My Blog

Posts for tag: dermatology

By Dr. David Fivenson, Sultan Qiblawi
April 06, 2020
Category: Uncategorized
Tags: dermatology   skincare   telemedicine  

Telemedicine is more important than ever. With the uncertainty the COVID-19 has bestowed on the world. We are being forced to rethink how we interact with each other, and conduct business on a daily basis. This extends to how we interact with our healthcare providers. With telemedicine in healthcare, there are ways that you can interact with your doctor and still receive the care and advice that you need without leaving your home. Dermatology is a visual field that is well suited to take advantage of the convenience and efficiency of telemedicine tools. With telemedicine, you are able to set up an appointment and use your internet enabled device to have a face-to-face appointment with you doctor. Your dermatologist will be able to see your skin, answer your questions, and give advice about what to do next in your treatment plan, without being in the same room as them. Since this technology is relatively new, people may not know much about how it works.  Here are a few important concepts to know about telemedicine and how it is done:

  1. Synchronous versus asynchronous appointments:

There are two main types of telemedicine appointments that you can schedule with you doctor, synchronous and asynchronous. Synchronous telemedicine appointments involve both parties to be online at the same time having a live session that includes both audio and video components. Essentially, this means that you are able to video chat with your doctor in real time and discuss your concerns with them, just like you would in a face-to-face appointment.

Asynchronous telemedicine is a term used to describe store-and-forward transmission of medical images and/or data that is recorded by the patient and then sent to the physician over a secure web server, encrypted email, specially designed store and forward software or electronic health record. Once the physician receives the information, they can assess the patient’s concern and send back their diagnosis, treatment, and recommendations back electronically or fax their recommendations. This means that a patient is able to record themselves with their questions and concerns and send this to their physician and wait for their recommendations. The difference between this and synchronous telemedicine, is that asynchronous encounters do not occur in real time, as where synchronous encounters happen in real time.

  1. Digital platforms:

Telemedicine software is a sector of health IT that focuses on delivering clinical healthcare via secure audio and video connection. These platforms are the means in which you can interact with your doctor and discuss your concerns with them. There are numerous platforms in which you can interact with your physician via telemedicine. Mobile applications (we use Chiron and Hale at Fivenson Dermatology currently) can be downloaded onto your computer or mobile device and securely run your virtual appointment with your physician.  This is similar to popular apps like Facetime, What’s App, Skype but with all the necessary security to protect our personal health information

If you are interested in doing setting up a telemedicine appointment at Fivenson Dermatology, you can request a virtual appointment here.The rise of these applications makes telemedicine easier than ever and it offers great convenience for patients. This encounter is ideal for patients who are not able to make to the office. This includes people who cannot leave their place of work, taking care of their children, or not able to leave their homes. It also allows people to get the advice of physicians that they trust while they are out of town, and still need advice about their skin.  Insurance coverage is still variable but growing (temporarily it is much more widespread due to the government’s response to the COVID-19 pandemic with relaxation of the HIPAA privacy rules)


By Michael J. Visconti, BSc & David Fivenson, MD
November 05, 2019
Category: Uncategorized

Sunscreen is a vital tool in the prevention of skin cancer, photoaging, and worsening of certain light-sensitive skin conditions. Because of this vast application, numerous formulations of sunscreens have been developed to encourage their use, including creams, lotions, gels, sprays, sticks, and powders. In this post, we highlight various formulations of sunscreen available today and discuss their recommended uses (Table).

Before discussing sunscreen formulations, it's important to highlight general sunscreen facts. When choosing a sunscreen, an SPF of 30 blocks ~97% of ultraviolet radiation and is the lowest recommended SPF. Sunscreen products with an SPF of 30 or higher that are also broad-spectrum (blocking multiples types of harmful ultraviolet radiation) and water-resistant are highly recommended.

Table - Various sunscreen formulations and their applications.

Sunscreen Formulations
Formulation Applications
  • Moisturizing, cosmetically pleasing formulation beneficial for dry skin.
  • Particularly useful for the face (especially if you are prone to dry skin).
  • Thin and easily spread - making lotions useful for providing coverage to large body areas.
  • Shot glass rule: it generally requires enough sunscreen to fill a 1.5 ounce shot glass to cover the entire body surface.
  • Useful in hair-bearing areas (scalp, forearms, lower legs, male chest and back).
  • Shot glass rule applies.
  • Easy to apply
  • Users often do not apply enough spray sunscreen.
    • Ensure you spray four passes (back and forth, back and forth) to each body region.
    • sunscreen with the skin surface and provide even coverage.
  • Be sure to hold the spray canister close to the skin and use caution in windy conditions in order to promote coverage and avoid inhalation.
  • Wax or petroleum-based formulation - assisting with water resistance.
  • Most beneficial for the skin around the eyes since this formulation won’t run or drip.
    • Also beneficial for the back of hands (an area of high sun exposure).
  • Apply four passes (back and forth, back and forth) to a skin region.
    • Rub in thoroughly afterwards.
  • Contain mineral sunscreens only.
  • Beneficial for “touching-up” and reapplying protection to the face (nose, midface, upper forehead) throughout the day since powders can easily be applied over make-up or moisturizers.
    • Generally, not recommended as a lone source of sunc protection.
  • Apply two passes (back and forth) over a skin area for the adequate protection.


* Special note on lip protection:
The lips are especially prone to sun damage and may also develop skin cancer. Numerous dual-action lip balms exist providing both moisturization and sun-protection.

When choosing a sunscreen formulation, it's important to choose one a product that is easiest for you to use so that you will routinely use it and adhere to a sun protection regimen. Despite the importance of sunscreen in protecting yourself from the sun’s ultraviolet rays, no sunscreen formulation is able to block all of the damaging light. Avoiding prime sun-exposure time (10 A.M. to 4 P.M.), wearing sun-protective clothing, and seeking out shaded areas are vital components of sun-protection.

* Disclaimer: This discussion summarizes the look and feel of sunscreen products but does not approach the nature of the active ingredients, which will be covered in another blog post.

By Michael J. Visconti, BSc & David Fivenson, MD
September 30, 2019
Category: Uncategorized
Tags: Skin   dermatology   medicine   psoriasis   topicals   therapy   eczema  

Many skin conditions are treated with topical medications. Instead of applying active medicine directly onto the skin, “vehicles” are combined with the chosen medication to aid in its delivery. Vehicles are inactive creams, lotions, solutions and/or ointments that change the properties of the medicine mixed into them – assisting its application.

The primary components of vehicles include powders, oils, and liquids. The inherent properties of these three ingredients is translated to the vehicle, and thus how the medicine is delivered on the skin. For example, a vehicle with a prominent liquid component can assist with the drying of wet skin lesions through evaporation, whereas oils can provide an occluding coating to the skin and enhance the penetration of the active medicine.

When vehicles are combined with active medicines, you get “formulations”. Formulations can be creams, ointments, lotions, solutions, and foams embedded with active medicine. Different formulations have different potencies (i.e. triamcinolone ointment is more potent than triamcinolone cream) and different body region applications (i.e. solutions for the scalp instead of creams). The consideration of which formulation to use is crucial, as certain formulations are easier to use, therefore promoting adherence to a treatment regimen and overall improvement of a patient’s skin condition.

Outline of formulations:

  • Cream
  • Ointment
  • Lotion
  • Gel
  • Foam
  • Solution

Creams are predominantly mixtures or emulsions of oils in water. Creams are usually white in color and easily rubbed in without leaving much of a residue. They are applicable to numerous body regions. For these reasons, they tend to be favored by patients and frequently prescribed by clinicians. Creams are particularly beneficial in the skin folds and offer a drying effect to help with wet or damp skin lesions. Additionally, certain creams can be “augmented”, meaning they are more potent and penetrate the skin deeper (i.e. betamethasone dipropionate vs. betamethasone dipropionate augmented). Because a cream is an oil in water emulsion, it requires added agents to keep the mixture stable. This is the same idea as the difference between oil and water salad dressings and a thicker one like ranch or thousand island.

Ointments are mainly composed of oils and greases with a small amount of water. Oils are translucent and greasy, with the latter characteristic making them cosmetically unfavorable for some patients. They provide great lubrication and can be used on dry skin lesions. Ointments are more occlusive, which allows for better penetration of medication through the skin and higher potency. Because of this effect, ointments may not always be indicated for certain regions of the skin that are naturally thinner than others (i.e. the face, armpits, groin folds, etc.). Ointments work best in smooth skin regions lacking hair and on thick and dry skin lesions.

Lotions are composed of powder and water. Lotions are easily spread but only slightly occlusive, making them the least potent topical vehicle. However, lotions are useful in the treatment of moist or exudative skin lesions, as they provide a drying effect through evaporation after application. Lotions can be useful in hairy areas of the skin, as well as large areas due to their ease of application.

Gels may appear similar to ointments, except they are composed of water, carboxymethylcellulose beads, propylene glycol, and occasionally alcohol. Gels are translucent, greaseless, and easy to apply. For comparison, think of the common surgical lubricant or K-Y Jelly. Gels dry and form a thin film, which does not stain or leave behind greasy texture. These features make gels cosmetically favorable, but they are poorly occlusive and do not provide hydration. Gels are particularly applicable for acne and hair-bearing areas, since they do not mat down the hair after drying.

Foams are composed of liquid film and gas bubbles. Foams easily spread and absorb into the skin while leaving behind little residue. Because of this, they are cosmetically appealing and more expensive formulations. Foams provide little to no hydration or occlusion. However, certain types of foams called emollient foams can provide skin hydration and build up the skin barrier - making them advantageous over traditional foams. Because of their easy application, foams are often utilized on the scalp or other hair-bearing areas.

Solutions are very thin and light. They are made from water, alcohol, and other liquids. Solutions come in a clear or hazy, thin-textured, liquid phase. As a result of this, they can be drying from evaporation, easy to spread, and messy to apply. Solutions are most useful for the scalp, as they can penetrate the skin through hair. Due to the presence of alcohols, they are more prone to stinging sensations when applied to inflamed skin.

By Sultan H Qiblawi
September 04, 2019
Category: Uncategorized
Tags: Skin   dermatology   psoriasis   trigger   strep   stress   beta blocker  

Plain Field in Front of Mountain Peak


Psoriasis is a disease that many of us have encountered in our daily lives. Chances are you know someone who has it, or you may even have it yourself. Psoriasis is a disease that causes flaking of the skin with inflammation and thick white, silvery, or red patches of the skin. The scaly patches can be anywhere on the body, but tends to effect the elbow, knees, face, hands and feet, nails, and skin folds (e.g. armpits).

So what causes psoriasis?

Psoriasis is an autoimmune skin condition that speeds up the life cycle of skin cells and causes them to build up on the surface of the skin. The patches and scales that are seen on the affected areas are from this process. There are common things that can trigger a psoriasis flare that are important to know about if you or a loved one has psoriasis.

Triggers of Psoriasis:

1. Strep infections:

Strep throat infections have been linked to causing flares of psoriasis in some people. When you get a strep throat, your immune system responds by sending many immune cells to the tonsils to fight the infection. It is believed that some of these immune cells go to the skin and can trigger a psoriasis flare up. According to a study that looked at the relationship between psoriasis and strep throat, 42% of plaque psoriasis patients reported that their psoriasis got worse when they had a sore throat. Interestingly, 48% of patients who had their tonsils out after getting psoriasis reported that their psoriasis got better.  


shallow focus photography of prescription bottle with capsules


2. Beta blockers:

Beta blockers are a very common drug class that is used for controlling arrythmias, high blood pressure, and many other conditions. This class of drugs has been reported to induce and exacerbate psoriasis in many people. The latency period between taking a beta blockers like propranolol, atenolol, and metoprolol, and a drug eruption can range from several days to 48 weeks. It was also found that eruptions were usually resistant to psoriasis medications until the Beta-blocker was discontinued.

3. Anti malarial medications:

Medications that are used to treat malaria have been shown to exacerbate psoriasis in many patients. Antimalarials are commonly used to treat psoriatic arthritis, which is an arthritis that can be caused coexist with psoriasis, but can commonly precipitate eruptions and flares of psoriasis. Because of this, some authorities say that antimalarials are contraindicated in patients with psoriasis.

4. Stress:

Stress is commonplace in many of our lives, and it can have negative effects on many parts our life. Unfortunately, this is also the case for psoriasis and flareups. Stress is a very common trigger for psoriasis and it is important to reduce stress to lower your chances of having a psoriasis flare due to stress. Exercise and meditation have been shown to help patients reduce their stress and thus reduce the amount of psoriasis flares that can occur due to stress that compounds throughout a long period of time.

Check out the National Psoriasis Foundation website:  for more information about psoriasis.

By Sultan Qiblawi
June 16, 2019
Category: Uncategorized
Tags: Skin   dermatology   pemphigus   autoimmune   medicine   skincare  


There are a subset of dermatological diseases that are not very well known to the general public that can be painful, and potentially life threatening. In today’s post, I want to shed some light on one of these diseases: pemphigus vulgaris.

First off, I would like to give you some stats about how frequently this disease occurs in the general population. Pemphigus vulgaris affects about 0.7-5 people per 1,000,000 per year in the general population. This is not a very common disease, but its affects can be debilitating and missing this diagnosis can pose serious problem for the person who actually has it.

Dr. Fivenson is a nationally recognized leader in bullous diseases, like pemphigus, and he sees hundreds of these patients. He, and his team, are here to make sure you get the most accurate distilled information about rare dermatological disorders, and what you should look out for.

So what is pemphigus?

Pemphigus is a rare chronic blistering skin condition that is caused by the immune system attacking the body. These types of diseases are called autoimmune diseases, and in this case, your immune cells are making antibodies against your skin, specifically the epidermis. This means that the disease is not contagious, and cannot be transferred to people by any mode of transmission (i.e. blood, fluids).  It can happen to people at any age, but it tends to happen to middle aged adults or older adults.

Pemphigus vulgaris: this subtype of pemphigus creates blisters that generally start in the mouth and then appear on the skin or the genital mucous membranes (i.e. vagina, urethra, and underside of the foreskin). There can also be nail loss, alteration of the skin pigment, and severe disability if it is not taken care of quickly. Pemphigus vulgaris is not a disease that will go away by itself. It needs active treatment to control the flares and reduce downstream complications.

What should you look out for?

Pemphigus causes severe blistering in the mouth and other parts of the skin. Sometimes your skin can readily peel off and this can lead to increased infection, dehydration, and disfigurement. The blistering can be very painful, can have severe itching, and can even burn. 

The type of blister you get is also characteristic of the disease: big, flaccid bullae that burst easily. This means that the blisters will rarely form because they rupture almost immediately after they form. The rupturing blisters lead to multiple, superficial, ulcerated sores throughout the mouth. These painful sores are the more common sign that people initially see. 

What should you do if you suspect you have this?

If you suspect that you have this type of dermatological disease or any other concerns with your skin, contact your dermatologist. They will be able to guide you and work with you to see exactly what you have. There are also fantastic resources on our website about pemphigus and other blistering skin diseases that you can read about on Patient Resources page.

Dr. Fivenson is a nationally recognized specialist in autoimmune skin disorders, like pemphigus. He is board certified in dermatology and immunodermatology, and has published over 125 peer reviewed articles in dermatology. 




Contact Us

Office Hours
Monday:8:00 AM - 5:00 PM
Tuesday:8:00 AM - 5:00 PM
Wednesday:8:00 AM - 5:00 PM
Thursday:8:00 AM - 5:00 PM

After Hours

For Non-Emergency questions, use the patient portal or use the Contact Us form

In case of Emergency, call St Joseph Mercy Hospital Operators at
( 734) 712-3456 and have Dr. Fivenson paged