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Archive for January, 2015

Heritage Fund of Atlanta Medical Association, Inc. Scholarship Ball

Saturday, January 31st, 2015

January 31, 2015, Atlanta. For more information, visit Medical Association of Atlanta


Physicians’ Day at the Capitol

Wednesday, January 28th, 2015

January 28, 2015, Georgia State Capitol, Atlanta. For more information, visit Medical Association of Atlanta 


Helen Selser, M.D.

Monday, January 26th, 2015

Helen Selser, M.D.Dr. Helen Selser practices Dermatology for The Southeast Permanente Medical Group, which cares exclusively for Kaiser Permanente members in Georgia. Dr. Selser received her medical degree and completed her residency at the Louisiana State University School of Medicine. She also holds a master’s degree in medical management and completed a fellowship in patient safety. She is board certified in Dermatology.

Dr. Selser wrote Diagnosing and Treating Nail Fungus from ATLANTA Medicine, Dermatology, Vol 85, No. 5


Kenya H. Anders, M.D.

Monday, January 26th, 2015

Kenya H. Anders, MDDr. Kenya Anders, board certified in dermatology and internal medicine, received her medical degree and dermatology training at the Medical College of Georgia. She has been serving members of Kaiser Permanente of Georgia as a dermatologist for 24 years.

Dr. Anders wrote To “D” or Not to “D” from ATLANTA Medicine, Dermatology, Vol. 85, No. 5. 


31st Annual Atlanta Breast Surgery Symposium

Friday, January 23rd, 2015

January 23, 2015, Intercontinental Hotel Windsor Ballroom, Atlanta. For more information visit Southeastern Society of Plastic and Reconstructive Surgeons 


Diagnosing and Treating Nail Fungus

Thursday, January 22nd, 2015

By Helen Selser, M.D.

From ATLANTA Medicine, Vol. 85, No. 5

Helen Selser, M.D.

Dr. Helen Selser

With an estimated 35 million cases each year, Onychomycosis (fungal infection of the nail unit) is one of the most common dermatological problems in the United States. While oral medications carry risks and often do not produce a lasting cure, new topical medications provide viable monotherapy alternatives.

Medical and consumer organizations are focusing on quality and safety in the diagnosis and treatment of nail fungus. The American Academy of Dermatology has collaborated with Choosing Wisely, a trademarked national initiative of the American Board of Internal Medicine (ABIM), to promote the most appropriate, cost-effective, evidence-based treatment. One of their five recommendations is to confirm nail fungus prior to starting oral therapy. This article will present information that may assist clinicians in diagnosing and treating this condition.

Types of Nail Fungus

It is estimated that only half of the cases diagnosed as fungal nails, and in some cases treated as fungal nails, are fungal. The other 50 percent of dystrophic nails are conditions that mimic fungal nails. Of the 50 percent that are fungal, 90 percent are dermatophyte. Ten percent are mold or other opportunistic organism. (Bologna)

There are several types of nail fungus:

1. Distal/lateral nail – commonly T. rubrum

2. Superficial white – often T. metagrophytes, cephalosporium, Aspergillus, Fusarium and, in HIV patients, T. rubrum.

3. Proximal subungual – less common and often with immunosuppression.

4. Destructive nail plate_– with marked hyperkeratosis and often with paronychial involvement. This is seen in immunosuppressed cases or chronic mucocutaneous candidiasis. (Andrews)

Testing and Diagnosis

Dystrophic nails may appear as fungus, but a culture is needed to confirm fungus. No single method to confirm nail fungus provides 100 percent sensitivity. When a culture is taken, the dystrophic nail and subungual debris at the junction of the attached nail and nail bed must be submitted.

To obtain a nail culture, clip away loose nail plate and take the culture from the junction where the nail plate attaches to the nail bed. Having the proper tools to obtain this specimen is key. Many labs will accept nail clippings, so maintaining various media in the office is not necessary.

The nail plate may also be sent for PAS stain. This has a higher degree of accuracy (41-93 percent) than culture. Taking this sample requires a full thickness nail plate clipping. This does not require a biopsy of the nail bed, an invasive procedure. The sample is submitted to a pathology lab.

KOH shaving, which requires a very thin sample of the distal nail, is reported at 57 percent sensitive. The KOH result is impacted by collection technique and experience/training of the microscopic examiner.

The KOH and the PAS tissue stain confirm hyphal elements but cannot provide species identification. A fungal culture may provide species identification, but this may not add value to treatment. Additionally, KOH is an office procedure, while the PAS stain is a lab test. (Weinberg JM et al. J Am Acad dermatog 2003,49193-197)

If the fungal culture returns negative, be sure the patient has not used topical antifungal preparation prior to the culture. Taking a second culture for fungus of the nails is helpful. If the second culture is negative, the problem may not be nail fungus.

The differential diagnosis of nail fungus includes psoriasis, lichen planus, squamous cell carcinoma, verruca, and other eczematous dermatosis. Squamous cell carcinoma is the most challenging and is a rare occurrence in dystrophic nails. It is more common in the fingernail than toenail, but does occur in both.

Periungual erythema and pain may be clues to squamous cell carcinoma. Onycholemmal carcinoma is a distinct type of squamous cell carcinoma arising from the nail isthmus. It is an indolent carcinoma confirmed by biopsy. (Chaser, BE, Renszel, KM, Crowson et al Oncholemmal carcinoma: A morphologic comparison of 6 reported cases. JAAD.2012.07.015)

If the nail culture is negative on two samples, consider a podiatry or dermatology consultation. If the nail is painful, bleeding or shows erythema, it may be important to send the patient for a nail bed biopsy.


Treatment of nail fungus is challenging. The toenail grows slowly, only 1mm per month, fully regrowing in 12 to 18 months. The fingernail may regrow in six months.

Oral medications are not always effective, have systemic risk and may interact with other medications. When informed of the risks, many patients decline treatment. Lab testing prior to, and during, treatment is recommended, based on the oral medication selected.

Pulse oral treatment may provide higher cure rates and reduced systemic risk. Treatment with oral medication has a high relapse rate. Clinical cure, where the nail appears normal, may not be confirmed by a mycological cure.

There are other considerations in treating fungal nails. The infected nails may infect others in the home. Studies have shown that the specific genetic type of T. rubrun infection is the same from adults with fungal infection in the same household.

There are new topical medications for fungus of the nail.

Efinaconazole 10 percent is the first topical triazole antifungal agent approved by the FDA. Tavaborole 5 percent is a boron-based benzoxaborole that has completed phase 3 trials.

Laser treatment with Nd:Yag is currently approved in the U.S. for temporary increase in clearing of nail fungus. The reports from randomized controlled trials do not show significant mycological or clinical clearance. (Hollmig, T et al JAAD 2013. 12.024 p911 923)


1. Dermatology Essentials, Bolognia, Schaffer, Duncan, Ko Elservier Saunders C 1914

2. Dermatology Third Edition Bolognia, Jorizo, Schaffer, Elservier Suanders c 2012 reprinted 2013

3. Dermatoloical Signs of Internal Disease Fourth Edition Callen, Jorizzo, Bolognia, Piett3 ZoneSaunders, Elsevier c2003

4.  Andrews Diseses of the skin Eleventh Editiion James, Berger, Elston Elsevier Saunders c 2011

5. Clinical Dermatology Fifth Edition Habif Mosby Elsevier c 2010

Choosing Wisely is a registered trademark of the ABIM Foundation



8th Annual Oculoplastic Symposium

Thursday, January 22nd, 2015

January 22, 2015, Intercontinental Hotel Windsor Ballroom, Atlanta, Ga. For more information, visit Southeastern Society of Plastic and Reconstructive Surgeons 


To “D” or Not to “D”

Thursday, January 22nd, 2015

By Kenya H. Anders, M.D.

From ATLANTA Medicine, Vol. 85, No. 5

The human body requires Vitamin D to function, yet how we obtain the essential vitamin – and what we as physicians can safely recommend to our patients – is constantly up for debate.


Just one hundred years ago, rickets debilitated more than 80 percent of children living in New York City, Boston and London. In many northern cities, increasing industrialization, and the resulting factory work, shifted adults and children indoors, creating a disease not seen in the squalor of much poorer rural communities or cities of more equatorial climates.

By 1921, JAMA editorials touted cod liver oil as an effective antirachitic; scientists later isolated Vitamin D and recognized the connection to solar radiation. Two decades later, the USDA had instituted fortification of milk, breads and cereals. Rickets was largely eradicated, Vitamin D dropped off physician’s radar, and cod liver oil became a distant, distasteful memory.

Transportation and technology catapulted us into the age of trains, automobiles, air travel, indoor plumbing, electricity, radio, television, Hollywood, appliances, grocery stores, computers and the Internet – all of which made it more convenient, conducive, climate controlled and safer to work and play indoors

Dietary sources of Vitamin D2 and D3

Figure 1: dietary sources of Vitamin D2 and D3


Many physicians and patients assume that a well-balanced, vitamin-fortified diet is adequate to meet all nutritional needs – including Vitamin D. Unfortunately, Vitamin D occurs naturally in only a few types of foods. The rest is naturally formed when sunshine strikes skin, cycling semiannually. (Figure 1).

Milwaukee-based Schlitz Brewing Company, maker of the now-defunct “Sunshine Vitamin Beer,” boasted in a 1936 ad, “As the summer sun heads south; as days grow shorter and stormier – we get less and less of sunshine’s benefits. Likewise, our ordinary foods are lacking in Sunshine Vitamin D, so essential to robust vitality. … [Our beer] gives you the sunny source of health you need the whole year around … and at no increase in price.”


Dermatologists discourage deliberate ultraviolet radiation exposure; 90 percent of cutaneous malignancies are linked to cumulative and delayed effects of sun on our skin. Despite these efforts, one fifth of the United States (U.S.) population can expect to develop skin cancer in their lifetime. The National Cancer Institute estimatesone death per hour from melanoma in the U.S. this year.

Many risk factors for skin cancer are largely unavoidable (family history, natural skin pigmentation, history of childhood sunburns, altitude and latitude of residence) but lifestyle adjustments can limit ongoing exposure. These include staying inside during the middle of the day when the ultraviolet (UV) B rays are the most intense; avoiding tanning beds; wearing protective clothing, hats and glasses; and correctly applying (and reapplying!) a sufficient amount of sunscreen to exposed skin. In a December 2010 position paper, the American Academy of Dermatology issued a strong monition, warning that “There is no scientifically validated, safe threshold level of UV exposure from the sun or indoor tanning devices that allows for maximal vitamin D synthesis without increasing skin cancer risk.”


The epidermis protects against solar damage and also makes Vitamin D3 for systemic use. Increased melanin content in the epidermis, either genetically directed or developed due to radiation damage as a tan, confers some barrier to penetration of longer wavelengths of light into the dermis. High concentrations of melanin also dampen Vitamin D synthesis in the skin so that darker complexions take longer to form the same amount of Vitamin D when compared to fair complexions exposed to the same intensity of light for the same amount of time.

world map used by permission from

Figure 2: world map used by permission from


Figure 2 depicts rough, relative latitudes of countries and continents. Hundreds of years ago, before significant mass transportation, many people lived within walking distances of their ancestors’ habitats. Natives near the Arctic Circle, such as the Inuit of Alaska, tolerate months of complete darkness each winter, but their typical diet includes fish rich in Vitamin D.

Compare the latitude of the United Kingdom to that of Australia, used by colonial England as a penal colony. Australia’s indigenous peoples have darker complexions to compensate for their proximity to the equator, but, in general, the transplanted criminals did not, resulting in high rates of skin cancer that persist today. Compare also how much further north the United Kingdom is to the southern United States. The striking difference in latitude demands awareness and lifestyle accommodation for skin cancer prevention and subsequent Vitamin D supply.

Vitamin D pathway

Figure 3: Vitamin D pathway


There are two sources of Vitamin D: the sun and our diet. There are also two forms of Vitamin D supplements, D2 and D3, which are bioequivalent and handled identically by the GI tract. D2, a vegan source, is available in a prescription form of 50,000 IU; D3 – the form made in the skin – is the most commonly used over-the-counter supplement.

Both D2 and D3 have two names. D2 is also known as ergocalciferol; D3 is also known as cholecalciferol. Together they are called calciferol. Supplements are dosed in either international units (IU) or in micrograms, with 40 IU equal to 1 microgram.

Vitamin D can be measured as two metabolites in the serum called 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D; 25-OH is the best form for screening and is the best marker of available bodily stores, working in concert with the parathyroid hormone to maintain calcium homeostasis. The 1,25-dihydroxyvitamin D form is complexly regulated and used to finesse levels in renal failure and sarcoidosis. (Figure 3) Test results are also given using two units. Most U.S. laboratories use ng/mL units for serum Vitamin D levels; others report using the international system of nmol/L. To convert from ng/mL to nmol/L, multiply by 2.5.


Vitamin D deficiency in infants is classically associated with rickets in children, osteomalacia and osteoporosis in adults. The distribution of Vitamin D receptors throughout the body, including in the brain, breast, prostate and macrophages, indicates a much wider role than in calcium homeostasis, including in autoimmune diseases, certain cancers and cardiovascular disease. It is hard to pick up a journal in any specialty without seeing ongoing studies of the effect of Vitamin D.

Medical necessity codes for Vitamin D testing

Figure 4: medical necessity codes for Vitamin D testing


25-hydroxyvitamin D blood levels (CPT code 82306) determine whether current supply is adequate. Fasting is not required. Medicare will not cover checking Vitamin D levels unless the patient has a documented Vitamin D deficiency or a limited number of diseases. (Figure 4) Consider testing – or perhaps empiric supplementation – in patients with those conditions or at increased risk of deficiency: people of color; who are elderly, obese or shut-ins; people on medications including anticonvulsants, HAART and cholestyramine; those with poor absorption due to inflammatory bowel disease, cystic fibrosis and celiac disease; and sun avoiders either due to cultural preferences or practicing “safe sun” for skin cancer prevention and anti-aging benefits.


Vitamin D levels are not static; they are highest in late summer and lowest in early spring, proportionate to the length and intensity (angle) of seasonal sunshine. The World Health Organization (WHO) defines 25-OH Vitamin D insufficiency as serum levels <30 ng/ml and Vitamin D deficiency if levels are < 20 ng/ml. Variations in Vitamin D binding protein levels in some people and certain medical conditions (malnutrition, liver disease) may affect the circulating levels.

Ideal levels and safe upper levels are still being discussed and studied. Some have suggested that African Americans have lower “normal” level than European Americans. However, a 2012 study from the British Journal of Nutrition revealed that Hadzabe and Maasai natives of East Africa, hunter-gathers wearing sparse clothes but avoiding sun during the hottest part of the day, had average levels of 44 ng/ml. Studies across eclectic populations including Hawaiian skateboarders, pregnant women on prenatal supplements, and resident physicians in Boston, Southern Brazil and India, show the majority (sometimes 80 percent or more) as Vitamin D deficient using WHO’s criteria.


Vitamin D is absorbed in the distal duodenum and proximal jejunum of the small intestine. Patients with inflammatory bowel conditions, small bowel resection and bariatric surgery may need substantially higher supplement dosing. Food fortification will not be beneficial to people who avoid them due to lactase deficiency and/or gluten avoidance.

Dosing compliance and intestinal absorptive capacity are the driving factors. For many adults, 1000-2000 IU a day may be sufficient, but for post-bariatric surgery obese patients, significantly higher doses may be needed. Toxicity has been reported but is rare.


The Kaiser Permanente Center for Health Research assayed Vitamin D supplements andnoted a startling difference between the printed strength and the assayed activity (from 9 percent to 146 percent of the stated dose) of calciferol. The U.S. Pharmacopeial Convention (USP), an independent, nonprofit organization, annually audits voluntarily participating manufacturers of dietary supplements; approved Vitamin D products tend to test more closely to the stated dose than those from non-participating labs.Consider looking for the USP Verified Mark on supplement packaging to increase the likelihoodof quality, potency and purity of the product.


“The devil is in the details.” More work needs to be done before we have a satisfactory solution to keep our patients and ourselves simultaneously protected from carcinogenic radiation while adequately providing for Vitamin D needs. We might have been spared this dilemma if our forefathers had not left the lands, latitudes and lifestyles of our ancestors. Personally, I prefer to stay in my current climate and maintain my mainly indoor lifestyle – even if I have to be mindful of the sun and Vitamin D.


  1. American Academy of Dermatology and AAD Association . 2009. Position statement on vitamin D. Accessed August 20, 2014.
  2. Kennel KA, Drake MT, Hurley DL. Vitamin D Deficiency in Adults: When to Test and How to Treat. Mayo Clin Proc. 2010;85(8):752-758.
  3. Vanchinathan V, Lim HW. A Dermatologist’s Perspective on Vitamin D. Mayo Clin Proc. 2012;87(4):372-380.
  4. National Institutes of Health Office of Dietary Supplements Vitamin D June 24, 2011.
  5. Holick MF. The Vitamin D Deficiency Pandemic: a Forgotten Hormone Important for Health. Public Health Reviews 2010; 32:267-283.










5th Annual Georgia Trauma Commission Strategic Planning Workshop

Thursday, January 22nd, 2015

January 22, 2015, Macon Marriott City Center, Macon, Ga. For more information, visit Georgia Trauma Commission


Southern U.S. Has the Nation’s Lowest Five-Year Survival Rate Among Those Diagnosed with HIV/AIDS in 2003-2004

Monday, January 19th, 2015

The southern U.S. had the nation’s lowest five-year survival rate among those diagnosed with HIV or AIDS in 2003-2004, according to new research.

Fifteen percent of people diagnosed with HIV and 27 percent of those diagnosed with AIDS in that year had died within five years of diagnosis.

Nine southern states (Alabama, Florida, Georgia, Louisiana, Mississippi, North and South Carolina, Tennessee and Texas) are hit disproportionately hard by HIV/AIDS. Patients in this region tend to be younger, more rural, African-American and female. They are also more likely to attribute their HIV infection to heterosexual sex.

“This research documents the dire consequences that having an HIV diagnosis in the Deep South region has for too many individuals,” said Duke University law professor Carolyn McAllaster, who directs the Southern HIV/AIDS Strategy Initiative (SASI) and the law school’s AIDS/HIV and Cancer Legal Project.

The research team included the Center for Health Policy and Inequalities Research at the Duke Global Health Institue, SASI, the Centers for Disease Control and Prevention and the University of North Carolina School of Public Health. Their findings appear in the December 2014 edition of the Journal of Community Health. (link below)

Differences between U.S. regions in demographic characteristics and transmission risk did not explain the higher death rate among persons living with HIV in the targeted Southern states, indicating that other factors contribute to this disparity.

Lead author Susan Reif of the Duke Global Health Institute said a number of factors likely contribute to the differences in outcomes seen among individuals living with HIV in the Deep South, including poverty, lower levels of education and insurance coverage, social stigma associated with the disease, and racism.

“These differences are crucial to consider with creating strategies to address HIV/AIDS in this region,” Reif said. “Clearly greater investment and focus are required to address the unique nature of the HIV/AIDS epidemic in the South.”

The research was commissioned by Duke Law’s AIDS Legal Project through a grant from the Ford Foundation. The full text of the article may be viewed here.






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