Dr. Cherie Ditre shares cosmetic cases that offer valuable lessons learned for medical and cosmetic dermatologists, alike.
Cherie M. Ditre, MD is Director, Skin Enhancement Center and Cosmetic Dermatology and Associate Professor of Clinical Dermatology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
“Many times, my colleagues who are focused on medical dermatology ignore or poopoo cosmetic dermatology. We have to learn that what helps one, can help the other,” said Cherie M. Ditre, MD, who presented “Lessons Learned from Cosmetic Patients” at the Atlantic Dermatology Conference virtual meeting.
“A lot of times patients present to us not because they have a medical condition but because they look bad…,” she said.
Lesson 1. Confirm Your Suspicions
Dr. Ditre presented several patient cases, including that of a 63-year-old woman with painful papular nodules from what the patient believed were Restylane injections.
“This woman went to three plastic surgeons who wouldn’t touch her. They felt the painful and tender papular nodules located on her upper lip folds and glabella were something that she would have to live with,” said Dr. Ditre.
“It’s an interesting story because basically she is Russian, and she went to Russian technicians in an apartment in Philadelphia. They were injecting people with God knows what.”
The nodules felt like concrete, and ultrasound and CT scan confirmed the patient had not been injected with restylane, said Dr. Ditre.
“She had silicone granulomas that had to be excised.”
The lesson learned, according to Dr. Ditre, is not only to do a physical exam, including touching the area, but also to order the appropriate testing to confirm your suspicions.
Lesson 2. Know the History
A 33-year-old woman with a child who had a severe seizure disorder and autism had just gone through a rough patch with the child. She just wanted to feel better, so she went to a medical spa to get Botox and fillers, said Dr. Ditre.
“They actually did a high G prime filler in the forehead that should never be used, and it caused necrosis.”
The patient presented to another doctor who treated her with hyaluronidase with no success. She later presented to the emergency room with diplopia and exotropia (her eye drifted out), said Dr. Ditre.
ER staff thought she might have herpes zoster infection, but after Dr. Ditre consulted with the patient, her symptoms were dermined to be from necrosis due to the filler injection, and she was treated accordingly, said Dr. Ditre.
“The case in point is that it is great to take a culture, but know the history and the history will guide you.”
Lesson 3. Question Pathology
A woman presented with “a case of a mysterious colloid milium,” said Dr. Ditre.
“I had the pathology done and the pathology showed colloid milium, but it was not any colloid milium that I was used to seeing. These were large—I’m talking 1 cm to 2 cm nodules on her face that were waxy, brown, and large.”
“We thought it was xanthogranulomas or that it could be nodular amyloid and, indeed, a biopsy showed nodular amyloid.”
The patient was found to be free of systemic amyloidosis and had a few areas treated with the CO2 laser, said Dr. Ditre.
“She liked the results so much that she came back and had the rest of them done.”
“The lesson learned in this case was don’t just trust the pathology from the outside. You sometimes have to repeat path and do your own investigation.”
4. Look for Alternatives
A 67-year-old woman presented with postherpetic neuralgia that was so itchy and painful that the patient would cut her skin—to the point where she created a nonhealing ulcer, said Dr. Ditre.
“She had been on a sundry of tricyclic antidepressants [but wasn’t getting better]. I had read about a case of Botox use for postherpetic neuralgia.”
“We had to do a dose-finding study to figure out what was the best dose and found that, at 200 units of Botox into her neck between [cervical discs] C3 and C5, this woman completely healed … and was so grateful because she came off all her gabapentin and tricyclics. She said all the [medications] didn’t help her but made feel dopey.”
The lesson here is to look outside the box when recommended medical treatments might be doing more harm than good, she said.