked at, and then, you know, introducing this concept to, you know, a world where we have every single influence that’s on us as physicians is to biopsy those lesions and do more. Right. You know, it’s. It’s a systems issue. It’s not a, you know, someone, you know, some greedy dermatologist or at least.

This is my. This is my take on it, as, you know, a greedy dermatologist is wanting to do more. A lot of the times the patient is like, cancer. Get it off me. And then, you know, really what it takes and what Eleni’s work has led us to is we can then take that sentiment and be able to unpack it and say, well, hey, there. There’s actually options here. And if we’re seeing you regularly, this probably has almost no risk of becoming more than it is right now. But it’s still controversial from time to time. And anytime I mention that I do geriatric dermatology to a Mohs surgeon, they’re like, well, do you think that I’m, like, trying to hurt people or what? So it’s a. It’s as every good research does, like it. It provokes people. And I think ultimately, at the end of the day, we’ve leveled off a little bit.

Alex 26:18

Yeah. Eleni, could you say a little more about. I remember talking to you when you were either in Greece or headed to Greece about your work on an island. Was. Is that one of the blue zones? And you saw very old people, and some of them had sort of untreated basil, watchful, waiting sort of approach. Is that.

Eleni 26:36

Yeah, yeah, that was. It was a really fun study. And it came. It came about because I remember being at UCSF in. In Medcren, my mentor’s office, and we were looking at this New York Times article with beautiful photographs, portraits of these, you know, 90, 100-year-old people living on. On the island of Icaria, which is one of the blue zones. And as dermatologists, we were looking, we were studying them carefully and thinking, like, ooh, I see something there. I see.

You know, because we could spot the AKs or, you know, potential SCCs or BCCs, even from these photos. And. And that’s when we realized that maybe there are populations that are not. Because in the US as soon as someone has even a. An ak, it’s frozen. Right. There isn’t a population that is living with these potential skin cancers. And, you know, we thought a rural island without a doctor on site, probably. And from, you know, we had. We had suspicion from these photos probably may have several people, especially if it.

It has a significant older population. And sun exposure has a significant number of people living with untreated AKs, untreated basal cells. And so we. We designed the study to go investigate that there. But since actually there’s been a much better study than ours in the Netherlands that looked at watchful waiting for basal cell and. And that, you know, followed patients longitudinally and showed very similar results. So I’m. I’m really happy it’s been repeated.

Eric 28:13

Great. I wonder if it’s okay if we move on to another topic. Anything else you guys want to say on aks or basal cell?

Alex 28:20

I’ll just reflect on Eleni’s story about that chagrin of, you know, having felt like, what was I doing cutting off this patient’s ear and they weren’t going to die of this cancer anyway. Um, and then they ended up dying and then. And that we can learn from those clinical experiences. And in some cases, it, like, launches a career. And so if people are listening and they’re like, you know, what was I doing there? What was I thinking? What were these other people thinking? That’s, like, a really important question. And sometimes that’s the beginning of an insight that’s, like, fresh and new for the field. And so I just want to thank you for sharing that story.

Eleni 28:57

Yeah. Yeah. And I might add to that, Alex, that for all the younger people listening, your ideas, that you may not be sure if they’re good ones or, you know, nobody else is thinking it. Those are the best ideas for. For the field, because you, by definition, are seeing a whole area of medicine with fresh eyes. For those of us who are older and have been here, we. We don’t have that. We. We can’t. We’re already in it. We can’t see through to it. So your clarity is. Is a superpower. So. So trust your instincts. If you think something is not right, you’re probably right. And if you have an idea that seems crazy, you know, follow it for a little bit, at least.

Daniel 29:39

I love that. And I remember Elena, you saying something similar to me, you know, over 10 years ago. So it’s great advice. The only Other thing that I want to add to this is, is something that sort of captures this together, which is there’s a famous quote from Jurassic Park. Believe it or not, a very famous text, Jurassic Park, Jeff Goldblum’s character asks the question. He says, or it says, your scientists were so preoccupied with whether or not they could do something that they never asked if they should.

And I think oftentimes that’s the plight that we’re talking about here, which is like, you have these hyper specialized people, these dermatologists who are trained to see the smallest basal cells, and that’s sort of like what they’re supposed to do, and these Mohs surgeons who can do incredible procedures and reconstructions, but someone has to be having the conversation of like, hey, I need to actually see if this is something we should be doing. And if it’s. If this amazing skill set is really indicated here.

Alex 30:37

I love that. And I think that’s the first time, Eric, in over 400 podcasts we’ve had Michael Crichton and Jurassic park quoted, life

Eric 30:45

will find a way. That’s terrific.

Alex 30:47

Well played, Daniels. Well played.

Eric 30:50

Whose job is it? How should we work with the dermatologist then?

Daniel 30:55

I love this question because it’s different everywhere. And I always use the analogy. And we’ve sort of talked about it. Elena, you pointed to it. It’s. There’s something called the conveyor belt in medicine, which is like you have a diagnosis and once that diagnosis is there, you get on the conveyor belt and someone has to have a stop at that conveyor belt. So sometimes the general dermatologist is needing to have that conversation. Sometimes it’s the Mohs surgeon who needs to be having conversation, but it’s basically asking the patient, hey, here is a low risk lesion. And there’s a lot of context to this, but let’s say it’s just a standard basal cell. It’s a low risk lesion.

It’s very unlikely to cause problems for the next five, even 10 years. If we follow up, you know, relatively closely, three to six months, and we watch it, you are safe in doing that, but it may require a bigger surgery. If we need to do a surgery later. How do you feel about that? And then here are the risks of the surgery. So somebody has to be able to stop the conveyor belt. And I don’t think as dermatologists or any specialist, they should be putting that on the geriatrician or the primary care to be doing.

And that’s partially my wife speaking through me, but I really firmly believe in that. If you do the procedure, biopsy or excision, you should really be the one who’s stopping the conveyor belt and having that conversation. And I will say, sometimes you talk to people and they say, I want, you know, 100 year old, want that gone. And really, Mohs surgery is a very geriatric, friendly surgery. It’s very well supported, it’s outpatient. So there’s a lot of pluses to it. And you listen to the patient there, you say, that’s fine, and the conveyor belt continues.

Eric 32:30

But it does sound like the concept of lag time to benefit. How long does it take to see a benefit? You’re looking at least five to 10 years for these more innocuous basal cell carcinomas.

Eleni 32:40

I will say it depends on the location, too. So if anything is near the eye or, you know, somehow impeding function, obviously, you know, I, I would be more likely to recommend treatment or excision. But sometimes they’re in the middle of someone’s back and they don’t even know they’re there. So. And they’re tiny and not ulcerated. So we do have, we do have guidelines on, and I think they’re based on, like, size for, for watchful weighting. So small size, I think it’s either less than half a centimeter or less than a centimeter on the back, not ulcerated. In someone who has a short life expectancy, then the recommendation should be to follow up clinically or watchful waiting.

Eric 33:23

All right, I got a question. One of the most common symptoms that we see in older adults and in the palliative care population, too, is itching more of that generalized itch? Any quick thoughts or how we should be thinking about the, you know, itching in older adults or itching in palliative care populations?

Daniel 33:41

This is, you know, Eleni’s favorite, is the basal cell discussion. This is my favorite discussion. Itch is my favorite thing. And the reason why I love it is part of the answer to this, which is, you know, we, we for a really long time have minimized the symptom of itch, despite the fact that it’s the most common chief concern that people go to a dermatologist for over the age of 50 and for a really long time, itch and allergy were sort of intermixed. So if you were itchy, then you were allergic. And like, that was the answer as to what was going on.

But what made me so interested in it is now we really understand the pathophysiology of Itch. And it’s really complex, but fun. And in all these systems that we have that are aging in our skin, things like the barrier of our skin, the immune system in our skin, the nerves in our skin, they all get as they age, they all contribute to that itching phenotype. And so targeting each one of those different systems is what we’re now doing to treat these itchy patients. So I know I got nerdy and scientific there, but there’s something there.

Because when people ask me, hey, Dr. B, I’m itching, what’s going on? I say, it’s not that you’re eating the wrong thing. It’s not that you’re allergic to anything. It’s one of these three systems, the immune system, the nervous system, or the barrier of your skin that are aberrant, that are behaving incorrectly. And we need to figure out how to recalibrate and rebalance. So that’s how we do it. And each one of those has a different target.

So the barrier moisturizing. So many older adults are xerotic or dry. We start with the barrier. And sometimes that’s enough, sometimes it’s not. If it’s. If it gets them 50% better, great. Then we look to the nerves or the immune system. So the immune system would be something like if you’re seeing eczema on the skin, we could treat that. And then there’s also these, these cutaneous nerve dysesthesias or itch syndromes, like notalgia paresthetica, which is when someone itches Right. On their mid back. So there’s a lot of variance between these, but that’s really very specific.

Eric 35:43

Mid back itch loca.

Daniel 35:45

How does that.

Eric 35:46

Why, why in the mid back?

Daniel 35:48

Like, what’s cervical spine? The ongoing theory is there’s some sort of entrapment of the nerves from the cervical spine. As they leave the cervical spine, they can get entrapped in the foramen, they can get entrapped in the trapezius. They can even get trapped in the brachial plexus. So these are all places that can contribute right back to itch there. The other place that you’ll often see it is on the dorsal forearm, which is called brachioradial pruritus.

Alex 36:13

And the one in the back is notalgia paresthetica.

Daniel 36:17

Yep.

Alex 36:17

Now I have a name for the reason my wife asked me to scratch her back.

Eric 36:21

Yeah. Besides a back scratcher, what else do you do about that?

Daniel 36:26

I don’t mean to monopolize the discussion so.

Eleni 36:28

No, no, no, go for it, Go for it, Daniel.

Daniel 36:31

You know, usually if it, if it really is that central mid back itch, then we’ll use something that’s nerve related. So something like a sarna lotion, something that has a coolant effect or even an ice pack. Those are more targeted than say, I’ve used the bad word in a geriatric podcast.

Eric 36:50

Oh, okay.

Alex 36:51

What did he say?

Daniel 36:52

Or gabapentin. You know, you know, you want to go for something that you’re actually targeting in there. Now we do use gabapentin for really severe cases.

Eric 37:00

Yeah.

Daniel 37:00

This type of itch, but certainly never where I’ll start. I’ll try to do even interventions. I’ll do like, I’ll send them over to pain management for a spinal injection if they need it, rather than get them on high dose gabapentin. But from a starting standpoint, for this podcast, something like, you know, an itch cream, you can go find a cerave itch cream which usually has some promoxine in it, which is a cooling agent or again, ice packs and cool showers. Those actually hit the itch receptor and cool it off.

Alex 37:29

Ah. So when we did a podcast about palliative care in kidney disease, they talked about the itch which is so common in advanced kidney disease, particularly if you are treating conservatively without dialysis. I think they said gabapentin. They said gabapentin because they said it’s neurologically mediated, which I think falls in line with what. What do you think when you hear that?

Daniel 37:54

Yeah, well, I will say that’s another. We’re sort of re reimagining itch everywhere. There’s actually evidence of this nephrotoxic itch that we see that it responds to gabapentin. It also responds to immune suppression. Um, so we don’t really know which of the two it is. And it’s probably a mix. Some people are more immune related, some are more nerve related, but it’s certainly not just a pure algorithm of like if someone has that nephrogenic itch and they’re not doing dialysis or something to. To clear, then they’ll respond to gabapentin. Sometimes they need an immune targeted agent. So I’m only putting that in there to say that it’s a total open world there that we’re just starting to understand.

Eric 38:35

So I got the skin, I got the nerves, then you got your immune system. How do you target that? Let’s say if they have more generalized itch.

Alex 38:44

Target the immune system.

Eric 38:46

Yeah.

Daniel 38:48

I mean, I’ll keep going here. Cause I. This is my favorite. Yeah, yeah, run with it. Usually we start with, you know, topical steroids are a great place to start. Not just as a forever treatment, but as. Almost like a. As like, almost like a. Theranostics is the word I use, which is like therapeutic, diagnostic. So I’ll give an older adult a topical steroid and say, look, I’m not giving you this forever.

Eric 39:08

If there’s a specific location for the itch.

Daniel 39:10

No, that’s usually when it’s generalized. I’m worried about an immune related itch. So I’ll give them a big tub of triamcinolone, which is a fairly low cost, easy to use.

Eric 39:20

Yeah.

Daniel 39:21

Topical steroid. And have them use it for three weeks, even up to three months. Like all over. All over, yeah.

Eric 39:28

Wow.

Daniel 39:28

And I’ll say, hey, if you come back and this is working for you, then we’ll have a discussion of if this is going to be something that can work with your life. You know, do you have someone who could put it on? What are your abilities when you can actually use it? For the record, if you’ve ever put a cream on all over your body or an ointment all over your body, it’s generally a miserable experience and it ruins everything in your house. So we also have to talk about sort of the practical side of, of using that. But from a diagnostic standpoint, that can be really helpful in that initial step.

And then we’re really lucky to live in this advanced age where. And 10 years ago I would never have believed we would be there. But we now have these advanced therapies that are traditionally used for eczema and atopic dermatitis, that are really clean medications, they don’t have drug interactions and they really work for. For this immune related itch. And we call them, they’re in a class called the biologics. They’re used all over the place. You’ve seen commercials for them. But they’re really wonderful. And I find that they work wonderfully for older adults. And they really fit the sort of geriatric mantra because it’s easy adherence or easier adherence. You get, you know, one, one or two injections a month and that really helps.

Eric 40:36

Can I have two lightning round questions? Because I do want to go to Eleni and just ask a question about digital health and AI. But before we do that, two questions around itch is are there medications that you as a dermatologist will think high risk, high risk for itch, causing it…

Daniel 40:55

…causing itch yeah, and this is always the tough question. There is no single medication that like you give and it leads directly to itch. Interestingly enough, the best evidence for a medication that leads to itch is actually delayed about a year and it’s calcium channel blockers, particularly in older adults. The other one that can lead to it is ACE inhibitors. But I think sometimes they get a bad rap because you’re seeing a lot of people on them and then you’re seeing a lot of people with itch. And so that connection has been made. The one that’s the most growing right now where itch is the number one cutaneous concern is the immune checkpoint inhibitors. So particularly in the palliative care population, you may see that very regularly because that is so common in that group. And there’s a lot of reasons for that.

Eric 41:43

What do you do about that one? Anything?

Daniel 41:45

Well, that one’s. I wouldn’t say it’s fairly easy, but at least diagnostically we know where it’s coming from because typically if they’re on an immune checkpoint inhibitor, we know of the three buckets that they’re very likely immune related. So we can kind of go up our immune ladder, which again starts with the topical immune control and then goes to the more aggressive systemic immune control.

Eric 42:05

My last lightning round question is you. You haven’t actually mentioned antihistamines. Do they play a role in any of those three?

Daniel 42:13

No. And that’s intentional. Yeah, that’s intentional. I, like, I’m, I’m well trained. The geriatrics community has made it, you know, and, and this is part of like, sort of what I see as our role in geriatric dermatology is uncoupling this concept of like, itch allergy, antihistamine. Because honestly, you know, 50% of people who go in for itch to an urgent care or even a lot of dermatology clinics are going to get an antihistamine. And there’s very, very limited evidence that it actually is effective and, or targeted. So I do not use antihistamines for itch. There is just to be comprehensive. There’s a subpopulation that people are now starting to study where they see some mast cell over activity that are part of the chronic itch group that can respond to some advanced antihistamine type therapies. But for the most part we never use it.

Eric 43:06

Wonderful. You had a paper too, right, Daniel, on chronic itch and older adults, and it was a. Was it JAMA Dermatology or was it JAMA im? I forget which one?

Daniel 43:15

It was Jama. It was the. The. The. The big jama. I think the big Jama.

Eric 43:19

The big Jama. We’ll have a link to that in our show notes too. Um, so if you want to go walk through that, you can. Eleni, I’m gonna turn to you for my last question. We’ll see if Alex has more. You know, sometimes it’s hard to get our patients to see a dermatologist.

Alex 43:32

Yeah. Can we just take a picture of that and upload it to ChatGPT or Claude or Gemini?

Eric 43:38

How does AI fit into all of this?

Eleni 43:42

Yeah, this is. I mean, it’s such an exciting time for AI in dermatology and AI in medicine in general. Okay, well, you already know that these models pass the board, step one, have factual medical knowledge equivalent to physicians. Several studies have shown that they are just as good as dermatologists as diagnosing images of potentially malignant lesions. So they can, in terms of a single point of time, is this kind of cancer? Is this melanoma? These models are ready already to diagnose with the same accuracy.

One really interesting study we did recently, about a year ago, was to look at the combination of AI plus human to see how these AI models assist or augment the abilities of a physician in diagnosing a skin cancer. And interestingly, they improve everyone’s performance, regardless of their level of training. So they will improve a medical student’s diagnostic ability, a primary care doctor’s diagnostic ability, and a dermatologist diagnostic ability. So the combination of AI plus clinician kind of raises everyone’s accuracy. What’s really interesting as a next step is to figure out, and we’re working on this now, what the most effective way to present that information to clinicians are. Because ultimately, it’s about implementation. People are busy. They don’t want to go to, you know, another app or have to do anything that takes more time.

And so it’s really interesting to look at what are the most effective ways to. To support clinicians so that these tools can be used in routine practice. But also, interestingly, the way the information is presented to clinicians may vary by the way they cognitively analyze data. So we did one study where, for a group of dermatologists, we showed them other examples of AI generated malignant lesions or other similar sort of like a Google Images search versus for another portion of dermatologists. We just describe the text like, these are the reasons the features that, you know, seem malignant. And depending on whether you process things visually or you’re better at analytic cognitive reasoning. The way the AI assistance is presented to you makes you, you know, more or less effective. So there’s a lot to do here.

Eric 46:18

Are there any current tools? Because I think if you go to ChatGPT or any of the big language models right now, if you upload a picture, it will say, it won’t tell you.

Alex 46:28

Oh, really?

Eric 46:28

Yeah, I, I tried that like a month ago. I tried it and it would not be my dermatologist.

Eleni 46:34

Yeah, I have done it with, you know, my son’s X rays for broken bones and stuff until. For waiting for the report. I think there are a lot of tools right now. There’s a lot of very effective tools,

Eric 46:46

anyone’s that you trust that you.

Eleni 46:48

I, I don’t know if any of them yet have made it into the clinical flow, so I’ll get back to you on that as soon as soon as some are ready.

Alex 46:59

Eleni’s in the heart of Silicon Valley. She’s in the leading edge there. She’s right.

Eleni 47:03

Well, yeah, but yet we still don’t have something in our clinic that we use routinely. We do. You know, I. One thing I will mention is we do really care about longitudinal follow up. So for inflammatory diseases and even for basal cells that you’re watchful, waiting that you don’t want to remove, what you want is a tool that can assess change over time. So that’s the next step.

Eric 47:25

Daniel, do you use any of these tools? Have you seen anybody use any of these AI tools?

Daniel 47:30

They’re incredible. And I think every dermatologist is, you know, hoping that Eleni can usher in a collaborative world with AI But I know a lot of us are like, oh, my eyes are about to be secondary here, so I better be really good at sort of geriatric care principles. So I come see me and can walk me through this. But, you know, we don’t use anything. But I think it’s. It’s front and center now, and I think, you know, the coin of the realm, you know, will change.

I think visual diagnostics, which is a huge part of our job as dermatologists, will become a little less necessary and, you know, while it’ll still be a major part, you know, are we’re gonna have to be people who are explaining treatment options and walking people through the variable chances that the algorithm shares with us. And I, I. This is just off the cuff, Elena. You could probably explain this way better than I can, but that’s kind of where I know a lot of us are in the clinical world, Cass.

Eric 48:27

One more Question. Because I know time is up because telemedicine is playing a bigger part. Like, can you diagnose people via telemedicine?

Eleni 48:37

Yeah. So I’ll answer this very quickly. Yes. And what’s really important that we’re studying now is how to make sure older adults are not left behind from any telemedicine innovation. So we’re doing a study on, specifically on older adults and photo sharing to try and make sure that the quality of the images that patients send from home, especially if you want to collect them longitudinally, you know, is adequate for clinical use and diagnosis. And so far we’re finding, you know, amazing results. Like, older adults can send high quality images. It’s very dependent on the body location.

Eric 49:16

Yeah.

Eleni 49:16

So they may need different instructions and lighting depending on where it is.

Eric 49:20

When I’ve been to the dermatologist, they brought it. What is the thing that put in the. That there’s a, like, it looks like a loop. How do you deal with that? Like, you don’t have one of those on a iPhone. Camera.

Alex 49:32

Zoom, zoom.

Eleni 49:34

Yeah. A lot of people are too.

Alex 49:36

Yeah.

Eleni 49:37

I feel like if you have us back on in like a year, the world will have changed.

Alex 49:42

Okay.

Daniel 49:44

There are companies out there that are doing full body dermoscopy, which is that, you know, that overpriced microscope that you see for every lesion on the body and having AI analyze every single one of them.

Alex 49:55

Right.

Daniel 49:55

Wow, that’s imminent.

Eric 49:58

Well, I want to thank both of you for being on. We’re going to have part two in, I guess, one year with both of you and our AI overlord. But maybe before we do, we’ll have a little bit more.

Alex 50:08

(singing)

Alex 51:20

Lovely.

Eric 51:22

Eleni, Daniel, thank you for being on the podcast.

Eleni 51:25

Thank you.

Daniel 51:25

Thank you guys.

Eric 51:27

And to all of our supporters, thank you for your continued support.

This episode is not CME eligible.

For more info on the CME credit, go to https://geripal.org/cme/