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
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.)
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.
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
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.
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.
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/
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.
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.
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."
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.
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
Skin Biopsies-all techniques (shave or punch)
Incision and drainage of abscesses
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.
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.
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
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