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Dermatology Practice Today

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:

Cryosurgery

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.

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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.

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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.

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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.

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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.  

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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.

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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.  

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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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Alopecia Areata
August 1, 2013 2:14 PM by Amy Gouley
A 54-year-old male presents for a total body mole check and reports hair loss for 6 months. The patient says, "I don't care about the hair loss, I am here to have my moles checked for cancer. I'm going to buzz my hair anyway."

 

After completing the total body mole exam, I explained the condition on his scalp - alopecia areata.

 

After screening for stress, trauma, loss of a loved one and family history, we discussed inerlesional injections of Kenalog 10mg/cc, 0.1cc-0.2cc per patch. The patient agreed to the treatment.

 

Blood work was also performed and returned WNL. This patient was instructed to return to the clinic in three weeks for repeat injections.

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Bullous Impetigo
July 26, 2013 8:32 AM by Raymond Shulstad
Having practiced in dermatology for close to 12 years now, it is rare that I see something in the clinic that I have not treated or diagnosed before. This past month I had such an experience. A fourteen year old boy presented to the office with multiple annular erythematous patches, with irregular borders, peripheral scaling and ulcerative centers. 

 

The lesions rapidly appeared over the last week and began as small bullae of less than 1cm. The patient and mother reports the areas itched and are tender. Their primary care provider had given him antihistamines and cortisone cream and sent him to me.

 

The diagnosis of bullous impetigo was suspected due to the multiple vesicles on non erythematous skin that, when unroofed, ulcerated and created the rings seen in the following images. A culture was taken of one of the unmolested vesicles which showed staph aureus. The patient was given doxycyline 100mg twice daily for two weeks and on follow-up the lesions had resolved.

 

Though not a particularly rare disorder, I had not seen bullous impetigo in the clinical setting because I do not see children under the age of 12. For me, this was a chance to hone my skills in history taking and refreshed my memory as to how to treat this disease. That came in handy as the following week two other patients presented to the office with the same condition. What are the chances that after not seeing something for 12 years that three cases present in a month. 

 

In the end, understanding the progression of the lesions from their presenting symptoms to what they became was key to properly diagnosing and treating these skin infections and is the key to treating most all dermatoses.

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Treating Acne: The Basics
July 12, 2013 9:06 AM by Raymond Shulstad
As the summer comes to a close and students and parents begin to plan for the next school year, inevitably there is a mad dash to the dermatology office to treat acne. Freshmen want to be clear to start high school, seniors want to be pimple-free for senior pictures. The problem is that they like to wait until 2 weeks before the start of school to come in.

I have found the easiest way to get teenagers to comply with therapies, acne or otherwise, is to manage expectations. This includes explaining what the medications are for, how they work, and expected side effects.

Generally, there are two types of medications to treat acne. Many would argue this point with me and, technically, they would be right. There are topical retinoids, oral retinoids, keratolytics, oral antibiotics, topical antibiotics, and anti-inflammatories. These medications take the forms of creams, foams, gels, washes, leave-on and short contact preparations, pills, capsules, tablets, etc. The various amounts of medications and their mechanisms of action can be overwhelming. I would argue that the two types of medications are the ones that treat the causes of acne and ones that treat the symptoms of acne.

There has been a perception, justifiably so, that when a patient leaves the dermatology office he or she has a handful of prescriptions for acne: topical retinoids, benzoyl peroxide washes and gels, topical clindamycin or erythromycin, doxycyline/tetracycline/minocycline and a sulfa wash. I call this carpet bombing the face. It is an aggressive and often effective way to treat acne but, as prices of prescriptions rise and coverage for medications shrink, patients are unable to afford this type of treatment. Furthermore, for our young patients, the side effects of the medications and the time required to maintain the regimen make adherence a huge problem.

Acne is a disease of the pilosebaceous unit. The lesions commonly seen are open/closed comedones, papules, pustules, nodules and cysts. The most common mistake I see in young patients that are referred to me for acne treatment is that they were either not prescribed or are not using the retinoids. If they are not using one, then they are not treating their acne, only managing the symptoms. In the simplest terms, retinoids are the only medications that treat the causes of acne. They cause the skin to turn over faster, opening the pilosebaceous units and decreasing their depth. If the pores don't get blocked, then you can't have acne. Topical and oral antibiotics decrease the amount of P acnes on the skin, reducing the inflammatory lesions, but they do nothing to the pores. Keratolytics such as benzoyl peroxide and salicylic acid reduce the adhesion of the superficial kerotinocytes and can open some of the pores, but they are not nearly strong enough to keep the pores permanently open.

Many patients, especially teenagers, shy away from the retinoids because of the peeling and irritation they cause. This is where managing their expectations and educating them on their importance is most vital. Tell them that peeling is to be expected for the first several weeks as the medication works to decrease the depth of the pores and open them. Once this phase is clear, the acne begins to improve and healing begins. The peeling is not a side effect, it is the desired outcome. Gentle cleansers and moisturizers can and should be used to reduce irritation and oil production. It takes 2 months to see a difference with the medications and 4 months before the maximum effects can be seen. Skipping days results in starting the process over again, so consistency is the key.

In patients with mild to moderate acne, consisting of primarily comedones, papules and a few pustules, my first-line treatment includes a retinoid every night and a topical antibiotic every morning. For moderate to severe cases in which pustules and a few nodules predominate, oral antibiotics are added to more rapidly reduce the inflammatory lesions and prevent scarring. Patients are informed that on follow-up, I expect to see a reduced number of inflamed bumps and a bunch of red smooth spots where the acne use to be. These spots will fade over time if medication is used consistently. If inflamed lesions have resolved, the oral medications are tapered and discontinued and the acne is managed topically. Keeping it simple and managing expectations has allowed my patients to consistently improve and reduce the need for extra medications, costs and office visits.

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Update on Melanoma Patient
July 11, 2013 7:45 AM by Amy Gouley

 

This post is an update on the patient I reported on in my March 1 post. He is 75 years old and came to our office as follow-up after excision of scalp lesions. He was diagnosed with Stage 4 metastatic melanoma.

 

The photo shows his scalp involvement 3 months later. These satellite lesions are growing at an exponential rate. The patient is fatigues, having difficulty ambulating and complains of intestinal pain.


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Top 5 Summertime Dermatoses
June 28, 2013 11:11 AM by Raymond Shulstad
As the temperatures rise and people begin to venture outdoors to enjoy all the activities that come with beautifully sunny days, providers will see an influx of patients presenting with a variety of dermatoses. Over the last 12 years in practice, this is my empirically derived top 5 list of what to look for and how to treat it.
  1. Irritant/Allergic Contact Dermatitis: As the diagnosis implies, these patients will present with a pruritic eruption after coming in contact with something that they were either allergic to or sensitive to. The distribution is usually seen in exposed skin areas on the arms and legs. Most people will report that they were working in the yard, pulling weeds, trimming bushes, cleaning with harsh chemicals, fertilizing, or spraying weed/insect killers. If patients were going without a shirt or wearing a tank-top or bathing suit top, the rash can also appear on the abdomen or chest; the back is usually spared. The reason is that people will cut limbs, pull weeds, cut the grass and then pick up the clippings and hold them against their body to put in lawn bags/compost areas. The eruptions are erythematous with evidence of excoriations. Treatment includes topical steroids class 1-3 (5-6 for face) twice daily until clear or no longer than 2 weeks and avoidance of repeat exposure. This is a self-limited condition and would resolve if we did nothing, so symptom management is the key.
  2. Discoid Lupus: Presents as multiple annular/semi-annular erythematous pruritic plaques erupting in sun exposed regions, usually within 24 - 48 hours. Patients may believe they have contracted a fungal infection but the pruritis and rapid development can eliminate this as a potential diagnosis. Gutatte psoriasis and nummular eczema can be excluded because they tend to improve with sun exposure. Biopsies should be taken to confirm the diagnosis and an ANA ordered to rule out systemic lupus. Treatment once again relies heavily on topical steroids classes 1-3 and avoiding sun exposure. Sun block and protective clothing should be used daily.
  3. Tinea Versicolor: Fungal infection presenting most commonly after sun exposure. Common presentations include hypopigmented, annular macules on the exposed areas of the trunk, upper arms and thighs. The sun has nothing to do with the infection itself, the affected areas just don't pigment normally and patients will say they have "sun spots" or look like a leopard. Mild pruritis can be seen, but is rare. Treatment includes topical antifungal shampoos applied like a lotion to the exposed areas, allowed to sit for 15 minutes then rinsed. Done correctly every day for two weeks, most will be clear of the infection but should continue to use the shampoo in this fashion once or twice a week. Repigmentation can take several months to occur. In extreme cases, oral ketoconazole can be used.
  4. Cutaneous Herpes Simplex Type I: The same virus that causes "cold sores" can result in a cutaneous eruption. Seen commonly on the back 24 - 28 hours after sun exposure, the patient will present complaining of an itchy, slightly burning sensation on the affected area. On examination, there is usually a well demarcated erythematous patch with multiple small vesicles or scabbed papules. This can be differentiated from shingles by its limited surface area; spots tend to be small and don't follow a dermatome. Also itching tends to be reported more than intense pain and this area tends to break out repeatedly in the same location whereas shingles is usually one and done. Treatment includes antiviral medication and sun protective measures. Patients should also be made aware that this is contagious so sharing of towels and clothes is ill advised.
  5. Photoallergic Drug Eruption: Differentiated from a drug allergy by the distribution and sun exposure being the precipitating factor. Eruptions occur most commonly on the forearms but can occur in any area of prolonged sun exposure. Unlike drug allergies which cause an overall erythematous eruption and is associated with an actual allergy to a medication, this eruption is caused by a metabolite of a medication reacting with UV radiation. It is important to differentiate because the patients do not need to change their medication - they need to avoid sun exposure. Topical steroids can be used to calm flares but UV avoidance is curative.

I hope this list can help narrow down the diagnoses that you will be seeing soon as temperatures rise and UV exposure increases. 

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Facial Skin Presentations
June 6, 2013 10:39 AM by Kelly Wolfgang

Editori's note: The information and photos in this post were provided by Amy Gouley.

 

A patient presented today for a patch on left temple that "stings."
Diagnosis: Proven by biopsy, Basal Cell Carcinoma

 

A 12-year-old male presents with a new lesion on his forehead that has been growing for 2 years.
Diagnosis: Verrucous Vulgaris

 

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NADNP 2nd Annual Conference
May 23, 2013 3:40 PM by Raymond Shulstad
I have been fortunate enough to have spent the last week at the 2nd annual National Association of Dermatology Nurse Practitioners (NADNP) conference in Clearwater Beach, Fla. It has been personally rewarding to see all the hard work over the last year pay off as the conference has been a huge success. Professionally, it has been wonderful to see the mixture of dermatology specialists and primary care providers who have come to expand on their current knowledge base or begin to explore the specialty I love.

Many times during the conference, after my lectures, attendees approached me and asked how they can learn more or what resources would be good for them to get. I want to take this time to encourage every practitioner to get a good, basic dermatology book to reference in their office. Text books that I recommend for students I mentor include: Andrews' Diseases of the Skin: Clinical Dermatology, Clinical Dermatology by Thomas Habif, and Fitzpatrick's color atlas and synopsis of Clinical Dermatology.

Additionally, reach out in the community and talk to local dermatologists or dermatology specialists to consult when needed and refer to when applicable. Also, if you are sending biopsies off for pathology, make sure a dermatopathologist is reading your samples. If they are not, find one. 

The most important thing you can do is take the time to read the articles in ADVANCE for NPs & PAs that reference dermatology. May's issue spotlighted dermatological conditions and included a profile of my good friend, colleague and mentor Dr. Debra Shelby who is the president of the NADNP.  You can view a webinar Dr. Shelby presented on dermatology here.

You should also attend a dermatology conference or ask local dermatology specialists if they will allow you to shadow for a few days. Seeing things in texts and trying to match pictures to patients is suboptimal, but from what I heard, routine practice. Meetings will have some basic lectures concerning dermatological conditions and therapies that will enhance your practice. 

In short, utilize the resources that are available to you. They are there for the choosing and readily available. Most, if not all of us received very little training in dermatology while in school. As professionals it is our responsibility to attain the knowledge needed to care for our patients. It is there for the taking, so take it.

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