Richard H. Flowers, MD, FAAD, is an assistant professor of dermatology at University of Virginia in Charlottesville, VA. Amongst this his titles also include phototherapy unit director, director of the Institute for Dermatologic Research and Advancement, associated program director, and dermatology global health leadership track director. His particular expertise and interests lie in rheumatologic dermatology, blistering diseases, vasculitis, complex medical dermatology, inpatient dermatology, and sarcoidosis. Dr Flowers joined The Dermatologist to give insights into his session at 2021 Summer AAD titled, “Hot Skin and Bellringers from the Kodachrome Collection of Dr. Kenneth E Greer”.

Can you speak about Dr Greer’s Kodachrome collection and the importance of good photography?
Dr Greer has been very passionate about dermatology since the 1970s when he initially started practicing. His Kodachrome collection is a manifestation of his passion and love of the specialty. Over time, he has taken photographs of everything that he sees, and at this point, he now has tens of thousands of high-quality photographs of every common and rare dermatologic disease you can imagine. He has shared them with students, residents, and colleagues, and you can find his photographs in textbooks, research publications, and in his lectures. We are working now at the University of Virginia (UVA) to digitize his collection so that we can preserve them and categorize them by disease.

Good photography is important in dermatology, because of how visual presentation is in diagnosing diseases. Dr Greer has been very focused on emphasizing good photography. Good means no distractions, no clothing, no jewelry, good lighting, and framing the subject so that you know where you are on the body as well as where the lesions are in a focused image.

How can clinicians improve their recognition of rare cutaneous conditions?
There is not really a substitute for seeing rare skin diseases live and in the flesh. At UVA, a lot of what we do is to bring in residents and attendings, if patients are willing, to see rare or interesting diseases. Many times, that might be the only time we see it until years later.

To be more apropos to the talk given at the Summer AAD Meeting and to Dr Greer's Kodachrome collection, studying images is crucial as well. There are many images online, although you have to be careful because things can be mislabeled online. Using reliable resources such as a textbook is critical, and many residents are turning to VisualDx online. We also need to make sure we are seeing images of skin diseases in all skin colors. For many years now, we have had a deficiency in dermatology of good images of skin disease in particularly darker skin colors. As a specialty, it is something we are actively trying to change. At UVA, we are lucky that Dr Greer has a lot of photographs of skin of color that we have emphasized to our residents in recent years.

If you had to narrow it down to three factors, what tools, tests, or information would you recommend dermatologists use to make a differential diagnosis of inflammatory diseases or even for immunobullous diseases?
That is a really good question and a little bit of a tough one, but I will give it a stab. Three factors for me are history, observation, and clinicopathologic correlations.

History emphasizes the importance of talking to the patient: listening to what they are saying, getting a thorough history with their social history and occupation. It also incorporates establishing a longitudinal relationship with the patient to build that trust.

I consider observation our superpower in dermatology because we are such a visual field. Dr Greer talks about the “big eye of observation” as being a goal to work toward in practice for years, and I talked about that at the AAD Summer Meeting session. Basically, what Dr Greer is talking about is looking for subtle clues in the whole patient to inform your diagnosis and decision-making. For example, you would want to look carefully at the nails if you suspected psoriasis or in the mouth if you suspected lichen planus.

Then, finally, I would highlight clinicopathologic correlation. We’re really fortunate in dermatology that we have very easy access to our tissue of interest, so a skin biopsy is a really important test for many diseases, including inflammatory and immunobullous diseases. It is generally minimally invasive to the patient and, many times, it can be invaluable when we are making a differential diagnosis. Sometimes, we have to talk to the pathologist to get a good correlation between what we see vs the biopsy results. Other times, we have to repeat the biopsy if things are not responding like we think they should or if things are changing.

Can you reflect on the importance of making an accurate diagnosis for patients, especially how it pertains to building trust and treatment satisfaction?
I think that getting it right is really important for building patient trust, but we do not always get it right in dermatology or in medicine. Keeping an open mind, being willing to be flexible when things are changing, or revisiting your prior assumptions about a diagnosis are important as you try to nail down an accurate diagnosis. Sometimes, though, I will say we do just have to treat patients and make them feel better from a symptom standpoint, even if we are not exactly sure what the diagnosis is. Fortunately, since we are able to do biopsies, we are generally able to make a definitive diagnosis for most people.

Is there anything else notable about Dr Greer's Kodachrome collection or rare conditions that you would like to share?
I am extremely grateful to Dr Greer for his dedication to the field in general and to the UVA department of dermatology, where he essentially is the heart and soul of the department; for his mentorship to me; and just for being a great physician and role model.

Reference
Saavedra AP, Greer KE, Flowers RH, Forrester VJ, Kozak MD. Hot skin and bellringers from the Kodachrome collection of Dr. Kenneth E Greer. Presented at: American Academy of Dermatology Summer Meeting 2021; Tampa, FL; August 5-8, 2021.