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Editor's note: This post was written by Lakshi Aldredge, MSN, RN, ANP-BC, an adult nurse practitioner who practices at the Portland VA Medical Center in Portland, Oregon.

The Dermatology Nurses' Association (DNA) has joined First Lady Michelle Obama and Jill Biden in the "Joining Forces" campaign. This campaign gives our service members and their families opportunities and support they have earned through their service to our country. These veterans and their families have selflessly made commitments and sacrifices, in order to protect and serve the citizens of the United States and other countries.

The DNA sees the Joining Forces campaign as a wonderful opportunity for all members to show their appreciation. Each of us has our own way of doing this. In our field of dermatology nursing, we go the extra mile by providing outstanding care to our military patients.

As a nurse practitioner at the Portland VA Medical Center for the past 22 years, I have had the privilege and honor to help our veterans by providing the very best care to my patients, letting them know that their service is much appreciated. A simple "Thank you for your service" tells them that their sacrifice is recognized and appreciated.

Because of our veterans, we enjoy everyday rights and freedoms that many in other countries do not. I challenge you to consider ways that you, too, can be a part of this huge campaign to show appreciation and give thanks. Look for further information about the Joining Forces campaign on the DNA website in the near future!

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Editor's note: This blog post was written by Maggie Macy, NP, who specializes in dermatology and occupational health at Edith Nourse Rogers Memorial VA Hospital in Bedford, Mass.

A session at the recent Dermatology Nurses' Association conference made the case for a more robust method of appraising the knowledge and skills of NPs who specialize in dermatology.

The speaker presented the portfolio model as a more complete method of determining competency than the current process of obtaining dermatology nurse practitioner certification (DNCP).

According to Mary Nolan, ANP-BC, DNCP, the DNCP certification is a static measure, only proving a nurse practitioner's ability to recall information. It is not a broad enough indicator of knowledge and proficiency, she said. She believes we need a model that includes a measurement of clinical skills and decision making abilities.

Nolan pointed out that this challenge is not unique to our dermatology nursing profession. She cited the section of the Institute of Medicine's 2010 report recommending that nursing continuing education use methods that better measure ongoing competencies for nurses.

Use of web-based portfolios that justify and document what we know and do is a proposed method of measurement. Nolan showed the American Dietetic Association web-based portfolio, which organizes and catalogs continuing education, personal goals and peer review activities in one place.  Such a system could provide an immense benefit to the professional development and competency of dermatology nurse practitioners.

A 16-year-old girl with a 2-year history of acne has been complaining about tiny "pimples" around her nose and mouth. She says they "burn" and that they seem to be getting worse.

This patient does have a history of eczema, but her skin is clear today. She also reports a recent increase in stress. She noticed the bumps appeared shortly after the onset of stress. The patient had a prescription for triamcinolone 0.1% ointment for her eczema and she applied some to the troublesome area for a few days, but the condition only got worse.

Currently, she is washing her face with Cetaphil Antibacterial bar soap twice a day and applying a salicylic acid 2% cream twice a day. She also uses a 5% benzoyl peroxide gel to spot treat as needed, but has been reluctant to apply anything to these lesions because they burn.

Upon exam, her forehead was clear of any comedones or pustules. She did have a few small papules on her upper cheeks, but mostly perioral and perinasal discrete 1- to 2-mm papules on an erythematous base. Her lips were spared.

At first glance, one could easily confuse this presentation of perioral dermatitis with papular acne. But it is a classic distribution of perioral dermatitis. I always think these lesions are "cute and confined," whereas acne is much more angry and widespread. When perioral dermatitis is treated as if it were acne, the condition flares and worsens because many acne preparations are very irritating to perioral dermatitis.

This patient also has perinasal dermatitis, as demonstrated in the photo showing lesions surrounding the nasal creases. Her treatment involved a sulfur 10% face wash twice a day, clindamycin 2% topical solution twice a day and polysporin at bedtime. I opted not to have her apply the polysporin in the morning because the greasy appearance of the ointment would attract more attention to the area she was already feeling self-conscious about.

I typically like to prescribe tetracycline 500 mg twice a day for 30 days, but she hasn't tolerated the drug well in the past, so I chose Omnicef 300 mg twice a day for 14 days. I offered her the option to continue with her acne regimen on her forehead only (I don't like teenagers to fall behind on their acne adherence). I also instructed her to never apply the triamcinolone cream to her face, since it's very probable that application of this drug made this condition worse.

A 2-week follow-up visit is crucial for emotional support and reassurance because very commonly, this annoying little rash can last 4 to 6 weeks.

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The Dermatology Nurses' Association recently held its annual conference in Denver. A session I enjoyed attending was "Systemic Therapies in Dermatology," presented by Jarod Conley, MD, at the Nurse Practitioner Forum portion of the meeting.

Conley's talk focused on the uses and important considerations of systemic retinoids, methotrexate, biologics, antimalarials, and unique drugs such as mycophenolate, motefil, azapthiprine, dapsone and cyclosporine. It was a formidable amount of information, but the talk provided many take-home messages. Below are the key points that I took from this session.

For the retinoid class of medications, Conley provided some reassuring data on the decreased likelihood of associated risks of inflammatory bowel disease (IBD). The research cited consisted of retrospective studies that only prove associations and not causes. Additionally, only one of these retrospective studies showed a significant association of oral retinoid use and IBD. This is encouraging information because these medications have substantial impact on reducing the debilitating effects of severe acne.

For all of the drugs presented, there were some helpful details on prescribing and monitoring. For example, with methotrexate, checking albumin is critical because low albumin means more free methotrexate not bound by protein and more likelihood of methotrexate's dangerous side effects.

Conley also reported on the antimalarials. These medications, for reasons not understood, provide immune suppression by decreasing the activity of inflammatory cells. They also have significant ocular side effects, which require specific history taking and monitoring.

For the biologics, some of the mystery was taken out of long cumbersome generic names by the clear explanation of some their origins.

Many other take-home messages were offered, but they are too numerous to mention in this brief post. What an informative session! 

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Editor's Note: This blog post was written by Annette Fonteneau, MSN, RNP, DCNP, who practices at School Street Dermatology in Pawtucket, R.I.

I have been asked by patients more times than I can count if they should use artificial tanning beds to obtain more vitamin D. Many of them believe this is safer than tanning outdoors because it is a "controlled" dose of UV radiation.

The answer to this question is absolutely not! A tanning bed will never provide patients with the vitamin D they need, nor is it safer than tanning outdoors. Both ultraviolet A (UVA) and ultraviolet B (UVB) radiation cause cell damage that can lead to skin cancer. Tanning beds primarily emit UVA, which penetrates deep into the dermis of our skin. It is the UVB rays, not UVA, that help the skin make vitamin D.

Patients who use tanning beds are increasing their risk for developing skin cancer and premature aging without receiving any benefit. Tanning beds deliver a dangerous dose of UV radiation. This may be one reason why indoor tanners are 74% more likely to develop malignant melanoma than people who never tanned indoors.

Artificial tanning bed users are also 2.5 times more likely to develop squamous cell carcinoma and 1.5 times more likely to develop basal cell carcinoma.

Most adults should obtain their recommended daily dose of 600 IU of vitamin D from foods such as fortified dairy products and cereal, oily fish and supplements. There is currently no evidence to support vitamin D's role in the prevention of breast cancer, colorectal cancer, heart disease and stroke.

Three weeks ago I saw a patient with the worst burn I have seen in nine years. My 23-year-old female patient was dressed in yoga attire when she spilled an entire pot of boiling water and pasta down the front of her. The lycra material of her workout clothes forced the hot water against her skin creating a strong suction effect, thus increasing the severity of her burn to second degree.

Of course, all serious derm cases happen after hours and forced her to the ER and she followed up with me a few days later.

The first picture is her burn four days after the incident. At this point, she had been applying Silvadene twice daily and taking Vicodin for pain. Upon examination were large bullous lesions on both areas of water contact surrounding lightly bleeding wide wounds.

 Subsequently, this patient was in the middle of her fourth month of Accutane therapy, taking a dosage of 40mg BID. I informed her to stop her accutane until the wound has completely healed. I prescribed her Omnicef 300mg BID for 7 days and instructed her to continue Silvadene mixed with Triamcinolone 0.025% Ointment TID until the blisters had completely resolved.

I followed up with the patient one week later, which was day eleven post accident. Her leg was healing nicely but her supra pubic area and waistline was healing slower. Biafine was prescribed BID mixed with the Triamcinolone ointment. I love love love Biafine! I use it frequently for quick granulation in numerous cases and each time the results are amazing!

Three weeks later, this patient is still feeling some tenderness but overall much improved. Once the inflammation has resolved we will continue her Accutane therapy. I suspect she will have some post inflammatory hyperpigmentation which I plan on treating with TCA peels and HQ 4% cream.

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Editor's note: This blog post was written by Ellen McCafferty-O'Connell, NP, who practices dermatology at Harvard Vanguard Medical Associates in Boston.

Most office appointments include a thorough review of systems, medications, past medical history, family history, healthcare maintenance and a physical examination. An examination of the skin is a small part of this process. How do you do an effective skin exam and recognize when a mole is atypical? Be systematic looking from head to toe, watching for the "ugly duckling."

Brief review of the ABCDE's of melanoma:

• Asymmetry - in color or shape?
• Borders - irregular edge, consistently irregular or finger-like projections?
• Color - is there erythema, blue/gray or black pigment?
• Diameter - greater than 6 mm or changing in size? A childhood nevus is apt to be larger than 6 mm. This is acceptable since the nevus "grew up" with the person.
• Evolving - is the nevus new, changing or can the patient vouch for its stability?

So now that you have done a general skin exam on your patient, have you been able to detect a pattern in the moles? Patterns are good ... Is there a nevus that doesn't fit the patient's pattern? These are the people who warrant a referral to dermatology.

Trust the patient who states that something has changed, even if it doesn't look worrisome. Most people can wait a month to be seen for a dermatology exam. However, if expediency is warranted and access is limited, consider a referral to a surgeon for biopsy. This does not replace a full skin exam by a dermatology provider, but it will provide definitive pathology of the worrisome lesion.

Moles can appear anywhere on the skin. The average person will develop 40 nevi by the time he or she is 40 years old. It is acceptable to develop a new nevus up until the late 40s, however it should look like the other nevi. Be suspicious of an inflamed lesion with or without pigment, unless the patient can account for its etiology. Routine referrals should be made for a person with more than 50 nevi, family history of atypical nevi or melanoma.

A full body exam means a full body exam. I start on the right side of the body and begin examining the nails, fingers and hand, moving up the arm to the posterior ear. After completing inspection of the back, I move to the left posterior ear and down the left arm, covering anterior and posterior surfaces.

The scalp must be checked, and some time must be dedicated to separating the hair into rows with two cotton tip applicators.

I palpate the lymph nodes of the head and neck for tenderness and swelling. I perform a facial examination, including ocular areas, prior to entering the mouth. A tongue blade is useful for checking under the tongue and buccal mucosa.

The chest, axilla and abdomen are next. A brief lesson about differentiating among hemangiomas, lentigines and keratoses is routine for me.

I love education, and patients enjoy learning to self-identify benign lesions. When patients feel empowered, they are more likely to take responsibility for their general health and happiness.

During the examination of the waist, genitalia, legs and feet, I begin my skin cancer discussion, explaining the two categories: melanoma and nonmelanoma. I show photographs of lesions and we discuss etiologies and contributing factors.

I spend a brief minute on the pathology of dysplastic nevus, which I find reduces questions during a future phone call and visit for re-excision. I provide a few SPF  facts in summation and then, "See you in a year!"

Many providers feel that general skin exams are boring. We must remember that this is an excellent opportunity for patient education and skin cancer prevention. Have fun with these appointments and try to make each exam more thorough. Birthday suit visits are a definite favorite of mine!

Plantar warts can be very stubborn and challenging to treat. Although some warts can be self-limiting, most often, warts are a nuisance for patients.

We share an office with a podiatrist, and over the past few months the podiatrist and I have created a successful combination treatment for our patients that is mutually beneficial.

First, the podiatrist debrides the wart. I follow with a liquid nitrogen treatment. We send the patient home with a prescription for Efudex (topical fluorouracil) and instruct him or her to apply the cream twice daily, followed by application of occlusive tape such as duct tape. The Efudex and duct tape method is applied twice daily for 2 weeks. The duct tape helps to create maceration and ulceration, which destroy the wart faster than new tissue granulation.

The patient returns for a follow-up visit after 2 weeks, for possible repeat treatment of debridement and liquid nitrogen. Very deep plantar warts may require 4 to 6 visits spaced every 2 weeks.

Prior to our combination therapy I was getting decent results with debridement and liquid nitrogen. However, the addition of Efudex and duct tape definitely reduces the amount of return office visits and treatments. I feel that clearance of plantar warts can rapidly increase using this method. Less treatments result in less pain to our patients!

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 Editor's note: This blog post was written by Annette Fonteneau, MSN, RNP, DCNP, who practices at School Street Dermatology in Pawtucket, R.I.

Although winter's end is approaching, patients are no doubt asking for advice about treating their dry, cracked, painful skin. The heat in their cars, homes and workplaces create an environment of low humidity that can be drying to the skin. Working with dry material such as paper or cardboard, and the use of sanitizers, harsh detergents and soaps (combined with hot showers) also contribute to dryness.

Bathing and hand washing with soap-free cleansers such as Cetaphil or CeraVe are helpful. Scratching and rubbing can lead to a worsening of the itch-scratch cycle, which may cause skin to become infected, hyper- or hypopigmented and even scarred.

The treatment of hands and feet can be particularly difficult. Feet are in the warm, moist, occlusive environment of our shoes all day. When footwear is removed, this damp skin rapidly dries out, becoming cracked. Hands that are in and out of water all day are damaged by repeated cycles of overdrying and subsequently develop hangnails and painful fissures.

The basic goal is to rehydrate the skin. I encourage patients to soak in tepid water for 3 to 5 minutes daily, and to then create a barrier to lock in moisture by applying Vaseline, Aquaphor or Bag Balm with socks or gloves before bed. In the morning, I advise them to apply a heavy emollient cream such as Eucerin, Cetaphil or CeraVe Cream after showering and handwashing. Light lotions should be avoided, since these are generally inadequate in harsh winter weather and may actually make dryness worse. Certain skin diseases are more susceptible to drying and irritation, such as rosacea, eczema and psoriasis. Patients with these skin conditions can be difficult to manage and may need to be referred to dermatology for consultation.

Editor's note: This blog post was written by Bonnie Marting, DNP, ARNP, who practices at Anushka Cosmedical Centre in Jupiter, Fla.

With the FDA approval of Restylane for lip enhancement and the anticipated direct-to-consumer marketing from Medicis, those of us in dermatology and aesthetics will undoubtedly receive more inquiries about this procedure and of course the ubiquitous question: "Does it hurt?" Well, it could. But it doesn't have to.

I frequently hear stories about past lip experiences in which "It hurt so much I had to ask them to stop!" Not being a fan of pain myself, I often wonder why a practitioner would not give the patient a choice. In my fairly large practice, I have one patient who doesn't want anything for pain control. Not even ice. I have another who will use the ice but no anesthetic. About 40% will take the topical anesthetic, and the rest are very happy to have a dental block, even if it persists for a while. I have found that more and more patients opt for the topical since the hyaluronic acids now contain lidocaine. But to use nothing? The time saved does not outweigh the critical patient experience, even if they loved the result once the pain dissipated.

One caveat, however, is to remember that some blocks can cause swelling, distorting the target. Moving fairly quickly when using a block facilitates the positive patient perception and results in everyone being happy.

There are several different ways to perform a shave biopsy. One option is a disposable scalpel that costs $1.82 on average. This works just fine for many providers, but it's a wasteful option and I dislike its cumbersome size. A second method is similar to the scalpel, but it only uses a disposable 15 blade. While this is the least expensive route, costing only 11 cents, I feel that it's cosmetically challenging to leave a nice dainty scar. Unfortunately, a scar cannot be prevented, but you can certainly have proper supplies to make a clean biopsy with nice even edges that will result in less of scar.

I was introduced to the Dermablade by a supervising physician 7 years ago and it was love at first "use." The blade was flexible and I was able to grab the lesion without taking much of the surrounding tissue.

My favorite was the Dermablade, costing $1.20 each, and I had convinced myself I could not practice without it (unless of course I was in Haiti).

Miltex also manufactures a similar shave biopsy blade called Miltex BiopBlade. They cost only 76 cents each, but they are very bulky and the plastic coating is super annoying.

Recently, a friend suggested I try Double Edge Prep Blades by Personna. These sell for around $31.85 for a box of 100.* The best part is that these double-edge blades can break in half along the seam, meaning that you actually get 200 to a box! My medical assistant breaks them in half and autoclaves them. This was a great discovery that reduced my cost to 16 cents each, saving me $1.04 per biopsy without compromising the quality of biopsy.

I think it's important to share these wonderful savings to help keep our overhead cost minimal. Please share your secrets to savings that do not compromise quality of care.

*My pricing reflects Henry Schein's American Academy of Dermatology discounted rate.

Hmmmm ... should I buy some bag balm, udder cream, olive oil or Ponds - or should I take cod liver oil for my dry skin?

Go ahead, perform a Google search for "dry skin care" and browse through the 66,900,000 available hits. Or, ask your friends what they do, and each will have their own favorite remedy.

When your patients ask you, their health care provider, what to do about the problem, what do you tell them? It really doesn't need to be complicated. Start off by asking the patient about his or her habits to see what needs to be modified: water temperature, frequency of bathing, type of soap, or body lotions used.

Our recommendations:

• Use comfortably warm water. The hotter the water, the dryer your skin will become.
• For bathing and showering, use moisturizing soaps such as Dove, Camay, Olay or Caress. Gently dissuade patients from using Dial, Zest or Irish Spring.
• After the shower, towel dry and immediately apply a good quality body lotion. Products that contain ceramide, such as Cetaphil Restoraderm, CeraVe and Aveeno Eczema Care, are deeply moisturizing without being greasy. This ingredient helps restore the skin's natural lipids.
• Use these products daily! How many times have our patients told us "nothing helps"? Using a product twice does not count. Be realistic - expect to wait at least 2 weeks to see a difference.

Lately, I have been seeing a few post-biopsy and post-excision site irritations. After every procedure in our office, I give the patient a handout that describes aftercare, along with a small packet of polysporin.

There are always exceptions and modifications to post-procedure wound care, but generally the following instructions result in quick, healthy healing:

1. Leave the Band-Aid in place for 24 hours only.

2. After 24 hours, remove and clean the area with hydrogen peroxide, followed by a tiny amount of polysporin. Do this twice a day.

3. Continue cleaning with hydrogen peroxide for 5 to 7 days.

4. Allow a nice scab to form. Do not pull the scab off.

5. Do allow your skin to air out.

6. Do not continue applying adhesive bandages.

So I believe at this point my patients are well informed by me and my medical assistant. Additionally, they receive a take-home sheet for review. So I was extremely stumped to see a handful of returning patients complaining of an "infection."

Upon examination, each site had tiny 1- to 2-mm papules on a severely inflamed base in the exact shape of a Band-Aid. There was no evidence of infection. Each patient swore that she followed the instructions - except for when the area turned redder. This caused each of them to decide that they would keep it covered with a Band-Aid!

Then one of the patients reported, "I kept putting on that neosporin that you gave me." Ahhhhhh! NEOSPORIN! Neosporin + Band-Aid = Contact Allergy secondary to neomycin! How did neosporin land in my office?

After a little research, I determined that our medical supplier delivered neosporin packets instead of polysporin! This experience was a good reminder that I need to continue to educate patients about the benefits of polysporin versus neosporin. Neosporin is a triple-packed ointment containing neomycin, polymixin B sulfate and bacitracin. Polysporin contains only polymixin B sulfate and bacitracin zinc.

Developing a contact allergy to the neomycin in neosporin is very common, especially during granulation, if the wound is continually trapped by a Band-Aid.

Since this incident, we have contacted each patient seen during those few days of the "neosporin invasion" and educated them about proper usage of the two ointments.

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Editor's note: This blog post was written by Kathleen Meyer, MSN, NP-C, who practices in the Department of Dermatology at Lahey Clinic in in Burlington, Mass.

Even though winter is here, daily use of sunscreen remains necessary. Here is a list of sunscreen use tips:

• A sun protection factor (SPF) of 30 or higher is recommended. About 1 ounce of sunscreen should be applied (a "shot glass" full).
• Physical blockers (zinc oxide and titanium dioxide) may appear more "white" on the skin, but they form a barrier from the sun.
• Chemical blockers are absorbed into the skin. Keep in mind that they need to be applied 30 minutes prior to sun exposure in order to work.
• Reapply sunscreen at least every 2 hours!
• Babies younger than 6 months old should be kept out of the sun. After 6 months, sunscreens can be used. 

In June 2011, the FDA released new sunscreen labeling rules. Here are some points to be aware of:

• Sunscreens can only be "broad-spectrum" if they provide protection against both UVA and UVB rays.
• The terms "sunblock," "sweatproof" and "waterproof" are no longer allowed.
• Use of the term "water resistant" is allowed, but the label must state that it offers 40 to 80 minutes of protection while swimming or sweating.
• Sunscreens can't claim to provide sun protection for more than 2 hours without reapplication.