I received a call from a nursing home staff nurse who stated that this patient "suddenly had blisters appear on the right forearm, wrist to elbow."
For those who have been in practice for a number of years, every now and then you get a patient who is a poor historian and getting a past history is impossible. After three years practicing in the nursing home and assisted living facilities, I have become accustomed to barriers to diagnosing or what I call "practicing dermatology with one hand tied behind your back." So what do you do if you have a patient with little or no past or presenting medical history, the patient cannot speak for themselves, or you have a dementia patient with no family? Well, you need to become an even better detective and make sure you do a thorough workup. Don't trust 100% what is being told to you second hand. Make your assessment and gather your data.
The photo to the right is what was sent to me via text by a facility. What we know is that the patient is male and 86 years old. The facility denies any changes in medications or environment. The patient has a history of dementia and no past history of blisters. At this time, a biopsy cannot be performed. The bullae are rupturing spontaneously. Nursing staff denies that the patient is in pain or noting paresthesia in that arm. No history of liver disease and patient is wheelchair bound and has not been outside (as far as they know). No known history of sensitivity to sun exposure or erythema/edema commonly seen with cutaneous porphyria.
Assessment: Multiple bullae right forearm with no erythema or edema noted. No other vesicles or bullae noted on head, trunk or lower extremities. No other dermatoses noted.
Differentials (In order of suspicion): Bullous pemphigoid, herpes zoster, contact derm, bullous impetigo, drug eruption, and porphyria.
Labs: CBC with diff, complete metabolic panel with LFT, ANA, U/A, Immunoglobulin panel, porphorin level, sed rate, and pemphigoid panel.
Cultures: C/S bacterial and viral
Treatment: Valtrex 1,000 mg TID, Prednisone 40 mg PO x 3 days, 30mg PO x3 days, 20mg PO x 3 days, 10 mg POx 3 days. Doxycycline 100 mg BID x 10 days, Gentamicin ointment to open bullae QD and cover with non-stick dressing.
Discussion: Keep in mind, treating a nursing home patient or ALF is different than a patient in private practice. While everyone may be trained differently and approaches may vary, this is general overview of my general workup of a blistering disease based on education, training and over 15 years of dermatology experience. Further workup and treatments will depend on the test results.
I always wait to start prednisone after at least two doses of Valtrex are given. Delivery of medications are often unreliable and you should not give prednisone unless the patient has started the antivirals. If there is a chance of herpes zoster, giving prednisone without antivirals can cause immunosuppression and the patient can end up in the hospital with a severe case of shingles or herpes meningitis. Even though the hallmark sign of vesicles on an erythematous base is not noted, this is a new rash and missing the early stages of zoster can be disastrous for the geriatric patient. Regardless, if it is bullous pemphigoid, the prednisone will help reduce further blistering. Always check for allergies, all antibiotics given within 90 days, and what medications the patient is on. Call the PCP if the patient is on Coumadin so they can repeat the INR early. Diabetics need to be watched for elevations in glucose.
Unfortunately, these patient care settings have higher rates of MRSA infections. The geriatric patient with open wounds and immunosuppression is susceptible. Doxycycline will treat the differential of bullous impetigo and/or prevent a secondary infection of MRSA. The same applies for the Gentamicin ointment which will help with wound healing.
No biopsy could be performed until power of attorney gives permission. In this case, if permission was granted, two 4 mm punch biopsies would be performed. Make sure the edge of the bulla and 2cm from the most current bulla is selected (yes, in an area where no bulla is present!). Make sure the specimen is placed in Michels solution and sent for direct immunofluorescence. You can take another biopsy from another area and send for H&E in a formalin container. Don't forget to give the pathologist a description and history to help with the diagnosis.
Stayed tuned for Part II where workup results are discussed.
Debra Shelby, PhD, DNP, FNP-BC
President and Founder NADNP
82 year old Female presented for her total body skin screening and this 0.7cm irregular shaped hyperpigemented macule with variegating colors of pink and brown. The patient could not recall how long she had lesion. The forearm was confirmed a Melanoma.
Her pathology report was the following: Malignant Melanoma
- Lentigo maligna melanoma
- Breslow Thickness 0.62mm
- Clark's level III
- Mitotic index: 2 mitoses/mm2
- No ulceration
- No regression
- Tumor infiltrating lymphocytes: non-brisk
- Dermal satellites: Not identified
- Vascular/lymphatic invasion: Not identified
- Perineural invasion: Not identified
- Pre-existing nevus: Equivocal
- Surgical margins: Peripheral tissue edges involved
- TMN classification (AJCC 7th edition) pT1b
Diagnosis: Erythema Multiforme
When starting in dermatology, most people look for the dermatology books with pictures and treatment. However, some skip the step of understanding what is happening in the skin and the reason for the morphology seen. Once again, I will recommend the Principles of Dermatology by Lookingbill and Marks. It is helpful to get the principles of diagnosis and understand the differences in presentation that will help you with your differentials.
I would like to give a brief outline of their discussion on rashes from the Chapter 4: Principles of Diagnosis pages 40-43.
- When looking at a rash, determine whether the epidermis is involved. There may be several changes in the epidermis, but usually one change is distinctive or predominant.
- Inflammation in the dermis causes pruritic papules where pustules are seen with inflammation within the epidermis. Dermal rashes without epidermal involvement are either inflammatory or infiltrative. Most are inflammatory.
- Redness in skin is either caused by erythema (increased blood contained within the vessel) or purpura (blood extravasated from disrupted blood vessels). Erythema is blanchable and purpura is not.
- Scale versus crust: Scale result from thickened stratum corneum and is seen more with papulosquamous disease. Crust is dried serum and debris. Crusts are associated with vesicles, bullae, or pustules.
- Vesicles and bullae occur when fluid accumulates within or beneath the epidermis. Differential diagnoses are based on whether a blister is intraepidermal or subepidermal. Check the fragility of the blister. Subepidermal blisters are tense where intraepidermal blisters are flaccid and easily ruptured. Take a biopsy on the edge of the blister and 2cm from the edge in unaffected area of the skin. Make sure you use at least a 4mm punch.
- Erythematous rashes can be generalized, localized, or specialized. A wheal or hive is a blanchable, transient, erythematous lesion. Fluid is not compartmentalized as in a vesicle so you will see edema in the surrounding tissue.
- Purpuric rashes can be either divided into macular or papular categories. As discussed in the previous blog, macular is flat and nonpalpable. Papular purpura is elevated and palpable. Sometimes it may be difficult to feel the elevation.
Macular purpura: Conditions associated with increased capillary fragility or bleeding disorders. There is no inflammation.
Papular or palpable purpura has inflammation in the vessel walls which is responsible for the elevation. This condition is usually immunologically mediated and is seen in sepsis, collagen vascular disorder, and drug reactions.
Lookingbill, D. & Marks, J. (2000) Principles of Dermatology, 3rd ed. W. B. Saunders Company: Philadelphia.
This 64 year old female patient with hx of Melanoma in 2008 on mid chest presented for a total body skin screening. Upon examining the melanoma scar on the mid chest, were two 3mm irregularly shaped pigmented macules delicately located on top of the scar.
A 4mm punch bx was performed on each side of the melanoma scar as seen in this figure.
The right chest punch biopsy found atypical lentiginous melanocytic proliferation.
The left chest punch biopsy proved to be a recurrent melanoma in situ, involving the peripheral tissue edges.
Treatment will be a 5mm excision of the entire scar.
I always compare the "language" of dermatology to visiting a foreign country: if you don't speak the same language, you stand out to people as an outsider. It's the same with using the correct terms when practicing dermatology. Describing lesions and rashes has its own terminology. It is imperative to learn the language of dermatology if you want to practice the specialty, but it also important even if you are in a primary care setting. When you refer a patient to the dermatology specialist, it gives a picture of what was seen in your examination. Using the correct terms when describing a lesion or rash is so important for assessing changes in a lesion or progression of rash. It also tells us what the morphology was prior to your treatment which can alter the appearance of a rash. For example: Tinea incognito after the use of topical corticosteroids on a dermatophyte infection.
I meet so many students and even experienced providers want to jump ahead without learning the basics. Terminology is the first thing a provider should master before moving towards diagnosing and performing procedures. Learning and understanding primary and secondary morphology will help assist you in deciding your differentials. Practice using these terms every time you describe a lesion or dermatoses.
- Macule: Small spot (<1cm), different in color from surrounding skin, that is neither elevated nor depressed below the skin surface
- Patch: A macule > 1cm and may have surface change, either scale or wrinkling
- Papule: Small (<5mm-1cm*) circumscribed solid elevation of the skin
- Plaque: Large (>5mm-1cm*) superficial flat lesion, often formed by a confluence of papules
- Nodule: Large (5-20 mm) circumscribed solid skin elevation
- Pustule: Small circumscribed skin elevation containing purulent material
- Vesicle: Small (<5mm ) circumscribed skin blister containing serum.
- Wheal: Irregular elevated edematous skin area which often changes in size and shape
- Bulla: Large (>5mm) vesicle containing free fluid.
- Cyst: Enclosed cavity with a membraneous lining which contains liquid or semisolid matter.
- Tumor: Large nodule, which may be neoplastic
- Telangiectasia: Dilated superficial blood vessels
- *Some text books vary is defining morphology based on size. Some use 5mm and some use 1cm for their guidelines. As a provider, choose what size you will use to determine which morphology you use to describe a lesion.
- Two books I recommend reading before looking at any other derm books are "Practical Dermatology" by Drs. Beth and Adam Goldstein and "Principles of Dermatology" by Drs. Lookingbill and James Marks. They give you the basics you need to know!
- Scale: Superficial epidermal cells that are dead and cast off from the skin.
- Erosion: Superficial loss of part of the epidermis, lesions usually heal without scarring.
- Ulcer: Focal loss of the epidermis extending into the dermis
- Fissure: Deep split extending into the dermis.
- Crust: Dried exudate, a scab
- Erythema: Skin redness
- Excoriation: Superficial, often linear, skin erosion caused by scratching
- Atrophy: Decreased skin thickness due to skin thinning
- Scar: Abnormal fibrous tissue that replaces normal tissue after a skin injury
- Edema: Swelling due to accumulation of water in tissue
- Hyperpigmentation: Increased skin pigment
- Hypopigmentation: Decreased skin pigment
- Depigmentation: Total loss of skin pigment
- Lichenification: Increased skin markings and thickening with induration secondary to chronic inflammation caused by scratching or other irritation.
- Hyperkeratosis: Abnormal skin thickening of the superficial layer of the epidermis.
Constructing your descriptions
- Lesions: When describing a lesion start with the size, color, primary morphology , secondary morphology and location. Be precise when noting location, do not use general location sites. For example: Instead of using left ear, you say left helix. Other examples include: Dorsal hand, left lateral upper thigh, nasal tip, malar cheek, nasal sidewall, nasal labial fold, outer canthus (corner of eye where upper and lower lid meets).
- 6 mm erythematous papule on the nasal dorsum
- 3 cm erythematous patch with scale right groin
- 2 cm erythematous plaque with lichenification on the right lower anterior leg
- 2.2 cm violaceous (violet or purplish hue) nodule on the left dorsal hand
- 1.1 cm erythematous nodule on the right helix
- Multiple erythematous brown and flesh colored papules and plaques located on the upper and lower back
- Dermatoses: Always document mild, moderate or severe erythema when describing a rash so you can monitor progression and effectiveness of treatment. Make sure you are specific on documenting location. Describe morphology of the rash and the location(s).
- Mild-moderate erythematous papular rash located on right upper thigh
- Multiple mod-severe erythematous plaques on lower back and buttocks
- Severe erythematous papular rash and lichenification noted on the left lower leg.
- Moderate to severe erythematous morbilliform (maculopapular) dermatosis located on upper and lower extremities, trunk, and face.
- Generalized papular rash with mild erythema
- Localized edema and mild erythema noted on right forehead
Citation: Goldstein, B. & Goldstein, A. (1997).Practical Dermatology Sec. Ed. Mosby: USA. Pgs.3-4.
Debra Shelby, PhD, DNP, FNP-BC
President and Founder NADNP
This 41-year-old navy pilot patient presented to our clinic stating his wife says a mole on his nose is changing. The lesion appeared in the man's mid 20's along with some "uneven skin" on his forehead. The patient denies pain or discharge but does report the nose lesion enlarging when he is in the sun.
A punch biopsy was performed in two locations to confirm a Nevus Sebaceous and rule out a Basal Cell Carcinoma.
The pathology was negative for a malignant neoplasm and confirmed a Nevus Sebaceous.
COMING SOON! MAY 11-16th, 2015. Registration will be open in November 15, 2014!
Course fees: $2,850* includes course texts and materials, membership for 1 year, NADNP annual dermatology conference registration, basic procedures and wound care workshops.
*Does not include: transportation, hotel, flights, or meals.
Location: Sheraton Sand Key Resort in Clearwater Beach, Florida.
- Must be a certified Adult or Family NP with current license and malpractice insurance.
- Didactic: One week of dermatology lectures. This will be available during pre-conference lectures, workshops and main conference.
- Dermatology project: Examples include writing a dermatology article, developing an educational tool, etc. All projects must be approved by course director/faculty.
- Clinical: 500 hours of general dermatology with your own preceptor in your home state or with available preceptors approved by NADNP. Limited availability for these preceptors! Preceptor fees are in addition to the course fees. Clinical Log and completed skills/competencies will be required.
- Optional: Additional hours in wound care available with approved preceptors. Please ask for details.
Upon successful completion of didactic, project and clinical hours, a certificate will be awarded. Conference and Certificate Program are subject to change.
National Academy of Dermatology and American College of Dermatology Nurse Practitioners Fellows Program
NADNP and the American College of Dermatology Nurse Practitioners are proud to announce the development of the first dermatology NP fellows program. We would like to recognize NPs who have contributed to the field of dermatology, impacted practice, research, education, political and advancement of our profession.
- Minimum of 5 years dermatology experience
- Demonstrates extraordinary leadership
- Contributions to the field of dermatology: Practice, education, community service and political agendas.
- Contributions to NADNP: Candidates will be evaluated on contributions to NADNP and will be expected to continue their contributions through Board service, blogs, articles, planning committee etc.
- Must be a NADNP member for 2 or more years.
In recognition for their achievements, the NADNP Fellows will receive:
- Free memberships for life
- Free main conference registrations for life
- The recognition of Fellow of the American College of Dermatology Nurse Practitioners (FACDNP) as part of their credentials
- Standing invite for fellow and guest to the NADNP President's Party each annual conference
Selection Process: All submissions will be reviewed and voted on by the NADNP Board Members. Board members reserve the right to all final decisions. All decisions are final and fellows will be notified on the decision by January 30, 2015.
Debra Shelby, PhD, DNP, FNP-BC
President and Founder NADNP
Two weeks ago, dermatologist and PA Amy Gouley participated in her fourth CareHarborLA event. The CareHarbor free clinic is held annually in the fall at the Los Angeles Sports Arena. This four day event is offered to the uninsured, underinsured and at risk populations in need of medical care. Medical consultations and exams, specialty care, mammograms, hypertension, diabetes and HIV screenings were offered.
Below are photos of various skin ailments found on patients at the event:
1. Vitiligo on a 57 year old woman who reports having condition since she was 14 years old.
2. Tinea Corporis
I&D relieved pain by 75%
Bactrim DS BID x 7 days
4. Allergic Dermatitis
Mechanic reports only wearing latex glove on his right hand. His left hand is totally clear.
Last week I was fortunate enough to participate in my fourth CareHarborLA event. The CareHarbor free clinic is held annually in the fall at the Los Angeles Sports Arena.
This four day event is offered to the uninsured, underinsured and at risk populations in need of medical care. Medical consultations and exams, specialty care, mammograms, hypertension, diabetes and HIV screenings were offered. Dental services included cleanings, fillings and extractions. There was a vision department that offered eye exams, prescriptions and free eyeglasses including bifocals. Self care education and counseling on issues of importance to this at risk population were provided. All patients received a warm lunch and those patients who required follow up were referred to community clinics who had volunteered to help.
"The goal was to provide a medical home for everyone that needs one."
In the four day event 3,096 patients filtered through and 2499 volunteers. 1,987 patients were Hispanic or Latino and of that number, females comprised 1,226.
I was the team leader for the dermatology division and the only dermatology provider until day #4, and the USC residency program participated for a half day. I excised skin cancers and offered all dermatology services to the best of my ability with the resources I had. The hours of operation began at 8am and patients were triaged and sent to sub specialists thereafter.
"Follow-up care and prevention resources that can create lasting change in the lives of the people we serve."
Pictures of various skin ailments seen on patients at the clinic coming soon! CareHarbor is considering an event in Detroit in the spring. You can follow them on Facebook or at http://www.careharbor.org/
Recently, I received an evaluation from one the registrants criticizing the NADNP's President's Party given each year at the annual conference. While I feel that I do not need to defend what we do at the conference, I did want to address what I feel is the bigger issue. Each year, NP education is supported by vendors who make it possible for free student registrations, low registration fees, meals, speaker support, etc. In fact, our annual conference would not be possible without this support. This is true for many, if not all, educational conferences.
While many NPs may be business savvy, there are always some who may not understand what happens "behind the scenes" of these events. Many people do not know what it takes to put on a conference, so it may be understandable why one would question a meeting, gathering, or party for vendors. To make it clear, these events would NEVER be possible based on registration fees! During the conferences the organization's board members are incredibly busy trying to make sure things run smoothly. In my case, this dinner party is the time for vendors to get uninterrupted time with the board. Just like the Exhibit Dinner Party is the registrant's opportunity to spend uninterrupted time with the vendors. However, for the record, thirty registrants were selected from the conference to join us at this party so we could spend some uninterrupted time with some of the members as well.
Another comment we received was about the necessity of symposiums. We seek out symposiums that offer the most current treatments in dermatology. For primary care NPs, these symposiums offer an opportunity to hear information you would not get in your practice setting. While these programs are optional and do not offer contact hours, it is the time to allow vendors unopposed time with the registrants. Again, this is common for most conferences and is crucial to the conference budget. Attending them and giving the vendors your time is a great way to say "thank you" to them.
So what does it take to make a conference like this happen? For the first conference NADNP planned, I was in shock of the cost to produce a conference. While I don't believe any other organization has discussed their budget before publically, I am happy to give some disclosure in order to help others understand what organizations may do for their members and conference registrants. Here's a small sample of items for the NADNP conference budget. It is not all inclusive, but it gives you an idea on the high end expenses.
- Marketing $30,000+ and this is a conservative cost because we keep it low.
- Hotel (Food , Beverage, service fees, etc.): $90,000+. BTW, for those who want coffee all day, that can cost $6,000 per day!
- Exhibit contractor: $2,000
- Speakers: $30,000+
- AV: $9,000+
- IT support: $6,700
- Photography: $2,000+
- CEU Application/Educational Specialist: $5,000+
- Eval Service: $1,500+
- Programs/bags/lanyards: $5,000+
For NADNP, we do not use a management company which can cost $20,000+ and volunteer students help keep costs down so registration fees have stayed the same. For example, the registration fee of $450 for 150 registrants brings in $67,500. This does not include the free registrations we give to support student education. The rest in brought in by vendor support. The budget for the President's Party is less than $4,000, yet it priceless to them and us to be able to spend time getting to know the needs of our profession and improving opportunities for practice and education. It is also a way to learn what is important to them so they keep supporting us. For me, the exchange is invaluable and ultimately benefits the conference participants. How do you think we get all of those great "give away" gifts at the exhibit booths and raffle items? So rest assured, no participant's registration goes for any support of this vendor event.
So as we move forward to the end of the year, please remember to thank those who have sponsored NP education. This includes all of the nursing organization's board members, volunteers, etc. who spend COUNTLESS of uncompensated time making this happen for YOU! I personally stopped counting after putting in over 1,500 hours of my time uncompensated doing this each year. At $75 per hour, that is at least $112,500. So I would say we are all cheap laborers with one dinner out each year!
I have tried to give you a brief overview, even though somewhat simplified, on what it takes to make this all happen. For the larger organizations, I am sure their budget far exceeds our costs. This is why at every the conference we always recognize and give thanks to these vendors. It is so important to us that we have their continued support and that we do everything we can to support them.
If you come across a company you support as an NP that is not supporting your organization (regardless of which organization), ask why. As I discuss each year, the relationship with providers and industry is a two way street. NADNP's mission is to bring you companies that support our mission and offer quality medications and products that the board members and colleagues use in our everyday practice. In the end, the provider will decide what is best for their patient based on empirical data, research and education given to them during these educational programs, not for the free pen, sample, or other "give aways" we get at these events.
NADNP would like to give thanks to the following 2014 conference supporters
President's Tea Party: Dermpath Diagnostics
Symposiums: DUSA, Genentech, Abbvie, and Leo
Educational Grant: Actelion
Exhibitors: Dermpath Diagnositics, Hill Dermaceuticals Inc., Calmoseptine Inc., Bio-Oil, Celgene Corporation, Trinity Medical Pharmacy, Allergan, Leo-Pharma, Dusa Pharmaceuticals Inc., Genentech, Zanfel Laboratories Inc., Hawaiian Moon, Galderma Laboratories, Bayer HealthCare, Abbvie, Syneron-Candela Inc., INNOVO Specialty Compounding Solutions, Smith&Nephew, LaRoche-Posay, Stiefel a GSK company, Merz Dermatology , a division of Merz North America, Inc., Derma Sciences, Pharmaceutical Specialties Inc., Actelion Pharmaceuticals, Prestium Pharma Inc., and Florida Nurse Practitioner Network.
Debra Shelby, PhD, DNP, FNP-BC
President and Founder NADNP
Dear Dr. Shelby,
My name is Ligita Centorino. I am a family nurse practitioner student in Phoenix, Arizona. I was researching NP national organizations and I was impressed to learn about your developed organization. I have chosen to promote your organization in my school, however, I have some additional questions I was not able to find answers on the website. Would you mind help me by answering those questions below please?
1. Could you please tell me more about residency program? Who is qualified? How long is the residency program? Is residency program available only in Florida?
Family and Adult NPs with at least one year of experience are qualified to apply. The residency includes 1,000 dermatology hours. Please read the article I wrote "The development of a standardized dermatology residency program for the clinical doctorate in advanced nursing" that was published by the Dermatology Nursing Journal. This program is only available at the University of South Florida. Please see the USF DNP website for other information relating to the program.
Shelby D. (2008).The development of a standardized dermatology residency program for the clinical doctorate in advanced nursing. Dermatology Nursing. Dec;20(6):437-47: quiz 438.
2. What are main dermatology-related issues?
In my opinion, the main dermatology issue we have is developing a cohesive dermatology team. There still seems to be some dermatologists that continue to write articles that are detrimental to relationships between dermatologists and dermatology PAs and NPs. There are many good dermatologists that support NPs and PAs, but there are some who criticize our practice without actual facts that support their views. Here is the link sent to me from one of my board members:
For instance, some dermatologists are critical about NP and PA dermatology education. Ironically, when I developed the first DNP dermatology residency program in 2006, I was attacked by the dermatology community. Not only did the physicians personally attack me and the program, but I also had dermatology nurses spread false information about the program and inaccuracies on the purpose of this program.
What many people may not know is that I support the AAD and the dermatologist led team. I also believe that NPs should have formal training prior to practicing ANY specialty. This was the inspiration for me to develop the concept of the dermatology residency program for NPs. Not only was it the first dermatology residency program, but to my knowledge, it was also the first specialty residency program in the country. This spawned many controversies over nurses using the term "residency" in our education. This program was not developed to replace dermatologists. The intention was to give NPs a foundation in dermatology so they could team up with a dermatologist and continue their training. In addition, the primary care NP may complete this residency to gain dermatology knowledge they can use in their practice. For those NPs who practice in states independently, this is a great opportunity to get the formal education you need to help support your practice.
The second dermatology issue is the HB699 Bill that was passed in Florida. To summarize, this limits the use of PAs and NPs in satellite offices. This bill was passed without any facts to support that NPs and PAs practicing in satellite offices pose a patient safety issue based on practice location and practice without direct supervision. Patient access is limited because a group of Florida dermatologists "felt" that the public safety was in jeopardy. No evidence to support this "feeling", but the bill still passed. Perhaps the real issue may be that dermatologists need to make sure that the PAs and NPs they employ are safe to practice wherever they are located. On the flip side, I also feel that PAs and NPs have a responsibility not to practice in any situation without proper education. Regardless what the dermatologist says, the NP/PA is a professional responsible for their own standards of practice. I have met NPs who have allowed themselves to practice dermatology under general supervision after only 1 week of training.
The third dermatology issue that is important to me involves the dermatologists who allow their MAs to perform biopsies and suture on patients. I cannot speak for all states, but I know it is illegal in Florida. I hope that the AAD with focus their attention on this patient safety issue.
I realize some of these issues are controversial, but they are real and valid. Standardization in education and practice is the key to safe practice. Core competencies should be met prior to any provider seeing patients on their own. I believe a plan for direct dermatologist support is important for the first two years of specialty practice. After that, the "team" can determine the strengths and weaknesses of each provider and develop their own plan for patient care, not by those with political agendas and turf wars.
3. How has the Affordable Care Act affected nurse practitioners practicing in dermatology?
I think it is too early to tell the affects of the Affordable Care Act on the profession as a whole. We have not gathered any data regarding this topic. As far as my practice, people may have insurance, but the deductibles are so high. Some patients are not seeking dermatology services because they are unable to meet these deductibles, some as high as $10,000. The geriatric population, especially those in extended living facilities, seems to have fewer benefits. This is especially true with medications. I am still waiting for the "affordable" part of this act.
4. What core competencies in advance practice nursing and how the organization support those competencies?
NADNPs mission is to support NPs education, research, leadership, practice and political issues. We have reached out to all NPs throughout the country and internationally. The NADNP conference, Advance for NPs and PAs blogs, webinars, and articles, USF DNP dermatology residency program, and forming the dermatology planning committee with the National Nurse Practitioner Symposium to develop a dermatology track for their annual conference. All support the core competencies for advanced practice. Not to mention, the two new announcements just made by NADNP regarding the NADNP/American College of Dermatology NPs Fellows Program (FACDNP) and the post-masters certificate program being developed for 2015.
While we are a fairly new organization, we have made connections with our South East Asia and European dermatology nursing communities. NADNP is excited to work with our international colleagues and help unite the dermatology nursing community worldwide.
5. How many NPs belong to the organization?
We fluctuate with membership and have 1,500-2,000 members from all of the country. We also have affiliations with international nursing communities.
Debra Shelby, PhD, DNP, FNP-BC
President and Founder NADNP
This 57 year old patient presented for a total body skin examine. She was wearing a hat and when asked to remove it the photos below show my findings of Trichotillomania.
The patient reports having the condition since she was 14 years old and has tried every medication possible, including several antidepressant drugs.
At this stage we will monitor for pruritus and infection secondary to vigorous plucking.
This is a female patient who had been treated for months with antifungals and nystatin powder Q.D. by her primary care provider. The morphology of this rash is moderate erythematous patches/plaques with desquamation located under her breasts.
What is your diagnosis?
- A. Tinea corporis
- B. Intertrigo
- C. Inverse psoriasis
- D. Erythrasma
If you guessed inverse psoriasis, you were right! If a rash is unresponsive to antifungals after 2-4 weeks, then the provider needs to think about inverse psoriasis. Confirm your suspicions with a biopsy.
Treatment includes a low- to mid-potency topical corticosteroids mixed with an antifungal for preventive measures. Be cautious with the use of topical steroids because of atrophy and striae. The facility was instructed to keep the patient clean, dry, and discontinue all other previous medications.
This rash is difficult to treat in the geriatric population because of obesity, poor hygiene and incontinence. The plastic adult underpants make this worse so change to Poise pads if possible. Remember, you will not see the scale typically seen with plaque psoriasis. This is one of the reasons why it is difficult to differentiate from tinea cruris.
Debra Shelby, PhD, DNP, FNP-BC
President and Founder NADNP
88 year-old male presented with a poor healing wound on his right anterior lower leg which had been ongoing for four months.
The lesion presented as a group of pustules that were well circumscribed, annular, and boggy, resembling a small carbuncle.
The lesion was biopsied and determined to be Majocchis Granuloma, a perifollicular granulomatous disease caused by T. rubrum or T. mentagrophytes.
The patient was prescribed Lamisil 250mg PO bid and two weeks later the lesions showed great improvement.
The image to the left shows the woundbefore treatment and below is the leg 10 days after oral Lamisil.
In dermatology, we discuss the importance of identifying and understanding morphology and changes in a rash. Here is a case of a rash with a sudden change in morphology after prescribing medication for her dermatosis.
This geriatric patient was being treated with clobetasol cream B.I.D. for Grover disease. You see pruritic erythematous papules noted on the lower back. The rash was biopsied and confirmed for acantholytic dyskeratosis (Grover disease). The patient came back two weeks after being treated with the topical steroid cream and complained of increased pruritus on the left upper back. What was observed was new morphology consisting of erythematous plaques with scale and a raised border. Noting the morphology had changed, I was suspicious for a dermatophyte infection from the use of the topical steroids. Biopsy confirmed tinea corporis.
When I interviewed the patient, it was revealed that this patient had been confined to her bed during treatment and did not shower. With heat, sweat and poor hygiene, she developed a fungal infection which worsened with the use of the clobetasol cream.
Use caution when prescribing corticosteroid creams and make sure you monitor the patient every 2-4 weeks until the rash resolves. If you see a change or worsening of the rash, you just may have a secondary bacterial, fungal infection or a completely different rash all together. It is appropriate to culture, perform a KOH and re-biopsy as you deem appropriate. A clinical pearl for pathology is to remember to let the dermatopathologist know that the patient has been using topical corticosteroids. This will assist them with the diagnosis because topical medications may alter the histology. Photos also help if you have the means to attach a copy. Remember, tinea incognito after topical corticosteroid use may not look like a fungal infection at all and deceive you.
I now consider using Lotrisone cream with patients who may be excessively sitting or confined to bed. The combination of clotrimazole/betamethasone works well and helps reduce the risk of secondary fungal infections. Use extreme caution or avoid use in the groin and axillary areas due to atrophy and striae.
Debra Shelby, PhD, DNP, FNP-BC
President and Founder NADNP