“Doc, What’s This Rash?” — Key Dermatology Insights from Dr. Danya Traboulsi

Dermatologic presentations are among the most frequent, and often most challenging cases seen in primary care. To help clinicians strengthen their diagnostic confidence, Alethea recently hosted a virtual learning session with Dr. Danya Traboulsi, dermatologist and Alethea consulting specialist.

This session addressed some of the most common dermatology questions received through Alethea’s eConsult platform and offered practical, evidence-based strategies for front-line care providers.

1. When to Refer for Patch Testing

Dr. Traboulsi began by reviewing when to suspect allergic contact dermatitis and the indications for patch testing.

While irritant contact dermatitis remains more common, chronic, localized, or treatment-resistant eczema, especially affecting the hands, face, eyelids, or lips, should prompt consideration for patch testing. She explained that patients can become sensitized to products they have used for years, and patch testing remains the gold standard for identifying allergenic triggers.

Key takeaways included:

• Refer patients with chronic hand or facial dermatitis or non-responsive rashes.
• Patch testing uses the North American Standard Series of allergens, with readings at 72 and 96 hours.
• Positive results require contextual interpretation, clinicians must determine whether the allergen is clinically relevant.
• It can take up to six weeks of allergen avoidance for visible improvement, requiring supportive care and patient reassurance.

2. Isotretinoin: Low-Dose Therapy in Acne Management

Dr. Traboulsi emphasized that isotretinoin (commonly known by the brand name Accutane) remains the gold standard for acne management, including cases with moderate severity or significant psychosocial impact.

Low-dose isotretinoin (typically 10–20 mg daily) has become a safe, well-tolerated, and effective treatment option that minimizes side effects and monitoring requirements.

Clinical pearls from the session:

• Begin at 10 mg daily to prevent flares; titrate based on tolerance and response.
• No routine labs are required for healthy patients on <20 mg/day.
• For doses >20 mg/day, monitor ALT, lipids, and β-hCG (for females) after one month.
• Stress the need for two forms of contraception during therapy; conception is safe one month after stopping treatment.
• Low-dose isotretinoin can be continued long-term and is even used to reduce skin cancer risk in transplant patients.

Dr. Traboulsi highlighted that isotretinoin is not only safe but also simpler to use than many clinicians realize, making it a practical option for family physicians treating persistent acne.

3. Recognizing Viral Exanthems

Viral exanthems are a frequent cause of patient concern and physician uncertainty. Dr. Traboulsi outlined a systematic approach to identifying self-limited viral eruptions, emphasizing reassurance and supportive care.

Common features include diffuse blanchable macules or papules that resolve within two weeks. These rashes are typically caused by enteroviruses (in summer/fall) or respiratory viruses such as RSV and adenovirus (in winter).

Red flags requiring escalation include:

• Mucosal erosions (oral, ocular, genital)
• Painful rather than pruritic lesions
• Toxic or unstable appearance

Most cases require only topical corticosteroids and emollients for comfort; antihistamines are generally ineffective unless used for sedation.

4. Longitudinal Melanonychia: When to Worry

Longitudinal melanonychia, brown or black linear nail pigmentation, is common, particularly in individuals with darker skin tones, and is benign in most cases.

However, Dr. Traboulsi reminded clinicians to maintain vigilance for subungual melanoma, which, although rare, carries significant morbidity if missed.

Clinical pointers:

• Multiple nails affected → usually benign pigmentation or melanocyte activation.
• Single dark band on one digit → requires closer evaluation.
• Worrisome features: irregular color variation, band width >3 mm, or Hutchinson sign (extension of pigment onto the cuticle).
• Adults with new or changing bands should be referred for nail-matrix biopsy.

5. Choosing the Right Topical Corticosteroid

Selecting the appropriate topical steroid potency and vehicle is essential for effective management of eczema and inflammatory dermatoses.

Dr. Traboulsi advised clinicians to consider:

• Site and skin thickness:
  
  • Low potency for face, folds, and infants.
  • Mid potency for trunk and limbs.
  • High potency for palms, soles, or lichenified plaques.
    
• Vehicle: Ointments are most potent; creams and lotions are less so but may improve adherence.
• Duration: Stop once the area is smooth and non-itchy—pigment changes alone are not a reason to continue therapy.

She also addressed the widespread misconception of “steroid withdrawal syndrome,” clarifying that most relapses are due to undertreatment or lack of maintenance strategies, not steroid dependence. Maintenance therapy can include Protopic (tacrolimus) or Elidel (pimecrolimus) applied twice weekly to high-risk areas for flare prevention.

Practical Takeaways

This learning session offered practical frameworks for primary care providers managing common dermatologic concerns. Dr. Traboulsi’s key message: primary care clinicians can confidently manage many skin conditions with the right tools and education, reserving referral for atypical or refractory cases.

Access the Full Learning Materials

Click here to read the full Learning Session Notes summarizing all discussion points in detail.
Alethea users can also email sales@aletheamedical.com to request a copy of the session recording. Not yet registered with Alethea? Sign up for free here to access upcoming sessions, eConsult learning opportunities, and ongoing clinical education.