Tuesday, November 24, 2015

Khloe Kardashian Acquires Staph Infection

Khloe Kardashian, 31, recently acquired a staph infection on her leg as a result of visting her husband and former NBA player Lamar Odom in the hospital. The lesion on her leg became painful, and Kardashian later experienced high fever and swollen glands as a result of the infection.

Staph infections are most commonly caused by Staphylococcus aureus bacteria. Signs and symptoms of Staph infections vary widely, depending on the severity and location of the infection. Skin infections caused by Staph bacteria include boils, impetigo, cellulitis, and Staphylococcal scalded skin syndrome (SSSS). Signs and symptoms of a localized Staph infection include pus, redness, swelling, and tenderness, as well as possible fever. MRSA, or methicillin-resistant Staphylococcus aureus, is a type of Staph infection resistant to many different antibiotics. Staph infections are treated with topical, oral, or intravenous antibiotics, depending upon the type and severity of the infection. However, antibiotics are not always effective in fighting Staph infections due to an increase in antibiotic resistance.

The most effective method for decolonizing topical Staph is bleach baths. However, baths with sodium hypochlorite are cumbersome and bleach may not be used above the neck, thus leading to poor patient compliance. Chlorhexidine, the second option for decolonizing topical Staph, is not as ideal as bleach baths because it is drying and irritating to the skin, doesn’t lather well, and may not be used on the face or genitals.

Dermatologists have also adopted CLn® BodyWash, a sodium hypochlorite wash that is safe to use from head to toe, as a preferred cleanser for ages 6 months and older to help maintain excellent hygiene to skin infections.  The cleanser may be used daily, and is lathered onto the skin in the shower for 2 minutes and then rinsed off (or as otherwise directed by a healthcare provider).

For more information on CLn® SkinCare, please visit: http://www.clnwash.com.


Mayo Clinic (2015). Staph infections. Retrieved November 19, 2015, from http://www.mayoclinic.org/diseases-conditions/staph-infections/basics/symptoms/con-20031418.

MedicineNet.com (2015). Staph infection pictures, symptoms, and causes. Retrieved November 19, 2015, from http://www.medicinenet.com/staph_infection/article.htm.

Ryan, C. et al. (2013). Novel sodium hypochlorite cleanser shows clinical response and excellent acceptability in the treatment of atopic dermatitis. Pediatric Dermatology. Retrieved October 18, 2015, from http://onlinelibrary.wiley.com/doi/10.1111/pde.12150/full.

Thursday, November 19, 2015

How to Use SEO to Attract New Patients

A 2012 study by Google found that 77 percent of patients search for their physician online prior to booking an appointment. This means that it is imperative that medical practices have a high-caliber website with effective search engine optimization (SEO), so that patients may quickly locate your medical practice’s website online.

What is SEO? Search engine optimization is the process of increasing a website’s ranking on search result listings generated by engines like Bing, Google, and Yahoo. The goal is to be as near the top of the search list as possible since web users tend not to click on links further down the page.

SEO is important for medical practices because patients spend their time surfing the internet for answers related to medical conditions, diagnoses, laboratory and diagnostic tests, symptoms, and treatment options. Having a website that answers these questions makes you the expert, increases familiarity with you, and increases the chances that the patient will call to schedule an appointment with you.

It is important that your website finds patients when they are in “buy” mode. Advertising on the radio or a billboard reaches a large audience, but not necessarily at a time when they are in need of your services. Investing in SEO has a high, measurable return on investment because leads that come through a practice website can be easily tracked. It is much more difficult to track leads from billboards and radio.

Before diving into SEO, know your budget and develop a strategy. SEO is an investment in your practice. For example, if a dermatological surgical procedure brings in a profit of $2,000, you only need to bring in two leads to surpass the spend of $3,500. Your strategy should include your needs. What exactly is your goal? Will SEO help you achieve that goal, or do you have other needs? A solid strategy not only includes the answers to these questions, but also a website analysis to help determine current needs from a digital marketing perspective.

According to Medical Practice Insider, steps that ensure your SEO is working for you include:

Research key terms. Find out what terms potential patients are actually looking for before creating any content. The Google Adwords Keyword Planner can help determine people’s search habits for a certain keyword, including geographic area and volume.

Sprinkle key terms throughout the content. If you would like to appear in a web user search for “Dallas dermatologist,” be sure to include this term in the text on your website. Using a keyword once per 100 words is a good rule of thumb.

Hyper-localize search terms. If you’re located in a large metropolitan area like Dallas/Fort Worth, there will be a lot of competition for the top-ranking spots. Focus on ranking well in community-centric searches, like “Park Cities dermatologist” or “dermatologist downtown Fort Worth.”

Maintain a blog. Creating and maintaining a blog is an easy way to keep creating fresh content that will help your site appear for varied search terms. This ensures you aren’t limited to the keywords on the standard pages of your website.

SEO is not the same regardless of industry; therefore, it is important to use an agency that understands the nuances of healthcare. Healthcare search behavior is different from other industry searches, so utilizing the correct keywords and search terms is very important.  Be sure to engage the services of an agency that understands healthcare and is able to develop accurate content that reaches your intended audience.


Medical Practice Insider (2013). Making SEO Work for Your Medical Office. Retrieved November 16, 2015, from http://www.medicalpracticeinsider.com/best-practices/technology/making-seo-work-your-medical-office.

Points Group (2015). Medical Practice SEO. Retrieved November 16, 2015, from http://www.pointsgroupllc.com/medical-practice-seo/.

Cutaneous Blistering Disorders

Blistering skin disorders are among the most interesting, but also the most challenging conditions in dermatology and dermatopathology.

Blisters are accumulations of fluid within or under the dermis. There are three types of blistering skin diseases—subcorneal, intraepidermal, and subepidermal. Subcorneal blisters have a very thin roof that breaks easily. Examples include impetigo, miliaria, and Staphylococcal scaled skin syndrome (SSSS). Intraepidermal blisters have a thin roof that ruptures and leaves a denuded surface, as seen in acute eczema, varicella, herpes simplex, and pemphigus. Subepidermal blisters have a tense roof that often remains intact. Examples of subepidermal blisters are bullous pemphigoid, dermatitis herpetiformis, erythema multiforme, toxic epidermal necrolysis (TEN), and friction blisters.

The mechanisms of intraepidermal vesiculation include:
  •        Spongiosis: intercellular edema
  •        Ballooning: intracellular edema
  •        Acantholysis: loss of desmosomal attachments
  •        Cytolysis: cell disintegration
  •        Other types like epidermolytic hyperkeratosis

Several examples of common cutaneous blistering disorders are detailed in the table below.

Blistering Disorder
Key Clinical Features
Key Histologic Features
Hand, Foot, & Mouth Disease

·      May simulate irritant or toxic contact dermatitis
·      Important to distinguish from erythema multiforme and TEN: No interface changes or clinical features
·      Lancet shaped vesicles on acra & mucosa
·      Caused by Coxsackie virus A 5, 9, & 16
·      Recent isolation of aggressive form caused by A6 with extensive involvement, onychomadesis, & extensive mucosal erosions
·      Perivascular infiltrate of lymphocytes & some neutrophils
·      Ballooning degeneration of epidermis
Necrolytic Migratory Erythema
·      Widespread erosive dermatitis with abundant crusting
·      Glucagon secreting tumor of pancreas
·      Superficial epidermal pallor with ballooning
·      Psoriasiform dermatitis late
·      Infiltrate variable
·      Identical histology in other deficiency diseases, such as acrodermatitis enteropathica & biotin responsive multiple carboxylase deficiency
Hydroa Aestivale
·      Blisters & erosions of sun-exposed surfaces
·      Children most commonly affected
·      Scarring
·      Epidermal hyperplasia
·      Spongiosis & ballooning degeneration
·      Epidermal necrosis
Parapoxvirus Infection
·      Inflamed, boggy plaque usually on hands
·      Exposure to sheep or goats (orf) or cattle (milker’s nodule)
·      Marked epidermal hyperplasia
·      Intracellular edema; pink inclusions
·      Granulation tissue; edema in dermis
Epidermolytic Hyperkeratosis
·      Widespread erythema with vesiculation in infancy (congenital bullous ichthyosiform erythroderma)
·      Systemized verrucous epidermal nevus (ichthyosis hystrix)
·      Palmoplantar hyperkeratosis
·      Widespread or solitary keratotic papules (epidermolytic acanthoma)
·      Intraepidermal vacuolar degeneration
·      Pyknotic nuclei
·      Reddish-pink keratohyalin-like granules in epidermis
·      Hyperkeratosis; some parakeratosis
·      Keratin 10 gene mutation
Pemphigus Foliaceus
·      Erythema with erosions covered by exuberant crust
·      Scalp, face, trunk most  commonly involved Mucosal surfaces less commonly involved
·      Exfoliative dermatitis in
severe cases

·      Cleft in subcorneal, intragranular or upper spinous layer
·      Some dyskeratotic acantholytic keratinocytes in granular layer
·      Perivascular infiltrate of lymphocytes and eosinophils with exocytosis of eosinophils

·      Direct IF: Intercellular IgG & C3 in epidermis in virtually 100% of cases; rarely IgA; slight accentuation in upper epidermis often
·      Indirect IF: Circulating antibodies to desmoglein 1 (160 kD desmosomal glycoprotein) in 33% & plakoglobin (85 kD adherens junction molecule) in higher percentage
·      Correlation between antibody titer & disease  activity variable & not always reliable
Pemphigus erythematosus (Senear-Usher)
·      Pemphigus foliaceus with features of systemic lupus erythematosus (SLE); +/- myasthenia gravis
·      Photosensitivity; positive ANA

·      Similar histology with vacuolar changes at DEJ

Solid clinicopathologic correlation is the key to making accurate diagnoses and initiating treatment for cutaneous blistering disorders.

Cockerell C (2015).  Cutaneous blistering disorders. [PowerPoint]

DermNet NZ (2015). Blistering skin diseases. Retrieved November 17, 2015, from http://dermnetnz.org/doctors/emergencies/blisters.html.

The History of Sodium Hypochlorite and the Bleach Bath

Sodium hypochlorite (NaClO), the main ingredient found in laundry bleach, is a chemical compound that has a range of uses, including bleaching textiles (particularly cotton) and paper, sanitizing food preparation equipment, refining petroleum, and disinfecting water and wastewater. Sodium hypochlorite is also the sodium salt of hypochlorous acid (HOCl). Hypochlorous acid is effective against a broad range of microorganisms, and is the major strong oxidant produced by neutrophils (white blood cells). The acid works as a potent microbicidal agent within the neutrophils, and has been shown to kill large quantities of E. coli in less than 5 minutes in vitro.

In 1789, Antoine Labarraque passed chlorine gas through a solution of soda lye to obtain sodium hypochlorite. In 1843 in Boston, Oliver Wendell Holmes determined physicians and nurses carried on their hands and clothing the microbes that caused puerperal (childbed) fever in patients. One physician was observed washing his hands with sodium hypochlorite between patient visits; this doctor’s patients were reported to be unusually free of disease. This opened the gates for the use of sodium hypochlorite in the healthcare industry.

During World War I, Henry Dakin—an English Chemist—and Alexis Carrel—a French surgeon—introduced the Carrel-Dakin technique, which became the best practice in wound care by delivering Dakin solution, a solution of 0.5% sodium hypochlorite and 4% boric acid, directly to damaged tissue in deep wound beds before closure. Dakin solution’s solvent action on dead cells increased the separation of dead from living tissue, and thus expedited healing. 

Today, hypochlorite is used in hospitals as a disinfectant for equipment and environmental surfaces. For example, it is used to disinfect dialysis equipment, dental equipment, syringes and needles, linens and clothing, and manikins used in the training of mouth-to-mouth resuscitation. Sodium hypochlorite is also used to clean up blood spills and to remove all traces of nerve agent or blister agent from personal protective equipment (e.g. gloves, gown, mask, shoe covers) as personnel move into toxic areas.

Patient use of hypochlorite includes dilute bleach baths that have been used to treat moderate to severe eczema—an inflammatory skin condition that causes skin to become dry, itchy, and red. The first use of a bleach bath to treat atopic dermatitis (AD)—a common type of eczema—occurred when patients who suffered from AD started to improve after swimming in chlorinated pools during the summer months.

As a consequence, physicians started recommending the use of dilute bleach baths for their patients with AD for as young as 6 months and older. A study by JT  Huang, MD  and colleagues found that chronic use of dilute bleach baths with intermittent intranasal application of mupirocin ointment decreased the clinical severity of atopic dermatitis in patients with clinical signs of secondary bacterial infections.

Patients with AD are prone to bacterial infections that worsen the condition, particularly Staphylococcus aureus. Bleach baths have been shown to decolonize Staph; however, baths with sodium hypochlorite are cumbersome and bleach may not be used above the neck, thus leading to poor patient compliance. According to a study conducted by Caitriona Ryan, MD and fellow researchers, sodium hypochlorite wash is beneficial in children diagnosed with AD where Staph colonization is present.

The challenges associated with bleach baths led Azam Anwar, MD and Clay J. Cockerell, MD to invent and patent the formula for CLn® Body Wash. The family of CLn® Skin Care products was created to elevate the life quality of people with impaired skin. CLn ® BodyWash is designed to cleanse skin prone to eczema, acne, and folliculitis without irritation and aids in the reduction of body odor. For more information on CLn® Skin Care, please visit: www.CLnWash.com.

BleachBath.org (2015). History. Retrieved November 15, 2015, from http://www.bleachbath.com/how-it-works/history/.

Huang JT, Abrams M, Tlougan B, et al. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics 2009; 123(5): e808-814.

Rutala WA, Weber DJ. Uses of inorganic hypochlorite (bleach) in health-care facilities. Clin Microbiol Rev 1997; 10(4): 597-610.

Ryan C, Shaw RE, Cockerell CJ, et al. Novel sodium hypochlorite cleanser shows clinical response and excellent acceptability in the treatment of atopic dermatitis. Pediatr Dermatol 2013; 30(3): 308-315.

Wang, L, Bassiri M, Najafi R, et al. Hypochlorous acid as a potential wound care agent. J. Burns and Wounds. 2007. Retrieved November 15, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1853323/.

New Children's Book Benefits Breast Cancer

In Grandma’s Garden (ISBN: 978-0-692-53795-4), by Brenda West Cockerell and illustrated by Linda Olafsdottir, is a book celebrating the wonderment of childhood and the unexpected surprises to be found in the beauty and sanctuary of a garden. The simple rhymes and verses are “child’s play,” enticing young readers while quietly building confidence—a teacher’s most cherished success.

Author Brenda West Cockerell, a native Texan and former elementary school teacher, tries to live each day by the words of her grandmother—“Sing loud even if you don’t know the words,” and “Everything looks brighter from behind a smile.” In Grandma’s Garden is her first children’s book and is her tribute to the memory of her friend and educator, Holly Horton who died of breast cancer.

The book’s illustrator, Linda Olafsdottir, lives in Reykjavik, Iceland and holds an MFA in Illustration from the Academy of Art University in San Francisco, California.  Linda has illustrated picture books, educational books, stamps, and children’s clothing.

All proceeds from In Grandma’s Garden benefit The Beacon Family Foundation. Its mission is to provide resources for families by providing funds for breast cancer research, educational scholarships, and special needs.

For more information about In Grandma’s Garden, please visit www.GrandmasGardenBook.com.

Monday, November 2, 2015

CLn® SportWash Provides Optimal Treatment of Staph Infections in Athletes

Athletes are exposed to environments where bacteria and microbes thrive, such as sports arenas, gyms, and locker rooms, which may lead to Staphylococcus aureus infections and fungal infections due to skin breakdown the athletes encounter during sports. Additionally, one-third of athletes are most likely colonized with a particularly harmful strain of Staph aureus—methicillin-resistant Staphylococcus aureus (MRSA).

Staph doesn’t affect just collegiate athletes. Many professional athletes have been diagnosed with serious Staph infections, and some athletes have had to end their careers due to these infections, including Brandon Noble of the Washington Redskins, Daniel Fells of the New York Giants, and Lawrence Tynes of the Tampa Bay Buccaneers.

The most effective method for decolonizing Staph is bleach baths and intranasal mupirocin. However, baths with sodium hypochlorite are cumbersome and bleach may not be used above the neck, thus leading to poor patient compliance. Chlorhexidine, the second option for decolonizing Staph, is not as ideal as bleach baths because it is drying and irritating to the skin, doesn’t lather well, and may not be used on the face or genitals. Antibiotics are not always effective in fighting Staph infections due to an increase in antibiotic resistance.

Dermatologists have adopted CLn® SportWash, a sodium hypochlorite wash that is safe to use from head to toe, as a preferred cleanser for athletes to help maintain excellent hygiene and decrease skin irritation.  The cleanser may be used daily, and is applied in the shower and left on the skin for 2-3 minutes (or as otherwise directed by a healthcare provider). The sport wash has a 99.9% kill rate of Propionibacterium acnes (bacteria that causes acne) at 30 and 60 seconds; 98% kill rate of Staph at 2 minutes; and a 99.9% kill rate of Staph at 3 and 5 minutes.

In addition to skin infections that affect the body, athletes commonly experience fungus, dermatitis, and infection in the hands, feet, and nails. CLn® Hand & Foot Wash, a daily wash that contains salicylic acid and is preserved with sodium hypochlorite, is recommended for athletes in addition to using CLn® SportWash. CLn® Shampoo is ideal for athletes with normal to oily scalps that are prone to folliculitis, dermatitis, and dandruff. The shampoo, that contains moisturizers, conditioners, and salicylic acid, is recommended for use 1 to 3 times per week. All three of these CLn® products, when used together, help maintain optimum hygiene and decrease the risk of skin, scalp, and nail infections in athletes.

For more information on CLn® SkinCare, please visit: http://www.clnwash.com/sports.

Boerner, C. (2014). Study finds college athletes more likely to harbor MRSA. Retrieved October 18, 2015, from http://news.vanderbilt.edu/2014/10/study-finds-college-athletes-more-likely-to-harbor-mrsa/.

Jimenez-Truque, N., et al. (2014). Longitudinal assessment of colonization with Staphylococcus aureus in healthy collegiate athletes. Journal of the Pediatric Infectious Diseases Society. Retrieved October 18, 2015, from http://jpids.oxfordjournals.org/content/early/2014/11/05/jpids.piu108.abstract.

Ryan, C. et al. (2013). Novel sodium hypochlorite cleanser shows clinical response and excellent acceptability in the treatment of atopic dermatitis. Pediatric Dermatology. Retrieved October 18, 2015, from http://onlinelibrary.wiley.com/doi/10.1111/pde.12150/full.

Dermatology Foundation Clinical Symposia: Focus on Soft Tissue Augmentation

The highly esteemed Dermatology Foundation Clinical Symposia provided the latest clinically relevant research and information on various surgical and aesthetic dermotological procedures. Hedi A. Waldorf, MD presented the address A Practical Approach to Soft Tissue Augmentation Based on Art, Science, and Economics that focused on three-dimensional facial rejuvenation.

The art. In the past, two-dimensional facial rejuvenation was used, which simply flattened wrinkled skin by deep abrasion or pulled the skin taut using surgical measures. This resulted in an artificial appearance. Today, this technique is replaced by a three-dimension approach that, according to Dr. Waldorf, is what “makes us look normal.” This third-dimensional approach addresses the dynamic reality of the full face, not just isolated features. Waldorf explained that the face must be assessed from multiple angles to determine which products and procedures will result in a more natural-looking and youthful appearance.

The science. Waldorf discussed the individual characteristics of different filling agents—cross-linking, chain length, particle size, concentration, viscosity—and their uses, such as filling, lifting, shaping, and boosting the skin. Not one product does it all, so varied products that work well together should be selected to create a natural, blended look. To maximize results and minimize complications, Waldorf advised using injection technique plus product choice and placement. For example, she suggested using only a very low viscosity hyaluronic acid gel injected superficially to reduce the risk of vascular occlusion in the treatment of glabellar lines.

The economics.  The patient’s finances and social and work obligations determine the timeframe for how quickly or slowly the work can be performed. Typically, the same results can be achieved with either one or two syringes of product at regular intervals over a year or two, or with multiple syringes in one or two sessions.
During her presentation, Waldorf discussed specific case studies including the patient’s presenting complaint, respective solution (e.g., where to treat, with what, how much, and over what period of time), and the results.

Dermatology Foundation. (Spring 2015). A practical approach to soft tissue augmentation based on art, science, and economics by Heidi A. Waldorf, MD. Dermatology Focus 34(1), 17-18. Retrieved October 17, 2015, from http://dermatologyfoundation.org/pdf/pubs/DF_Spring_2015.pdf.

Nonablative Laser Treatments: A Review

Murad Alam, MD and his team evaluated histologic and tissue effects of nonablative laser therapy in a review of the literature published in Lasers in Surgery and Medicine. The data reviewed by the researchers was accessed via MEDline during the years 1995 to 2003 and from unpublished reports presented at major national meetings. The focus of the review was to better understand the clinical efficacy of nonablative treatments.

The type of devices reviewed included the KTP laser (with 1,064 nm Nd:YAG); pulsed-dye laser; intense pulsed light device; diode laser (980 nm); Nd:YAG laser (1,064 nm), Q-Switched; Nd:YAG laser (1,320 nm); diode laser (1,450 nm); Er:Glass laser; and the Er:YAG laser.

Most of the studies that evaluated these lasers included a subjective comparison of pre- and post-treatment histology using H&E or special stains. The post-treatment biopsies were usually obtained at a few time points. Most of the data was anecdotal making it difficult to substantiate many of the conclusions. 

The generalizations that can be drawn about tissue effects associated with nonablative laser treatment include:
1. Laser treatments that are used in combination with epidermal pre- or post-cooling can protect the epidermis from ablation, but it can also deliver a thermal injury to the dermis. The depth of the dermal injury may be increased if greater epidermal cooling is applied simultaneously.
2. Thermal injury to the dermis affects the vasculature, which causes a cascade of inflammatory events, including up-regulation of collagen expression and fibroblastic proliferation.
3. Collagen deposits are increased weeks to months after a series of nonablative treatments. The deposits assume a horizontal position parallel to the plane of the epidermis. Overall dermal and epidermal thickening has been reported.
4. Several different light and laser devices are able to induce similar histologic changes following nonablative resurfacing.

The major differences between ablative and nonablative laser treatments are detailed in the table below.

Ablative Laser
Nonablative Laser
Removes entire epidermis and portions of dermis
Epidermis not visibly disrupted
Improves skin roughness, fine periorificial lines, and dyspigmentation
Improves surface irregularities, skin texture, and wrinkles; some also address dyspigmentation, telangiectasia, and superficial erythema
Possible side effects: itching, erythema, edema, infection, scarring, hypo/hyperpigmentation
Possible side effects: mild erythema and edema
Healing time: 2-4 weeks
Healing time: several minutes to a few hours
1 treatment as needed every few years
5-6 treatments every 3-4 weeks

Previous research studies on the efficacy of nonablative laser treatments have been descriptive and emphasized phenomenology rather than assessing mechanisms of action. Clinical evaluations have previously relied on before and after photographs.  Additionally, the difficulty in comparing outcomes has been exacerbated by the various different laser and light settings and sources used for nonablative resurfacing. Fluence, pulse duration, number of passes, and cooling parameters vary across lasers, and even among the same devices.

Dr. Alam encouraged future researchers to impose a high degree of rigor and standardization to help overcome the small sample size. Using similar treatment methods, such as the same number of passes and same number of fluences would make the data more comparable and meaningful.


M. Alam, MD, et al. (2003). Nonablative laser and light treatments: Histology and tissue effects—A review. Lasers in Surgery and Medicine 33, 30-39.