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Dermatology Practice Today

Now You Are Speaking My Language
October 23, 2014 2:11 PM by Debra Shelby
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.

Primary Morphology:

  • 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!

Secondary Morphology

  • 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).

Examples:

  •  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).

Examples:

  • 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.

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Visual Dermatology Clinic: Nevus Sebaceous
October 16, 2014 10:27 AM by Amy Gouley

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.

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Q & A with Dr. Debra: NADNP Post Masters Certificate Program
October 9, 2014 4:26 PM by Debra Shelby

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.

Requirements:

1. Must be a certified Adult or Family NP with current license and malpractice insurance.

2. Didactic: One week of dermatology lectures. This will be available during pre-conference lectures, workshops and main conference.

3. Dermatology project:  Examples include writing a dermatology article, developing an educational tool, etc. All projects must be approved by course director/faculty.

4. 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.

5. 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.

Requirements:

  • 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.

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Visual Dermatology Clinic: Nation's Largest Free Health Clinic Pt. II
October 3, 2014 1:08 PM by Amy Gouley

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

3. Paronychia
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.

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Visual Dermatology Clinic: Nation's Largest Free Health Clinic
September 19, 2014 3:05 PM by Amy Gouley

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/
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Q&A with Dr. Debra: Education Is Not Cheap
September 10, 2014 11:28 AM by Debra Shelby
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.

Symposiums

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. 

Conference Budget

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. 

NP/Vendor Support     

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

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Q & A with Dr. Debra: NADNP
August 28, 2014 2:06 PM by Debra Shelby

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:

http://dermcast.tv/sdpa-rebuts-inaccurate-jama-article-about-pa-billing-practices-and-education

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

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Visual Dermatology Clinic: Trichotillomania
August 21, 2014 3:13 PM by Amy Gouley
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.

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Q&A with Dr. Debra: Inverse Psoriasis
August 14, 2014 12:53 PM by Debra Shelby

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

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Visual Dermatology Clinic: Majocchis Granuloma
August 7, 2014 10:37 AM by Amy Gouley

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.

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Q&A with Dr. Debra: Tinea Corporis
July 31, 2014 2:26 PM by Debra Shelby
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

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Visual Dermatology Clinic: Squamous Cell Carcinoma
July 24, 2014 9:43 AM by Amy Gouley

These photos belong to an 80-year-old female who presented to our clinic for a total body skin screening. She has a history of Basal Cell Carcinoma on her forehead that was treated with MOHS in 2011.

All of these photos shown are positive for Squamous Cell Carcinoma. Additionally, this patient has two more SCC's not shown. (Hover your mouse over each photo to find out where the carcinoma is located on the body.)

WristAnkleLeft forearmFinger

A patient, who demonstrates numerous pathologies, requires teamwork and communication to construct a plan that is comfortable for the patient in the treatment of her cancers. 

This case was reviewed by my supervising attending and our MOHS surgeon. 

We decided to prioritize according to the pathology report and the size of lesion. 

The first priority was the digit because it was an invasive SCC. 

Next, we scheduled a second MOHS appointment for the forearm, also invasive.  

After two MOHS appointments back to back for this 80-year-old patient, we will attempt to shrink the SCC on her foot and wrist with Efudex and then possibly treat with MOHS. The Efudex is a wonderful adjunct therapy and also allows her to rest without overwhelming her with all these surgeries.

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Q&A with Dr. Debra: Super Bugs, Super Scary
July 16, 2014 10:39 AM by Debra Shelby

In our programs, we learned about antibiotic abuse and "super bugs." Years of prescribing these antibiotics have come to a point where treating skin infections have become very difficult. The incidence with MRSA has increased and years of treating this infection has made it resistant to many antibiotics. These bugs are bionic and we are the ones that help create them.

Through private practice experience, I made it a point to ask the patient what treatments were given prior to coming to me. Unfortunately, the patients may or may not remember. When I started treating patients in nursing homes and ALFs, I saw that providers are forgetting the basics of prescribing antibiotics. One rule that we were taught was not to repeat the same antibiotic within 90 days. Culture before prescribing and wait, if possible, before selecting an antibiotic. Time and time again, I see multiple antibiotics being prescribed without a culture. I even had an experience where I prescribed Doxycycline for MRSA only to have it repeated within two weeks because the primary care provider did not review the chart before prescribing.

I was watching a special on TV last week and an infectious disease specialist from the CDC was speaking about how science has not kept up with the development of new antibiotics to treat these resistant bacteria. The reality is health care providers will be faced with limited to no options for treatment.  One suggestion they made was for providers to use narrow spectrum antibiotics instead of broad spectrum.

So for what it's worth, I have come up with some tips for treatment. I welcome others to share stories or clinical pearls with situations they may have encountered. I think this is a really important topic to share with other providers in order to educate those through constructive communication about changing practice. While this is not all inclusive, it is a good start.

  • 1. When treating a skin infection especially MRSA, always culture and treat the nares with Bactroban ointment. I prescribe it TID x 10 days. This will help reduce recurrence.
  • 2. Stasis dermatitis is NOT cellulitis. I see this basic inflammatory dermatosis being treated with antibiotics. While a secondary bacterial infection may be possible over time, typically this condition improves with support hose, leg elevation, diuretics, and topical corticosteroids. I had a MD provider prescribe Doxycycline two times within a month because her bilateral, fluctuating mild-moderate erythema was not resolving in her lower legs. When I tried to explain that the patient needed leg elevation, topical corticosteroids and an increase in her diuretic for her + 2 edema, he told me I was wrong with my diagnosis. Sigh...... unfortunately the patient suffers.
  • 3. Hibiclens and topical antibiotics should be first choice for colonized skin infections. Use caution with prescribing oral antibiotics, especially with the geriatric patients. So many of them end up with C. Diff because of providers prescribing repeated antibiotics.
  • 4. Make sure that the primary cause of the skin disease is treated. For example, eczema may get a secondary bacterial infection. Some providers make an error thinking the condition is not improving because they fail to treat the primary condition along with the infection. Topical corticosteroids need to be used in addition to the antibiotics.
  • 5. When I prescribe an antibiotic, I look back 90 days to see what was given to the patient. I may try to treat topically if I see that the patient has been exposed to multiple oral antibiotics. Communicate with the primary care provider if you see an overlap of orders for the same condition.
  • 6. Don't forget that there may be a fungal infection involved. Make sure you biopsy or culture to confirm. Treat the fungal infection appropriately. Candida and dermatophyte infections respond to specific medications. For example, Nystatin is not effective on dermatophyte infections. I use econazole for tinea infections. There is a difference between fungicidal versus fungistatic!

One thing for sure, I will focus more on infectious disease at next year's conference. We need to put it on the forefront of everyone's mind. I compare it to global warming. If it's not right in front of us we tend to forget the massive impact our practice can have on future patient outcomes. If we don't change our practice now we will be faced with more people losing the battle of these infections.

Debra Shelby, PhD, DNP, FNP-BC
President and Founder NADNP

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Visual Dermatology Clinic: Sea the Skin
July 10, 2014 12:24 PM by Amy Gouley

This is a photo of a 56 year old male who arrived to our office for a total body skin exam.

Patient was born and raised in Washington with a negative history of skin cancer, both himself and family.
Patient enjoys sailing and boating and has spent numerous years outdoors.
The patient has a Fitzpatrick type 2 and admits to several "blistering burns."
His skin exam was unremarkable, two actinic keratosises were frozen on his face.
Upon examination of his foot was this (see photo right):

As I approached the spot closer with my dermscope and asked, "how long have you had this spot?"
I realized it was a sea shell stuck to his foot!
I have never been so happy and both the patient and I immediately started laughing.
I plucked the shell from his skin, "I went clamming yesterday," reported the patient.
The shell sat on my desk for a week as I shared the case and exchanged smiles with our staff.

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Q&A with Dr. Debra: Breaking into Dermatology
July 3, 2014 10:07 AM by Debra Shelby

I graduate FNP school next year and I am interested in Dermatology.  I do not have any experience in this area.  Who would be a good contact to learn how to get into the field?

I get this question submitted to the NADNP website many times. It is a difficult question because dermatology is so difficult to find an opportunity. The best thing to do while you are in school is to contact dermatology offices and go above and beyond the clinical time required by your college. Take the opportunity as a student, while covered under their malpractice, to learn as much as you can.  Ask permission from your college to do more hours in the "adult" rotation and spend time focusing on dermatology. Most colleges won't allow you to count these ours towards the required clinical rotation time, but who says you can't do more? This will give the dermatologist the opportunity to get familiar with you and your skills.  My biggest advice is go PREPARED! Know terminology, basic skin dermatoses and have a knowledge of the different types of skin cancer. It's your chance to impress! They do not want to spend too much time on the basics.

If you have already graduated, join a dermatology organization and network. Perhaps a colleague will allow you to follow them so you can learn. Show what you can do and what you know. The biggest problem with new NPs is that they are just learning their role and don't always make the best first impression after graduation. Most NPs coming right out of school are trying to gain confidence with working up a patient and presenting their findings and treatment plans. Adding the stress of learning such a difficult specialty sets the new NP up for failure. The best way to get experience is to attend the USF DNP Dermatology Residency Program and use this time to put toward your DNP. Otherwise, attend a fellowship or post masters' program like the one NADNP is getting ready to launch.

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    Occupation: Physician assistant and nurse practitioners
    Setting: Various dermatology settings
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