Smokeless tobacco keratosis is a benign lesion characterized by the formation of white, gray, or pale macules or papules with wrinkling or rugae. It forms in the oral mucosa in response to the use of smokeless tobacco products. We present a 50-year-old man with an extensive history of smokeless tobacco use and development of the characteristic lesion. Shave biopsy showed typical changes of this benign condition and tobacco cessation was recommended.

In the United States access to healthcare continues to be a major issue. Although "top down" public policy approaches hold promise for expanding access, a lack of political consensus has hindered progress. A review of the literature was conducted to investigate the efficacy of clinical interventions aimed at expanding access to care from the "bottom up." The greatest improvements in access to care over the past decade have harnessed teledermatology, shared care, appointment scheduling strategies, and team-based care. Optimization of these approaches will require additional population-based, dermatology-specific research. It is clear that dermatologists, using a "bottom up approach," can significantly expand access to care in their communities in a manner that is economically viable and maintains quality of care and patient satisfaction.