Madison Medical Dermatology and Rheumatology

Medical Screening
  • Skin cancer screening – If you have a changing mole or skin lesion, especially if it’s asymmetric, has irregular borders, uneven color, a diameter greater than 5 mm, and it’s changing or growing (evolving), you should have a full body screening exam for skin cancers. *Routine skin examinations/screenings are performed daily by all the dermatology providers.
  • Osteoporosis If you have any of the following risk factors – adult weighing less than 114 pounds, family history of osteoporosis, history of previous fracture, history of smoking, use of steroids (e.g. prednisone, Medrol dose pack, repeated Decadron shots), history of rheumatoid arthritis, menopause, premature menopause, celiac disease or gluten sensitive enteropathy, inflammatory bowel disease, or prolonged vitamin D deficiency – you should consider screening for osteoporosis.  Bone density is typically classified as normal, osteopenia (in which 20-30% of patients have an increased risk of fracture) and osteoporosis (highly increased risk of fracture.) Unfortunately, insurance companies are reducing benefits by limiting payments or not paying for osteoporosis screening – THAT DOES NOT REDUCE YOUR RISK FOR HIP, BACK, OR WRIST FRACTURE.  We are pleased to offer screening and recommendations for osteoporosis treatment at a reasonable charge of $100 for any one at risk ($90 for Medicare patients).
Medical Procedures
  • Cryotherapy – liquid nitrogen destruction of warts and other benign growths (e.g. skin tags, seborrheic keratoses, etc.)
  • Acne surgery –extractions of comedones and milia and injection of cystic lesions
  • Chemical peels – for acne, melasma, photodamage – Flowood only
  • Skin biopsy – for diagnosis of unknown skin conditions and cancers
  • Skin tag removal – cryotherapy or snipping
  • Blu light therapy – acne, photodamage and facial rejuvenation, and pre-cancers – Flowood only
  • Sclerotherapy – treatment of spider veins on legs
  • Laser treatment – acne, psoriasis, warts, seborrheic keratoses, spider veins and other vascular skin lesions, toe nail fungus, rosacea (adult acne), brown spots and aging spots, and facial rejuvenation – Flowood only
  • Microdermabrasion – fine line wrinkles and acne
  • Rejuvapen microneedling – facial rejuvenation, acne scars, stretch marks
  • Surgical excision/removal – moles, skin cancers, cysts, and other benign lesions
  • Botox – for excessive sweating (hyperhydrosis)
Diagnosis, Testing, and Treatment

We provide a wide variety of medical services that include diagnoses, testing, and treatment of a wide variety of pediatric and dermatologic and adult rheumatologic conditions including but not limited to:


  • Skin rashes
  • Hair loss
  • Skin cancers
  • Acne – Acne is one of the most common skin conditions affecting all ages and ethnicities.  It is most prevalent in teenagers and young adults, involves the face, chest and back, and consists of white heads, black heads, pustules, inflammatory papules and cysts which can lead to scarring.  Treatment depends on the type of acne and severity.  Many over the counter products containing benzoyl peroxide and salicylic acid may be adequate for mild acne. Moderate to severe scarring acne may require a combination of topical antibiotics, retinoids, oral antibiotics, oral contraceptives, and isotretinoin (more commonly known as Accutane).
  • Rosacea – Rosacea is an adult inflammatory acne involving the mid face, nose, chin and forehead with pustules, papules, and redness/broken blood vessels.  Some patients mainly have redness of the face which may fluctuate during the day and worsened by triggers such as hot spicy foods, red wine, heat, and sunlight.  The redness of rosacea can be treated with laser and two new medications, Mirvaso and Rhofade, which help constrict the blood vessels in order to decrease the overall redness and flushing that may occur.  The acne component is treated with oral low dose antibiotics such as doxycycline and topical medications such as metronidazole, Finacea, Soolantra, and sulfur/sulfacetamide creams.
  • Psoriasis – Psoriasis may affect all ages but typically presents in the second to third decade of life.  It is a chronic disease that can also present with arthritis. The scalp, elbows, knees, buttocks and nails are commonly affected with well defined thick red scaly plaques.  Treatment is tailored to the areas and degree of involvement. Topical emollients, topical steroids and vitamin D creams, ultraviolet light, and systemic agents such as methotrexate, and the newer agents such as Humira, Stellara, Cosyntex, Otezla and Talz.
  • Actinic keratoses – Actinic keratoses are precancerous lesions which have a low risk of developing into squamous cell carcinomas of the skin.  These red crusted irregular patches are most common on chronically sun exposed areas like the face, ears, nose, neck and forearms. Although all lesions may not require treatment, some lesions are painful, irritated, and itchy and due to the potential risk of progression intervention with liquid nitrogen (burning or freezing individual lesions), topical chemotherapy creams, and photodynamic therapy (Blu light) may be warranted.
  • Squamous cell carcinoma – Squamous cell carcinomas are the second most common skin cancer involving sun exposed skin most frequently on the head, neck, and arms. These cancers are usually red crusted scaly bumps and patches that may bleed easily and seem to not heal. Treatment can include topical chemotherapy creams, surgical removal, and in some cases radiation therapy.  If left untreated, local destruction and deformity may occur in addition to spread of the cancer to the lymph nodes in high risk areas such as lips, ears, and hands.
  • Basal Cell Carcinoma – The most common cancer with over 1 million cases reported a year, basal cell carcinomas present as pink to red pearly patches and bumps on the face, nose, ears, neck, arms and trunk. Although rarely do BCC’s spread, the cancer can lead to local destruction and deformity.  Treatment consists of topical chemotherapy creams, surgical removal, and radiation in rare situations.
  • Melanoma – Melanoma is the “black” skin cancer and the most deadly. Any changing mole is recommended to be evaluated to rule out the possibility of melanoma. The most common location for women is the lower leg and the back in men.  Surgical removal is the treatment of choice with evaluation of lymph nodes in some cases to rule out early spread.
  • Warts – Warts are caused by the human papilloma virus and are common in children involving the hands, fingers, feet, and toes most commonly.  Treatment may be difficult if multiple lesions occur but most commonly methods of destruction are used such as burning or freezing the wart and taser sometimes surgical removal. Topical agents with salicylic acid and prescription imiquimod are also commonly used.
  • Molluscum contagiosum – Molluscum contagiosum is a very common childhood viral condition presenting in 2-10 year olds typically with multiple small skin colored dome shaped papules.  These “warts” may spontaneously resolve if left alone but in the case of multiple lesions treatment with topical imiquimod, liquid nitrogen, Cantharidin “beetle juice” or curettage may be warranted.  There is currently no FDA approved treatment for molluscum.  Chicken pox like scars may occur with or without treatment.
  • Skin aging and rejuvenation


At Madison Medical  – Rheumatology we test for, Diagnose and treat common and uncommon rheumatic and arthritic diseases including, but not limited to, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout, osteoporosis, lupus erythematosus (SLE) and other connective tissue diseases (e.g.Raynauds phenomena, Sjogren’s syndrome, MCTD, polymyositis and dermatomyositis, scleroderma), as well as vasculitis and Wegener’s granulomatosis.  We also treat bursitis, tendonitis and osteoarthritis with a variety of medical therapies including joint injections, especially of the shoulders, knees, hands, and back.  We also screen for osteoporosis/ostepenia using a state-of the art Hologic bone mineral densitometer and treat bone diseases when appropriate.

  • Bone Mineral Density/DXA scanning – determination of fracture risk and presence of osteopenia or osteoporosis
  • Joint injections and aspirations
  • Knee – arthritis diagnosis, osteoarthritis, gout, meniscal tear, knee pain knee tendonitis, prepatellar or suprapatellar bursitis
  • Hip – trochanteric bursitis
  • Ankle – injections for osteoarthritis, tendonitis, gout
  • Foot – Morton’s neuroma, tarsal tunnel syndrome
  • Shoulder – rotator cuff tendonitis, bicipital tendonitis, subdeltoid bursitis, calcific tendonitis, rotator cuff arthropathy, rheumatoid arthritis, undiagnosed shoulder pain
  • Olecranon bursa – diagnosis of septic, traumatic, or gouty bursitis and treatment of bursitis
  • Elbow – medial or lateral epicondylitis
  • Wrist – carpal tunnel syndrome, tendonitis, ganglion cysts, rheumatoid arthritis
  • Fingers and thumbs – osteoarthritis, ganglion cysts, trigger fingers, Dequervain’s tenosynovitis
  • Tendon and trigger points injections – neck, scapular/mid back, and low back injections for acute or chronic pain, muscle spasm or radiculopathy, and sacroiliac joint injections
  • Depomedrol/toradol injections – for treatment of widespread pain including but not limited to myofascial pain, polyarthritis, osteoarthritis, fibromyalgia, gout, rheumatoid arthritis, and connective tissue disease flares
  • Rheumatoid arthritis  – An inflammatory arthritis that can affect any age and involving the hands, wrists, elbows, shoulders and knees with pain, inflammation, and morning stiffness lasting greater than 30 minutes.  It frequently responds to steroids (prednisone or Medrol) but ultimately requires treatment with DMARDs such as Plaquenil, sulfasalazine, methotrexate, or leflunomide or biologic response modifiers such as etanercept (Enbrel), adalimumab (Humira), Actemra, Orencia, or Xeljanz
  • Osteoarthritis – An arthritis primarily affecting patients over 45 years of age that involves the thumbs, occasionally several fingers, the neck and low back, and the hips and knees.  Also known as degenerative arthritis, it typically has less than 30 minutes of morning stiffness and gets worse as the day progresses.  There are a variety of treatments including, but not limited to, NSAIDs, muscle relaxers, Cymbalta, joint injections, Plaquenil when cases of inflammation are present, and recommendation of surgical intervention when appropriate
  • Osteoporosis – A condition characterized by extreme loss of bone mineral density (thickness) that leads to a markedly increased risk of fracture.  It is primarily diagnosed by a bone mineral density exam/DXA.  It addition to calcium and vitamin D treatment it almost always requires treatment with bisphosphonates (Fosamax/Actonel/Boniva), denosumab (Prolia), or, in the case of recent fracture, Forteo.  Untreated, hip, back and wrist fractures have a high risk of causing loss of independence, disability, or even death.
  • Lupus/SLE – A connective tissue disease primarily affecting women of child bearing age (although it can occur at any age and in older men) that cause skin rashes, arthritis, pleurisy, blood disorders, renal disease, neurological disorders, and characterized by immunological abnormalities.  The screening test for lupus is an antinuclear antibody test (ANA).  Treatment includes, but is not limited to prednisone, Plaquenil, Imuran, Cellcept, Cytoxan, and occasionally Rituxan.  Treatment needs to be individualized to each patient.
  • Sjogren’s syndrome – A connective tissue disease affecting the glands and primarily manifest by severely dry eyes and dry mouth.  Sjogrens or Sicca may be primary or secondary to another connective tissue disease such as RA or SLE.  Treatment is usually symptomatic but frequently includes drugs such as Plaquenil, Salagen, Evoxac and symptomatic treatments with eye drops and Biotene.  Advanced cases may be treated with Imuran, Cytoxan, or Rituxan.  ANA testing is positive and is characterized by positive SSA and SSB subtesting.
  • Polymyositis/dermatomyositis – A connective tissue disease characterized by proximal muscle weakness, elevated muscle enzymes and inflammation on laboratory testing, and abnormal muscle electrical activity or abnormal muscle biopsy.  It is frequently associated with photosensitivity or skin rashes including inflammation of the cuticle.  Unfortunately in older patients these conditions can be associated with cancer.  Treatment usually involves prednisone, methotrexate or Imuran, occasionally Cellcept, Arava, or Cytoxan.  Frequently other causes of muscle disease must be excluded.
  • Scleroderma – A connective tissue disease that involves tightening of the skin, the esophagus, fibrosis of the lungs, and scarring in the kidneys.  A variety of treatments have been tried and must be individualized to the symptoms of the patient but may include Plaquenil, methotrexate, Imuran or D-penicillamine while directing some treatment at complications such as renal hypertension with ACE inhibitors or pulmonary hypertension secondary to interstitial lung disease, which, with renal induced hypertension, are the most serious complications.
  • CREST/Limited scleroderma – A connective tissue disease which is a variant of scleroderma which is characterized by skin Calcinosis, Raynaud’s phenomena of the hands, Esophageal dysfunction, Sclerodactyly tightening of the skin of the fingers, and an abnormal number of Telangiectasias or hemangiomas of the skin.  The disease course is usually mild but can be associated with arthritis.  Treatment is primarily directed at control of the Raynaud’s color change phenomena of the hands with treatments such as Procardia, Norvasc, or Revatio if severe.  Anti-reflux treatment is important for esophageal symptoms.  Pulmonary hypertension in later life is the most serious complication
  • Mixed connective tissue disease –A common tissue disease with some sysptoms and signs of RA, and SLE, symptoms are usually mild to moderate and associated with an RNP antibody. The prognosis is usually good with a variety of treatments availble,
  • Abnormal ANA – A screening test utilized for the detection of possible autoimmune disease.  If positive, a history, physical and follow-up laboratory testing by an experienced rheumatologist is required to determine if connective tissue disease is present or not, as patients may have a “false positive” or connective tissue disease in evolution.  Conversely, a negative ANA result in the majority of cases excludes or rules out active connective tissue disease.
  • Psoriatic arthritis – A difficult to diagnose arthritis unless the skin rash – psoriasis – is already present.  Psoriatic arthritis is an inflammatory arthritis associated with pain, swelling, and morning stiffness that presents as arthritis in a single joint, arthritis in the low back/sacroiliac joints, as a rheumatoid pattern of arthritis frequently associated with nail pitting.  Psoriatic arthritis is classified as a “seronegative” arthritis in that serum (blood) testing for rheumatoid arthritis and connective tissue diseases is negative.  In some cases, the arthritis appears before the psoriasis does.   Recently several breakthroughs has identified psoriasis and psoriatic arthritis as an immunologically controlled disease which is why treatment with drugs such as sulfasalazine, methotrexate, Humira, Enbrel, Otezla, Stelara, and Cosentyx have been advanced to treat not only extensive skin disease but also the arthritis associated with Psoriasis.
  • Carpal tunnel syndrome – A relatively common condition caused by compression of the median nerve at the wrist that causes pain and numbness in the first three fingers of the hand with occasional pain radiation into the forearm.  Common causes are repetitive motion and stress of the hand and wrist, rheumatoid arthritis, pregnancy, thyroid disease, connective tissue diseases, and occasionally even gout.  While conservative treatment with splinting may help, most patients required treatment with injection of steroids into the wrist.  Surgery may be indicated in severe cases, but carpal tunnel syndrome may recur in as many as 20%.
  • Fibromyalgia – A myofascial pain condition usually affecting young to middle age women but occurring at any age is characterized by diffuse pain of greater than 3 months duration, multiple tender points, poor sleep, lack of exercise and, in 50% of cases, precipitated by an emotional, mental, or physical stressor.  Other diagnoses must be considered such as connective tissue disease in evolution, sleep or exercise disorder, vitamin disorder (vitamin D or B12), metabolic disorder (estrogen, thyroid, testosterone, or glucose abnormalities), or depression (occurring in 20% of patients). Treatment must be individualized and includes, but is not limited to: cardiovascular exercise, correction of sleep disorder, Desyrel, Cymbalta, Savella, muscle relaxers, Neurontin, or Lyrica, dependent upon the patients.
  • Gout – An arthritis caused by deposition of uric acid crystals primarily in the big toe, midfoot, ankle, knee, or wrist is extremely painful, associated with redness, swelling, and pain in the joint to the point that a “bed sheet can’t touch it”.  Commonly erupting in the middle of the night, it is associated with hypertension, diabetes, abnormal cholesterol, and metabolic syndrome. Alcohol intake and diuretics (fluid pills) typically make it worse, and it usually cannot be controlled by diet. Treatment includes lifestyle modifications, changes in blood pressure medications, and use of Colcrys, Allopurinol, or Uloric to lower acid levels in the blood.  Occasionally more aggressive therapy is required.
  • Ankylosing spondylitis – An HLAB27 gene disorder that is common in families and typically affects the spine –cervical, thoracic, lumbar regions – and sacroiliac joints in young to middle age men and women causing early am stiffness and pain which improves as the day progresses (as opposed to osteoarthritis or mechanical back pain which worsens as the day progresses).  Diagnosis can be delayed and difficult unless there is high suspicion as this arthritis is a seronegative arthritis, meaning that tests for rheumatoid arthritis and connective tissue diseases are negative.  Even inflammatory markers may be normal, so a good history and physical exam are paramount.
  • Sarcoid
  • Inflammatory bowel disease arthritis
  • Raynaud’s phenomena – A connective tissue disease that may be either primary or secondary to another condition.  It is characterized by finger or toe color changes upon exposure to cold (directly or indirectly) in which the digits turn white (and occasionally painful), then turn red, followed by blue.  A blue coloration change of the digits alone is termed acrocyanosis and is not Raynaud’s phenomena.  If nail fold capillary changes are present with Raynaud’s phenomena, there is concern for the development of an associated connective tissue disease.
  • Bursitis, tendonitis, and myofascial pain – Movement of joints requires orchestration of muscles, tendons, ligaments, and bursa (fluid filled sacs easing the movement of muscles and tendons over bone).  Unfortunately, multiple conditions can lead to inflammation, pain, swelling, and dysfunction of individual joints or muscle groups. Common sites of bursitis include the shoulder (sub-deltoid bursitis) or hip (trochanteric bursitis) and knee (pre-patellar or suprapatellar bursitis).  Common sites of tendonitis are the shoulder (rotator cuff tendonitis), biceps (bicipital tendonitis), elbows (medial and lateral epicondylitis where tendons originate), knee (patellar tendonitis), and ankle (Achilles tendonitis).  Myofascial pain occurs when large muscle groups in the neck, low back, or hip area are painful and spasm usually due to overuse, sprain/strain, or nerve pinch.  Treatments consist of exercise or physical therapy, injection, and medications such as NSAIDs, short courses of steroids, muscle relaxers, and Neurontin or Lyrica.  Injection followed by guided exercise is usually the best for rapid relief of pain and dysfunction in this group of disorders.
  • Polymyalgia rheumatic (PMR) – Usually occurring in patients over 50 years of age and associated with an abnormal erythrocyte sedimentation rate >50, it is characterized by proximal muscle pain, stiffness, and weakness of the shoulders and hips and has a dramatic response to low dose prednisone (<15mg/day).  It can be associated with a recent infection.  Prednisone is the best treatment but if prolonged has side effects and may require treatment with methorexate or Imuran to spare steroid side effects. Frequently other disease, including polymyositis, fibromyalgia, infections, and cancer must be excluded as causes of similar symptoms.
  • Acupuncture – for treatment of painful neuromuscular or arthritic conditions that are unresponsive to or have contraindications to traditional Western medical therapy
  • Obagi medical skin care products – utilized to restore healthy younger looking skin, blotchy pigmentation and melasma
  • Microdermabrasion – to improve tone and texture of skin – Belle Meade only
  • Rejuvapen (microneedling) – improves the overall appearance of fine lines and blotchy pigmentation, acne scarring, and stretch marks – Belle Meade only
  • Botox, Dysport, Xeomin – utilized to relax frown lines and wrinkles
  • Fillers – Juvederm products, Radiesse, Restylane are utilized to smooth away deep lines around the mouth, plump the lips, and lift the cheeks
  • Candela V-beam pulsed dye laser and GentleMax Pro Laser – utilized to treat “age” spots, facial and leg spider veins, cherry/spider hemangiomas, port wine stains, rosacea, warts, scars, hair removal, psoriasis, and nail fungus – Belle Meade only