Medical students are usually attracted to dermatology because they like its mix of both medical and surgical therapy. You can use both the prescription pad and the scalpel all in one day of seeing patients. A generalized knowledge of medicine is critical, for instance, when administering medicines with systemic toxic-ity such as intravenous steroids. You will provide your patients with a number of topical ointments (especially steroids and antibiotics) in addition to treating them with your hands with surgery.
Not all of the procedures are necessarily therapeutic, however. Dermatologists use their hands diagnostically as well. At the bedside or in the office, they conduct simple tests to confirm suspected clinical diagnoses. This includes skin biopsies of suspicious lesions, potassium hydroxide ("if it scales, scrape it") stains of fungal infections, gram stains for identifying bacterial causes of skin infections like cellulitis or impetigo, Tzanck preparation smears for isolating herpes infections, and oil preparations to rule out scabies in patients presenting with itchy rashes.
In the therapeutic realm, dermatologists are the master surgeons of the skin. One of the most demanding forms of surgery is Mohs micrographic surgery. This advanced treatment for skin cancer involves the removal of cancer from certain areas, such as the face or ears, where skin-sparing excisions are important. It offers the highest potential for recovery. Historically, skin cancers were removed with a standard margin that would ensure the removal of the entire cancer. However, a certain portion of skin removed would be cancer free. Mohs surgeons re move serial slices of skin and evaluate them under the microscope, ensuring clear margin free of cancer all the way down to its roots. It allows the dermatologist to see beyond the disease and remove the entire tumor while leaving the healthy cells alone. After completing removing the skin lesion, the Mohs surgeon repairs the wound with complex closures.
More surgically oriented dermatologists can perform Mohs surgery with complicated flaps and grafts. Surgical dermatologists also perform procedures typically performed by plastic surgeons such as liposuction, blepharoplasties (eyelid surgery), and even rhytidectomy (face lifts). Surgical treatments also include procedures like excisions, electrodessication and cutterage, cryotherapy, sclerotherapy, laser surgery, hair transplants, and tissue augmentation therapies.
Certain dermatologists also perform medical and surgical skin rejuvenation procedures in the form of cosmetic dermatology. Medical rejuvenation involves the use of tretinoin, apha-hydroxy acids, and topical anti-oxidants for the treatment of age-related skin changes. Surgical rejuvenation procedures include Botulinum toxin injection, soft tissue augmentation, chemical peels, dermabrasion, sclerotherapy, and laser skin resurfacing. Many people, of course, have heard about Botox, a cosmetic treatment method that falls under the special expertise of dermatologists. This technique involves the injection of very tiny amounts of purified botulism toxin into a targeted facial muscle. The injection causes a nerve blockage and subsequent immobilization of the facial muscle; paralysis of the muscle prevents wrinkling of the skin when the patient smiles or frowns.
Many cosmetic dermatologists also perform laser skin resurfacing, which involves the use of a laser (light amplification by the simulated emission of radiation) to treat wrinkles, pigmented lesions (such as birthmarks), scars, tattoos, warts, and unwanted hair. A related advanced technique known as electrosurgi-cal resurfacing uses micro-electrical radiofrequency to deliver a pulse of energy to the skin. Electosurgical resurfacing removes lesions without the loss of skin pigmentation, so it can be used on skin of all colors.
Compared to medical dermatology, the field of surgical dermatology seems to be growing rapidly. More and more dermatologists are specializing in surgical procedures. These private practitioners cite the perceived threat in the 1980s and 1990s that managed care would find ways to depress the earning potential of dermatologists practicing classical procedures. Furthermore, a recent study suggests that medical students who incur large educational debts in medical school believe that practicing surgical dermatology will be more lucrative than practicing classical dermatology.1 Medical students should keep in mind, though, that dermatology is a major branch off the tree of internal medicine. This is why many academic dermatologists believe that the core of dermatology comes from those diseases most often treated with medical, not surgical, therapy.
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