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Dermatology Practice Today

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.


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.

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.

Visual Dermatology Clinic: Deer Tick
June 26, 2014 2:15 PM by Amy Gouley

66 year old Male presented for a "skin tag" on his left posterior leg for 2-3 weeks. Patient denies pain but does report some tenderness when it brushes the sheets of his bed.
Upon examination was these photos:


A 6mm punch bx was performed and the insect was sent for identification.
The lab identified the tick as an Adult female deer tick (Ixodes scapularis). The patient then opted to pay $110 for 3 Pathogen Tick Panel which included:

Negative for Borrelia burgdorferi (the causative agent of Lyme Disease).

Negative for Anaplasma phagcytophilum (the causative agent of Human Granulocytic Anaplasmosis).

Negative for Babesia microti (the causative agent of Babesiosis).

DNA is extracted from the tick and the polymerase chain reaction (PCR) is performed using real time PCR detection time.

Interestingly, we are unsure about the tick's origin. The patient hikes on a daily basis here in Washington State, but reported hiking in upstate New York 3 weeks prior.

A fantastic website for the most current information of Lyme Disease is the International Lyme And Associated Diseases Society: http://www.ilads.org/

Q&A with Dr. Debra #2
June 19, 2014 11:18 AM by Debra Shelby
Here is another question sent to me on the NADNP website @ www.NADNP.net

"I am an ARNP with FNP-C certification and 10 years experience in dermatology. Recently, a new office manager was hired and has changed the billing for midlevel providers to direct billing with insurance carriers. Prior to this we all billed under the supervising MD who was onsite. BCBS of MA is denying some of the procedure codes including excisions with complex repair, ED&C, and others stating that they do not reimburse "this type of provider" for these codes. The solution at the office is for the NPs to not perform these procedures and refer to the MDs in the office.

I am reaching out to your organization, the Mass Board of Nursing, and the Mass Coalition of NPs to inquire as to the legality of this situation. I believe BCBS has no right to limit my scope of practice and am seeking advice as to what my options are and if your organization's scope of practice lists these procedures."

Technically, they are not restricting your scope of practice, but your reimbursement. Insurance companies do not have any authority over practice acts or scope of practice. However, they can financially impact your practice by not reimbursing for the services you provide. That could fall under a "restriction of trade". NPs and PAs had this situation with Medicare years ago, but they changed some of the rules. I would suggest writing to BCBS and show them the Medicare guidelines that support the reimbursement for these procedures. Be prepared to provide data that supports the reduction of wait times and the cost effectiveness of NPs and PAs providing these services. Do research on insurance companies, including BCBS, in other states that reimburse for these procedures. All states differ, even different regions may differ within the state.

With this discussion, I need to bring up an important point. There are many physicians who bill under their Medicare number erroneously thinking because they are on site that it qualifies them to bill "incident to" services (billing under your supervising physician's Medicare number in order to get 100% reimbursement). The physician must see the patient and prepare a care plan. The NP or PA may follow up with that patient for that specific problem and bill "incident to" if the physician is on site. If the patient presents with a different problem, the physician must first see that patient if they want to bill this way.

I recently met a dermatology NP who worked for a physician that had been billing under his or another physician's Medicare number in order to get the 100% reimbursement. This NP never realized that she did not have a Medicare number! She "trusted" them to do the right thing, but her lack of billing knowledge won't save her from a Medicare complaint or audit.

I caution each of you to make sure your billing is done correctly. You are responsible for ALL of your billing. This includes using the correct codes, office level visit and supporting documentation. Make sure they are using your Medicare number, not theirs. Take billing classes or seek professional billing advice. If you don't, you may find yourself in a qui tam suit and possibly have your Medicare number revoked. There are people, even other providers, who are looking to make money off of "whistle blowing". I know of a physician who has turned in multiple colleagues and has made millions. While I don't condone fraud in any form, it would be nice if we would reach out and educate our colleagues prior to filing a fraud complaint. The provider may be innocently unaware of wrong doing and could correct the error. Please see the attached link for further information.



Q&A With Dr. Debra
June 5, 2014 8:26 AM by Debra Shelby
The National Academy of Dermatology Nurse Practitioners recently received the following correspondence on its website. The questions are answered by Debra Shelby, PhD, DNP, FNP-BC, DNC, president and founder of the organization.

"I'm hoping someone can answer a few questions for me, not only for my own knowledge, but I have an assignment for one of my NP classes that requires communication with a NP professional organization."

1. As you've expressed on your website, specialty training in dermatology is not widely available. For NPs who want to specialize and practice in dermatology, what would be your recommendations?

I think the ultimate in dermatology training is the University of South Florida DNP Dermatology Residency Program. The program offers a multidiscipline residency with top dermatologists, dermatology NPs, surgical oncologists, wound care specialists, podiatry and Mohs surgeons. It was the first DNP residency of its kind and the first DNP Dermatology Residency. I developed it in 2006.

Second would be the new post-master's certificate program NADNP will be offering at the end of 2014-beginning of 2015. Stayed tuned for future announcements on the NADNP website. This program will include lectures, papers and a project. In addition, 500 clinical hours will need to be completed either with our faculty or back in your home town before the certificate can be administered. Very convenient!

For those of you who cannot attend a formal program, register for national dermatology  NP conferences like the one offered by the National Academy of Dermatology Nurse Practitioners (NADNP) or the National Nurse Practitioner Symposium, which now includes a dermatology track via their new collaboration with NADNP. Other dermatology conferences exist, just look at the topics and pick what is right for you.

2. Would you recommend any particular websites, texts or programs that would assist continued education?

For the basics, I like Fitzpatrick or Andrews dermatology books.  For the more advanced provider, dermatology texts by Bolognia are excellent and are what we use in the USF Dermatology Residency Program. On the NADNP website, we have a list of resources: http://www.nadnp.net/?page=resources

We talked about programs, but one that was really great for me was Dr. Greenway's Superficial Anatomy and Cutaneous Surgery program in California. If you want to learn surgery techniques, I really enjoyed it.  https://cme.ucsd.edu/superficialanatomy/

3. Dermatology and medical aesthetics are an excellent complement to one another. What would your recommendations be for training in medical aesthetics?

The first place to start is by finding a qualified instructor like the one we have at our conference. Make sure of their credentials are and ask about their training. You can also ask the reps who sell Botox, fillers and peels who they recommend, and they will arrange for you to train on their product.

Having an aesthetician in your practice is wonderful because it frees up the provider who needs to focus more on the general dermatology side and does not have the time to do microdermabrasion, peels, etc.

4. Would you say there is a recommended balance in an NP's practice between clinical dermatology and medical aesthetics?

I am a general dermatology and skin cancer specialist. I recommend that the dermatology nurse practitioner master general dermatology first, before branching out to cosmetics. Dermatology is such a difficult specialty to learn, so I advise my students to focus all of their attention on medical dermatology first, then look into learning cosmetics. In my DNP derm residency, I do not even offer a rotation in cosmetics because of this. It is really an art and not everyone is good at it.  After that, it's up to the provider to practice the way they want and what they prefer.

The Expert Truth on Sun Exposure
May 8, 2014 7:55 AM by Debra Shelby
 A nurse practitioner student recently emailed me on the NADNP website to ask the following:

"I am curious about sun exposure. Some small amount is good for vitamin D3 synthesis. Does your organization have a general rule about how much sun exposure is ok, and what to use for protection? For example, I always encourage folks to use zinc oxide for a broad-spectrum physical block. Are all suntanning beds bad?"

I support patients being outside. It's my personal belief that we have become drastic with our rules about sun exposure and this has led us to deficiencies in vitamin D. Being outside is important to your physical and mental health. Educate patients on sun protection like sunscreen, UV-blocking clothing, and the safest times to be outdoors. Wrist bands that monitor the levels of UV radiation you are being exposed to are now available. Go out during the early morning and early evening when the sun is not as hot. Be cautious during cloudy, overcast weather. People tend to stay out longer when they don't feel direct heat, yet they are still exposed to dangerous UV rays.

When it comes to sunscreens, be particular about which brands you recommend. There has been a debate over the chemical oxybenzone; it has been linked to cancer and hormone effects. Personally, I don't like these chemicals for a number of reasons, including photodermatitis. I recommend sunscreens that contain no oxybenzone, lanolin, parabens or fragrance. My absolute favorite line of skin products are from Pharmaceutical Specialties Inc. Their Vanicream products and sunscreens are great for sensitive skin, and you can get them in a water-resistant formula. These sunscreens have zinc oxide. Please don't forget the lips! Tizo 45 SPF LipTect with zinc oxide and titanium dioxide is great.

As far as my thoughts on tanning beds, I feel that you should be 18 or older no matter what parents say. Some parents are not capable of making the right choices for their children. What is the leading cancer in the age group 15 to 29? Melanoma.........enough said.

Please review the 2014 American Academy of Dermatologists Overview on Skin Cancer

(http://www.aad.org/media-resources/stats-and-facts/conditions/skin-cancer), which states:

"Melanoma is the most common form of cancer for young adults 25-29 years old and the second most common form of cancer for adolescents and young adults 15-29 years old. ... Exposure to tanning beds increases the risk of melanoma, especially in women aged 45 years or younger. In females 15-29 years old, the torso/trunk is the most common location for developing melanoma, which may be due to high-risk tanning behaviors."

A Sample Dermatology Protocol
April 14, 2014 9:44 AM by Debra Shelby

Many nurse practitioners have asked me about dermatology protocols. They are no different from other protocols and should be an outline of your practice agreement with your supervising or collaborating physician.

These protocols should remain broad and general, but list important and specific aspects of your practice like prescribing higher risk medications such as isotretinoin, methotrexate, biologics, etc. or performing basic dermatologic procedures such as excision and closures. Be specific when stating simple, intermediate and complex closures. Protocols should be based on training and proficiency. Also, don't forget to include the statement "The following protocols include, but not limited to ..."

Here is an example of a basic dermatology protocol you can use as a guide. It may be altered based on your experience, training and agreement of practice guidelines set forth by you and your supervising or collaborating physician. Remember, always be prepared to support your specialty practice with formal educational experience and supervised hours. PLEASE READ YOUR STATE NURSE PRACTICE ACT!

ARNP Protocol Agreement Between Collaborating Physician and ARNP

I. Requiring Authority

 a.        Nurse Practice Act, Florida Statutes, Chapter 464

 b.        Florida Administrative Code, Rules Chapter 6469-4 Administrative Policies pertaining to

 Advanced Registered Nurse Practitioners.

II. Parties To Protocol:

  • a. _______________________________________

Name and Address of Collaborating Physician, ME #, DEA #

  • b. __________________________________

Name and Address of ARNP, license # and DEA #(if applicable)

III. Nature of Practice:

This collaborative agreement is to establish and maintain a practice model in which the nurse practitioner will provide health care services under the general supervision of ___________________________________ (supervising physician)

This practice shall encompass dermatology specialty. The focus will be on health screening and supervision, wellness and health education and counseling, and the treatment of common health problems.

Practice Location(s):________________________________________

IV. Descriptions of the duties and management areas for which the ARNP is responsible:

 a.        Duties of the ARNP:

The ARNP may interview clients, obtain and record health histories, perform physical and development assessments, order appropriate diagnostic tests, diagnose health problems, manage the health care of those clients for which he/she has been educated, provide health teaching and counseling, initiate referrals, and maintain health records.

  • b. The conditions for which the ARNP may initiate treatment include, but are not limited to:

Skin Cancer     Psoriasis

Cellulitis Sexually Transmitted Diseases

Acne/Rosacea Verruca Vulgaris

Conjunctivitis  General Skin Infections

Alopecia Viral Infections

Dermatitis       Fungal/Yeast infections

Seborrheic Keratoses  Non-Melanoma Skin Cancers

Actinic Keratoses        Melanoma

  • c. Treatments that may be initiated by the ARNP, depending on the patient condition and judgement of the ARNP, include, but are not limited to the following:


Hyfercation of skin lesions

Laser Therapy

Skin Biopsies-all techniques (shave or punch)

Skin peels

Incision and drainage of abscesses

Collagen injections

Acne surgery

Botox injections

Skin tag removal

Electrodessication and curettage

Excision of melanoma and non-melanoma skin cancers including simple, intermediate, or complex closures.

Drug therapies that the ARNP may prescribe, initiate, monitor, alter, or order: Any prescription medication which is not listed as a controlled substance and which is within the scope of training and knowledge base of the nurse practitioner.

V.        Duties of the Physician:

The physician shall provide general supervision for routine health care and management of common health problems, and provide consultation and / or accept referrals for complex health problems. The physician shall be available by telephone or by other communication device when not physically available on the premises.

VI.       Specific Conditions and Requirements for Direct Evaluation

With respect to specific conditions and procedures that require direct evaluation, collaboration, and/or consultation by the physician, the following will serve as a reference guide: Clinical Guidelines in family practice, 3rd. Edition, by Constance R. Uphold, ARNP, PhD. and Mary Virginia Graham, ARNP, PhD.

When a Rash is Not a Rash
November 15, 2013 8:36 AM by Raymond Shulstad
Every day thousands of people go to their practitioner's offices, walk-in clinics and emergency rooms complaining of a "rash". Some of them itch, some of them don't. Some have been present for a few days, some for many years. Some come and go sporadically without warning, some present acutely, some appear like clockwork at specific times of the year or after exposure to specific irritants. 

Most of these conditions are either related to exposure to an allergy or irritant or are in the atopic dermatitis spectrum. Most practitioners can recognize and distinguish the urticarias and things such as scabies relatively easily and treat them appropriately. For the majority of patients, many exanthems will resolve without treatment; for those that don't, a topical steroidal cream or ointment will resolve or improve them.

Sometimes though, something that appears to be a rash is only a cutaneous manifestation of something that has the potential to be significantly more ominous. One such example of this is mycosis fungoides or cutaneous T-cell lymphoma. This form of lymphoma can look exactly like an atopic dermatitis and have the same symptomology (redness, pruritis, sporadic and transient).  The difference is that this condition, if it advances, can be lethal.

So, how can you tell the difference if they all look the same? In a word, BIOPSY! If an elderly person presents to your clinic with complaints of a long standing rash, treated for multiple years with minimal success with topical steroids and the erythema seems to be confined to photo-protected areas of the body, or those covered with clothing, take a sample.

It is unlikely that atopic dermatitis will acutely begin in the fifth or sixth decades of life with no previous history. It also usually presents on the antecubital and posterior knees. Mycosis fungoides usually presents in the fifth or sixth decades of life and ultraviolet light suppresses rash. Therefore, the exposed areas of skin are spared and as mentioned earlier, the trunk or covered regions of the skin are the most common sites of presentation.

If you take a biopsy and it is consistent with mycosis fungoides, don't panic. Refer them to hematology/oncology for evaluation and management. The majority of cases do not progress to the more dangerous stages and can be controlled with topical steroids and ultraviolet treatments. I would advise anyone who sees a person with rashes on the body that appear in the sun covered regions to keep this disease in mind and familiarize themselves with it.

Third World Derm Creams
October 25, 2013 10:47 AM by Amy Gouley
I just returned from a Culinary Tour in Morocco and one afternoon we ventured to the spice market in Marrakech.

After several days of cooking lessons, I had formulated my list of spices I would be purchasing and bringing back home to create decadent meals for my family and friends. To my surprise, I discovered their version of "dermatologic compounding," and I was immediately intrigued.

I also was humored to see the man behind the counter, wearing a white lab coat identical to medical providers in the states. I asked him if he was a pharmacist or attended any medical training. He replied, "No, my family is in the spices." Okay. So, a long standing family business of spices and no medical science background, (my translation assumption).

I was drilling him with questions, quickly jotting down ingredients and attempting to avoid looking like a lunatic tourist or compounding spy!

The herpes compound included saffron, almond oil and jasmine. The spice "expert" claimed he formulated this for canker sores, cold sores and cracked lips. Saffron? Hilarious. Can you imagine telling your patient to rub a little saffron cream on their lips BID? Maybe? Someone should try it. Might I suggest one thing: change the name! What would your date think if he/she used the restroom and your Herpe jar was accidently left on the counter?

Next up was my personal favorite because we all know I LOVE teenage acne: acne compound. This consisted of tea tree, Palm Oil, Argan Oil and Rosemary Oil. Clearly, I'm not versed in Arabic spice concoctions, especially for dermatologic application; however, this seems like a very OILY mixture.

I can't imagine the Tea Tree properties to be drying enough to overcompensate for all the oils. Maybe? Again, who's trying this? Argan Oil is simply delicious! Processed from grinding argan nuts, Moroccans serve this at every meal as a finishing oil. I quite possibly consumed several cups of this oil during my two weeks of indulgence.

Argan Oil was also found in his Exzema compound. I love the spelling of this! Rosemary nut oil and Clove oil are the other two components that "smooth the skin," he said. I don't know about you but if I rubbed Rosemary on my atopic skin, I‘d have urticarial wheals before I could count to one hundred. I do have several patients that swear by Rosemary drops to help their xerosis. Maybe?

Lastly, the Psoriasis cream compounded of Black Tar, Sulfur and yes, you're seeing the trend; ARGAN OIL. We all love the Black tar & Sulfa combo for psoriasis, minus the smelly mess. Does the Argan Oil take this compound to the next level? Maybe? Could Argan Oil be the next magical dermatology trend?

Traveling through third world countries is always fascinating, particularly when seeking out pieces of culture that relate to your profession. Stumbling upon these dermatology compounds was definitely unexpected and incredibly enjoyable.

Dust Mites
October 21, 2013 12:44 PM by Raymond Shulstad
It is fall again. If the temperatures haven't started to drop yet where you live, they likely will soon. It is time to break out the sweaters, jackets, coats, sweatshirts and warmer sheets, blankets and comforters. It is also prime time for dust mites. 

Usually around this time of year I see an influx of patients presenting to the office complaining of new onset itching and redness primarily to the neck, intertriginous areas and waist/trunk. As a young practitioner, this perplexed me and I would biopsy these rashes and they would invariably come back as being consistent with an arthropod assault. Not to age myself, but this pre-dated the time when everyone became aware of the bed bugs and dust mites in hotels that caused such a stir a few years ago.

What was happening with my patients is that they would take the warmer clothes and blankets off the shelf in the closet and wear them without washing them first. The dust that had accumulated in the closets and on the clothes/sheets had dust mites in them. Not all people are as sensitive to the bites but for those who are, this was a recipe for disaster ... or at least a lot of short-term intense itching.

How do we solve this dilemma? When the patient presents to the office with these symptoms, part of the history I take will be to ask if they recently started wearing the warmer clothes mentioned above or were using blankets they have been in storage or on a rack the last six months. 

I also find out if they washed them prior to use. Most of the time, the answer is no, because the clothes were clean when they stored them there for the winter. A mid-potency topical steroid and non-sedating anti-histamine can be given to alleviate symptoms and patients should be encouraged to wash all remaining clothes and linens prior to use, as well as using any one of the commercially available sprays that can kill dust mites and bed bugs.

Grover's or Something Else?
September 27, 2013 4:01 PM by Amy Gouley
This is a 68-year-old man who arrived in our clinic complaining of a rash on his trunk beginning four weeks prior. Treatment by his primary included anti-fungal creams and OTC cortisone. 

His first presentation resembled Grover's and was later confirmed by punch biopsy. The puritis seemed to be under control with Clobetasol solution mixed in Cerave cream. I also added Hydroxyzine 50mg QHS as needed for itch. 


We had his symptoms 90% improved and the lesions were faded about 75% with no evidence of new lesions. 

Exactly three weeks from his first visit he returned complaining of a "new rash". Upon examination were intact subepitheial bullous lesions on trunk and arms ranging from 4mm to the largest measuring 8mm.

Clinically this screamed bullous impetigo and was confirmed by two punch biospies. 


Initially, we started him on 40mg Prednisone QD but new bullae was forming, so we increased his dosage to 80mg QD. We will complete two weeks on this dose and taper him off. We also suggested he review blood pressure medications with his primary physician.  

Skin Cancer Webinars
September 19, 2013 4:18 PM by Raymond Shulstad
I'd like to thank everyone who tuned into the webinars on common skin cancers and their pathogenesis last night and on August 14. Having completed the second one in the series on squamous cell carcinoma and melanoma, I found myself wanting to offer so much more but I ran out of time. 

If you were unable to sit in and listen to parts one or two of my presentation, you will be able to do so at http://nurse-practitioners-and-physician-assistants.advanceweb.com/Web-Extras/Online-Extras/Editorial-Webinars.aspx. 

Part one of the presentation, "Basic Skin Anatomy" is available to watch now. Part two, "Skin Cancer Overview" will be up soon.

I have been practicing dermatology for over 10 years now and I still am learning new intricacies about the various malignancies and new treatment modalities. 

I hope to offer more of these sessions if people would like me to that can touch on some of the more rare cutaneous malignancies and specifics on treatments and response rates. I am planning to present again early next year, so stay tuned for coming announcements.

These sessions are available on demand, so whenever you have an hour to devote to learning more about skin anatomy and skin cancers, click the link, watch the video and tell me what you think. 

For those who tuned in, thank you and I hope you enjoyed.

Editor's note: If you have questions about upcoming webinars or questions for the presenter, contact assistant editor Kelly Wolfgang at kwolfgang@advanceweb.com.

Pet Therapy
August 29, 2013 2:56 PM by Amy Gouley
Occasionally after clinic, I will allow my red fox labrador retriever to assist me in chart completion and pathology management.

I absolutely love having her nap under my desk and her presence brightens up our entire office.

 Booker 1

I live in a very dog friendly community and the majority of my patients own a dog, which makes an easy conversation for even those personality challenged patients.

Booker is my first dog, aside from those I grew up with. I honestly can't believe I lived this long without a dog. Once you experience the bond with a dog there is an immediate connection with every human who also owns a dog. I imagine the same for cat owners?

I love talking to patients about their dogs and watching their faces light up with joy. Nothing compares to the amazing connection built from the incredible stories and tears that are shared with my dog owner patients.

Booker has become quite popular among my patients and one 72-year-old gentlemen last week asked if he could move his six month body exam up to three months so he could get a "Booker" update. The week prior, a bag of dog treats was dropped off to the front desk with an attached note: "For Booker."

 Booker 2

I can only imagine how the love would blossom if she hung out in the office during the day.

I would love to hear other "office dog" stories and your opinions on pets in the clinic.  

The Don’ts of Cryosurgery
August 9, 2013 12:51 PM by Raymond Shulstad
Cryosurgery is a process where liquid nitrogen is applied to a lesion to induce cell death. It is a procedure done every day in dermatology offices and is now done routinely in primary care offices as well. It is a relatively low-risk procedure, causes minimal scarring and can be used for a multitude of conditions, including actinic keratoses, warts, seborrheic keratoses, molluscum contagiosum, superficial basal cell carcinoma, and squamous cell carcinoma in situ.

Problems arise however when cryosurgery is improperly used. The effects can be devastating and potentially life threatening. In order to avoid this potential hazard I have come up with a short list of don'ts regarding its use.

  1. Do not use the cryosurgery gun within the ocular rim or the internal ear canal. The potential risk to the eyes and tympanic membrane if a patient moves are too great. Employ the old Q-tip method.
  2. Do not use cryosurgery more than once on the same lesion, with the exception of warts. If you freeze something such as an actinic keratosis, superficial basal cell carcinoma or squamous cell carcinoma in situ and the lesion recurs, a biopsy should be done. This goes to the old adage that cutaneous malignancies on presentation may just be the tip of the iceberg and the lesion may be more involved than it appears. If the lesion is truly superficial in nature the liquid nitrogen will resolve it.
  3. Do not use cryosurgery on invasive squamous cell carcinoma, morpheaform basal cells, sclerotic basal cells or infiltrative basal cells. Although unlikely, squamous cell carcinoma can metastasize and kill patients. It is a necessity to know margins are free. The more aggressive basal cells can involve nerves and muscles and lead to significant tissue destruction. Treat them with caution. I recommend they all be sent for Mohs surgery.
  4. Do not over or under freeze lesion. The most common thing I see with students I mentor is either a fear of or a lack of respect for cryosurgery. Some will barely squirt an area for a fraction of a second. If the lesion does not sufficiently freeze, the cells will not be destroyed. Others pull the trigger on the cryo gun like the area shooting an M-16 on rapid fire. Blasting lesions for too long can lead to significant ulcerations and necrosis of the underlying fat cells. Lesions should be frozen for 3-5 seconds. The frozen, or white area, should extend about 0.3cm from the lesion edge. Utilizing a freeze thaw freeze cycle of 3-5 seconds each can enhance cellular death and should be used on thicker lesions.
  5. Do not use cryosurgery on pigmented or melanocytic lesions. This should never be done. If you do not know the difference between a melanocytic lesion and a seborrheic keratosis then you should not be using cryosurgery at all. If a lesion that appears to be a seborrheic keratosis has irregular pigmentation, take a biopsy to remove it. I tell my patients that I may be 99% sure the lesion is harmless but there is a 1% chance it can be life threatening. I am not willing to take that risk when there is a better alternative. Melanocytic lesions, or nevi all have a potential for developing into melanoma. That potential may be small but it exists. Freezing a melanocytic lesion can prevent pigmentary changes from being seen and can lead to deeper melanomas and death.  It's just simply bad practice and should never be done.


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