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Dermatology Education & Practice from NADNP

Reviewing Rosacea
February 13, 2017 8:48 AM by Guest Blogger
By Darrel Arthurs, ARNP, DCNP 

Rosacea is a very common disorder that affects the skin of the face with flares that wax and wane in severity. The condition can be mild, with only a light pink color on the cheeks and nose, or very severe and deep red. Very severe cases may have papules, pustules and broken blood vessels especially over the cheeks. Rosacea can also affect the eyes, causing itching or dryness. Over many years, the condition can also cause a thickening of the tissue across the nose. This particular condition is referred to as rhinophyma.

Frequently, people will experience multiple forms of the symptoms described above. A genetic predisposition to the condition is most likely. They also may have other contributing factors, such as over-reactive facial blood vessels, inflammation of the skin, and increased reaction of nerves that respond to triggers such as spicy foods, alcohol, exercise, or weather. An association with the demodex mite, which commonly lives on human skin, has been found to exacerbate rosacea.

How is Rosacea Diagnosed?

Some signs that a person has rosacea include:

  • 1. Chronic pink or rosy colored skin affecting the cheeks and nose.
  • 2. Small blood vessels on the cheeks, which are broken and plainly visible.
  • 3. Facial flushing of the skin, which occurs after triggers such as sun exposure, alcohol or spicy food consumption, warm drinks, exercise, wind, and warm temperatures.
  • 4. Small pink papules and/or pustules form on the cheeks.
  • 5. Enlargement of the nose or skin texture changes.
  • 6. Redness, dryness and itching of the eyes.

Treatment of Rosacea

There are many effective treatments for rosacea. Some common topical medications include metronidazole, azalaic acid, ivermectin, or sulfur-based products. Oral antibiotics are commonly used, such as doxycycline, especially when papules and pustules are present. Redness and broken blood vessels are much more difficult to treat with medications. A topical medication that was originally designed to treat glaucoma can be used, providing temporary relief by blanching the superficial blood vessels. This medication, called Mirvaso, is very effective for some people but, unfortunately, not all patients are responsive.

Frequently, laser therapy is warranted to treat both redness and the broken blood vessels. Lasers provide a longer-lasting relief from the symptoms of rosacea. They are capable of breaking up the superficial broken blood vessels, as well as decreasing the inflammation of the cheeks.

An acute awareness of the symptoms associated with rosacea, as well as the triggers that can exacerbate the condition, is tantamount to successful treatment. The National Rosacea Society has a wealth of knowledge for both clinicians and patients. The website should be utilized to further education concerning this very common condition.

Darrel Arthurs's passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

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Tackling the Plantar Wart
December 6, 2016 9:59 AM by Guest Blogger
By Darrel Arthurs, ARNP, DCNP

Plantar Warts

Warts that form on the sole of your feet are called plantar warts. Essentially, they are the same as warts that are found on the hands and knees except this strain forms on the bottom of the feet. The human papillomavirus (HPV) is the cause of these growths, and they thrive in warm and moist environments such as public showers and locker rooms. These warts can be painful since they grow up into the foot and put pressure on the nerves. Warts start life as tiny black dots and grow larger, usually about to the size of a pencil eraser. They are very tenacious and difficult to treat, frequently reoccurring despite your best efforts to eradicate them.

Treatment Options

Over the counter topical wart removers can be purchased relatively inexpensively and applied on a regular basis. Gels, pads, or liquids can be utilized. My personal favorite is Duofilm 17.5% SA, which costs around $9.00 per bottle. Some brand names include Dr. Scholl's wart remover, Compound W, and Wart-Off. Be sure to follow the directions for whichever brand you choose since these medications' mechanisms of action are to burn the skin. To improve treatment, soak the feet in warm water for approximately 5 minutes prior to applying the medication.

Duct tape can be used to treat warts, but it leaves a terrible, sticky residue and takes months of treatment to reach clearance. However, it is economical and can easily be done as a home treatment. Just apply the duct tape to the wart and ensure that the entire lesion is covered with no air reaching the wart. Leave the tape in place for 6 days without removing it. Then remove for only a short period of time to clean off the surrounding skin then immediately re-apply the tape. Continue with the tape until the wart is completely gone with no bumps felt across the area. It would not be unusual for this treatment to take monthspossibly up to 9-12 months of treatment to completely clear the wart.   

Cryotherapy is a safe and effective treatment as well but must be performed by a qualified healthcare provider. This treatment is still covered by most insurances and is the most common treatment in the dermatology office. The drawbacks include multiple treatments as well as pain at the time of treatment. Liquid nitrogen is an immediate frostbite to the skin, and it can sting quite a lot at the time of application. Afterwards, a blister will form and may cause some further discomfort depending on the amount of walking the patient has to do.

Most importantly in treating warts is to always be persistent in application. Missing one day of treatment can allow the wart to regenerate and start to grow again, so persistence is the key to success. As you can see from the methods utilized we are not actually killing the virus with treatment but instead destroying the surrounding tissue that allows the virus to grow and replicate. Therefore, daily treatment or very frequent treatment without breaks is the key to success.

Darrel Arthurs's passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

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Excess Facial Hair in Women
November 11, 2016 10:01 AM by Guest Blogger
By Darrel Arthurs, ARNP, DCNP

Frequently, women develop extra hair growth on the face, especially around their mouth and chin area. It can also occur on the breasts or even the lower portions of the abdomen. This hair growth is frequently referred to as hirsutism and can develop in the teen years, or more commonly, as a middle-aged adult or older. These hairs have become the bane of many women, since they tend to multiply and become darker and thicker over time. Frequently, women will come into the office and ask how to get rid of these hairs. Unfortunately, there is not an easy answer, and most women don't like the responses they hear. Even so, a few things can be done to decrease the occurrence and improve the appearance of these hairs.

There is actually a great deal to learn about hirsutism and its cousin, hypertrichosis. The science of these conditions, along with the proper way to evaluate for hormonal imbalances, including labs, signs, and symptoms, will be discussed at a later date. Today the focus is on the cosmetic issue of these hairs and some ideas that may help patients to be less insecure about them. The first method is tweezing, which is perfectly fine. Once the hair is removed it will take time to grow back since you are removing the entire hair bulb and all. Another method is shavingwhich I am not a fan of. No current studies, which I am aware of, exist that indicate shaving actually makes the hair grow in thicker, but from my experience that's what happens. I usually recommend shaving as a last resort and only at the minimum that it must be done.

Electrolysis and thermolysis have both been used for many years to help with hair removal. There are multiple types of treatments with these machines—some of them more effective than others. The drawbacks to this type of hair removal are the time required to treat and the length of treatments. Usually, the treatments are weekly with a time commitment of one to two hours and may last up to five years or more. The cost of these treatments can add up over time, which is why this procedure is best used in small areas only.

A topical medication exists for hair removal. It is a prescription and runs about $120.00 per tube, taking 4 to 8 weeks to show effectiveness. The cream must be continued or the hair growth will redevelop. For very small areas, this may be a good treatment plan, and I have several women who come in yearly to get refills. They say the tubes last about two months before they need refills.

Laser hair removal has gained a great deal of attention over the past few years and become much more mainstream in treatment. It is effective for most people and will remove the hair for up to six months after two to six initial treatments. At this time, there are companies selling handheld laser hair removal devices. These are still new and have not been thoroughly tested as to their reliability. The cost of laser hair removal is decreasing in many areas as more and more demand increases the supply. Some of the lasers will treat multiple areas such as the back, bikini, chest, face, neck, and shoulders. It must be noted that laser hair removal is only useful for thick, dark colored hairs and not fine vellous (peach fuzz) hairs. The method of action for the laser is to follow the color of the hair into the hair follicle to destroy the bulb.

Darrel Arthurs's passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

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Warning Signs of Melanoma
October 3, 2016 8:43 AM by Guest Blogger
By Darrel Arthurs, ARNP, DCNP

Melanoma is the most lethal of all the skin cancers. It is estimated that melanoma kills 10,130 people annually in the United States. Many of these deaths could be easily prevented with proper screening and catching the cancers in their infancy. These skin cancers are highly survivable if found earlybefore they are able to metastasize and affect internal organs. Being aware of the signs of melanoma is extremely important. Educating patients and their families about the warning signs of melanoma can extend life or possibly even prevent early death.

The ABCD&Es of melanoma are an effective method to educate our patients about the warning signs of melanoma.

AAsymmetry. If a mole has one side that is larger than the other it is asymmetrical. An easy way to assess this is to draw an imaginary line through the center of the mole and compare the two sides. If one is larger than the other the mole is asymmetrical.

Asymmetry

BBorder. Most benign moles have smooth borders that are even. Melanomas tend to have borders that are not smooth but instead uneven, possibly with scallops or notches.

Border

CColor. Benign moles are usually all one color often a shade of brown. When there are two or more colors present, the mole is a warning sign of melanoma. Secondary colors are frequently black, tan, red, white, or blue, as well as some deeper shades of brown.

Color

DDiameter. Normally benign moles will be smaller than 6 mm in diameter (the size of a pencil eraser), but melanomas frequently grow larger than this. While some moles that are benign can be this size or larger, most are not. The size of the lesion can be another warning sign.

Diameter

EEvolving. A typical benign mole will look the same over time with only minor changes occurring. Changes such as size, shape, color, elevation, or any other changing trait can be a warning sign of melanoma. In addition, symptoms such as burning, bleeding, itching, or crusting can indicate the need for further evaluation or possibly even biopsy.

 

Reference

Skin Cancer Foundation (2016). Melanoma. Retrieved September 28, 2016: http://www.skincancer.org/skin-cancer-information/melanoma

Darrel Arthurs's passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

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Scaly Skin: Home Therapies
September 2, 2016 8:59 AM by Guest Blogger
By Darrel Arthurs, ARNP, DCNP

Last month we discussed Seborrheic keratosis (SK)-those rough growths that develop on the skin of people who are becoming more mature. In-office treatments were reviewed, and now this month we will evaluate some home remedies that will help with these irritating growths. The best treatment is alpha hydroxy acid (AHA) and-more specifically-glycolic acid, because it is proven to be effective in loosening up the dead skin cells. This acid will remove the glue that holds the old dead cells in place from the upper layer of skin. By doing this, glycolic acid will enable new skin cells to grow in more effectively. This new growth has been equated with decreased SK thickness as well as helping with fine lines and wrinkles across the face. In addition, it causes compacting of the deeper skin cells, which will give the patient a more polished appearance.

Glycolic acid is found in many cosmetic lotions and creams on the market today. The Food and Drug Administration will allow companies to use glycolic acid in concentrations of 10% or less in lotions and creams. The exception to this is facial peels, which are dosed up to 50% and even 75% in a step-wise treatment regimen. Conditions treated with chemical peels include acne scars, a dark pigmentation across the face called melisma, as well as wrinkles and sun-aged skin. Side effects of glycolic acid are minimal, the main one being increased sensitivity to sunlight. Therefore, always apply sunscreen-SPF 30 or above is recommended-after using and when outdoors.

Photo credit: Bicheando Galicia

Without advocating for any one particular product, we will review a method to decrease SK across the body. To begin, use an exfoliating sponge or cloth in the shower or bath to those areas that are forming these growths with a body or bath wash containing glycolic acid. Some common places these barnacles like to grow are the face, backs of the hands and knees, as well as the top of the foot. Start at two times per week to allow skin to get used to the quicker-than-usual exfoliation, then slowly increase to nightly. Be particularly careful across the face and neck since these areas are more sensitive. Within 3 to 4 minutes after toweling off, apply a lotion containing glycolic acid to all of the skin. For the remainder of the five days, use a thick, rich, non-scented body cream or lotion after showering.  An exfoliating sponge or cloth can still be used in the shower on those other five nights. Over time the skin will adjust to the treatment. When it does, increase the nights per week that the glycolic acid lotion is used. Over time, a significant decrease in the roughness of those barnacles as well as increased skin softness and fullness will be noticeable.

Remember, it is important to never use exfoliation or any acids on open sores or broken skin. Dermatology professionals should evaluate any sores that won't heal or any new growth that does not go away. Please contact me via Facebook for some specific products to use if you are interested: Darrel Arthurs, NP-BC Dermatology Certified

Darrel Arthurs's passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

 

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Understanding Scaly Skin
August 5, 2016 8:42 AM by Guest Blogger

By Darrel Arthurs, ARNP, DCNP

Over the years, I have seen many people in the office asking about crusty Seborrheic keratosis (SK). These scaly, popular, bumpy growths occur on most people who are middle-aged or older. They are odd looking, with varying colors and configurations. Scale can come off them, and they frequently catch on clothing and get irritated. When I first started working in dermatology, a little old lady called them barnacles, because they resembled the growths that occur in the ocean. SK's of the body are similar to warts in structure in that they are made up of extra layers of skin cells, which are both living and dead. Since SK's are made up from your own skin layers, it indicates that some skin care products can help to alleviate these growths. Also, a few skin care tips can be taught to help decrease or even completely remove these growths.

SK's begin to form on many people after the age of 30. There is no predilictation to male or female. Both sexes are equally affected; however, there is a genetic predisposition to getting large numbers of growths across the body. These growths all have a stuck-on appearance and feel that way as well. Frequently they are darker than the surrounding skin, but they can be skin colored, yellow, gray, light brown, brown, mixed or even red. SK's can form on any part of the skin not just in the seborrheic distribution of the body, such as the scalp, mid-face, chest or upper back. SK's form because your skin grows excessively, and it develops a little mound or papule that is raised higher than the remainder of the skin. The papule is made up of living cells as well as excessive layers of dead skin cells, which is called the stratum corneum. This is why they have a crusty appearance and feeling as well as appearing stuck on, like a barnacle.

In-office treatment for SK's includes liquid nitrogen, which is used on thinner lesions. Occasionally, these lesions will need to be treated on a repeat basis until resolved. Curettage or scraping off the lesion with a sharp circular blade (curette) can be done, as well as a shave biopsy of the lesion. Electrocautery as well as ablative laser surgery can be used to treat some lesions that are not too large. Intralesional lidocaine will need to be used for all of these procedures. Finally, chemical peels may be beneficial some thinner lesions as well.  Many of these procedures are not covered by insurance any longer since SK's are benign growths. Often, patients will need to pay cash for the removal of these lesions.

SK's can be irritating to patients and adversely effect their lives. Frequently, patients will ask if there are home remedies, which can be done to lessen the severity of these lesions. Since SK's are stuck on to the surface of the skin, the key to treatment is exfoliating with physical buffing and to use alpha hydrox acid (AHA) products, which will soften and frequently entirely loosen these growths. We will touch on these home remedies further in the next blog.

Arthurs' passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

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SPECIAL ANNOUNCEMENT: New Education Opportunities Available
March 31, 2016 10:16 AM by Debra Shelby
The National Academy of Dermatology Nurse Practitioners and the American College of Dermatology Nurse Practitioners are pleased to announce our new collaboration with the National Institute for Dermatology (NID).

In response to the needs of our national NP and PA communities, we have joined forces with NID to bring you comprehensive dermatology education that is convenient for you. We will be traveling to states around the country offering dermatology workshops and lectures.

In addition, NPs who cannot make our national conference will be able to attend the didactic portion of the NADNP Dermatology Certificate Program in your own state. 

For details on classes, locations and dates, faculty and course descriptions please go to http://www.fsmsllc.com/ and look under the National Institute for Dermatology tab. There is also a link at http://www.nadnp.net/  and https://nadnp.enpnetwork.com/.

COMING SOON!

Dermatology Certification Seminars! Dermatology NPs looking to take the DCNP exam, we will help you prepare!

Other Info

Interested in Being Faculty? We are looking for expert dermatology faculty throughout the country. Please contact admin@fsmsllc.com or use the FSMSLLC.COM, NADNP.NET, or NADNP.ENPNETWORK.COM contact us forms.

Are you a NP or PA looking for a dermatology position? Contact us on http://www.fsmsllc.com/. You can also visit www.advancehealthcarejobs.com to find the right job for you.

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Eczema: An Itchy Nuisance Part 3
February 29, 2016 10:13 AM by Guest Blogger

By Darrel Arthurs, ARNP, DCNP

Last month, we discussed basic skin care and some of the over the counter treatments available for the eczema patient. In this blog I will discuss more treatments available as well as topical treatments, which can be helpful getting a more severe condition under control.

Wet Wrap Therapy

A patient with a significant flare or a very recalcitrant condition not responding to traditional treatments can be responsive to wet wrap therapy. This therapy is now used on an inpatient basis and the method is taught to the parents to continue therapy at home.

The success rate for wet wraps is extraordinarily high if used correctly. The best technique is to use a topical corticosteroid (TCS) applied to the skin with a moist layer placed over the body area treated. This could be tubular bandages for the extremities or any cotton clothing that can be moistened (footy jammies are actual useful for this application but not normally recommended for the eczema patient).

On top of this a dry layer is placed to decrease the effects of the wetness on furniture and the patient is allowed to sit for 2 to 12 hours. By occluding the TCS it increases the effectiveness as well providing much needed moisture to the skin and a physical barrier against scratching.

Topical Corticosteroids

TCS are used in both children and adults and are the go-to treatment for moderate to severe eczema. They act by decreasing inflammation and the immune response at the site of application. Normally, they are added to the regimen after good skin care and moisturization regimens fail. TCS's have been in use for over 60 years and their effectiveness is well documented. They are the standard that other topical anti-inflammatories are compared to. 

TCS's are grouped into 7 categories from very low (VII) to very high potency (I). Methods that can be used to treat with TCS's include two options. First the provider can start low and move higher until the condition is well controlled. The other method is to use a short burst of high potency TCS to get the condition under control quickly and then to decrease the dose to the desired level of treatment.

While there is no universal method there are other factors involved including length and severity of condition. Normally by the time they reach dermatology the condition is severe. For this reason I normally start high and drop the potency once the symptoms improve.  

Everyone wants a recipe to treat all of the eczema that walks through the door and unfortunately, there isn't one but I will give a brief, very basic synopsis of a treatment plan with actual generic TCS names.

For young children and pre-teens use triamcinolone (TMC)0.1% and then decrease to hydrocortisone 2.5% or a TMC 0.25%. For teens and adults with medium and severe disease start with clobetasol 0.05% then drop to TMC 0.1%. Ointments are preferred if possible and are more effective than creams. In addition, they normally do not burn and sting when used on excoriated skin. Always use only mild TCS for the face and groin areas and for short periods of time.

Gaining Knowledge

This blog is not meant to be a comprehensive treatment plan. My hope was to spark an interest in the subject with the reader and elicit more research. I am adding a great journal article reference to this blog and, in addition, education can be found at the NADNP website, http://www.nadnp.net/.

Starting this year traveling dermatology continuing medical education will available at different locations across the country to allow you, the reader, an opportunity to further your knowledge of this fascinating subject.

References

  1. Eichenfield FL, et al. Guidelines for the management of atopic dermatitis. J Am Acad Dermatol. 2014;70(2):338-351. doi: 10.1016/j.jaad.2013.10.010
  2. National Academy of Dermatology Nurse Practitioners. http://www.nadnp.net/

Arthurs' passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

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Eczema: An Itchy Nuisance Part 2
January 28, 2016 12:33 PM by Guest Blogger

By Darrel Arthurs, ARNP, DCNP

This month some of the treatment options available to the nurse practitioner in treating atopic dermatitis (AD) will be reviewed. One of the cardinal features of AD is dry skin or xerosis. Using topical moisturizers reverses this dryness of the skin by increasing hydration.

Over the years a number of clinical trials have concluded topical moisturizers lessen the symptoms and signs of AD including erythema, pruritus, fissuring and lichenification. There is no side effect profile for these moisturizers or a limit to their daily use; therefore they should be the mainstay of treatment for all patients with AD. In addition, they reduce the amount of prescription medication needed to decrease inflammation. For mild disease moisturizers can be the primary treatment, but they also should be an integral part of the plan for moderate to severe condition as well.     

Bathing practices can have a huge effect on atopic dermatitis depending on the manner in which it is carried out. For instance, water can hydrate the skin as well as remove scale, crust, allergens and irritant contacts which can be helpful to the patient. However, if the water is left to evaporate from the skin after bathing it will increase the transepidermal water loss. This causes the skin to be even dryer than it was prior to the bath and the reason that moisturizers must be applied immediately after the bath to lock in moisture. There are no recommendations as to how many baths per week a patient with AD should have, but the length of bathing should be kept to a minimum of  5-10 minutes.

One exception is that for patients with extreme inflammation in which soaking the skin for 20 minutes immediately followed by application of a topical steroid can dramatically improve symptoms. Most soaps are alkaline and cause damage, dry skin and irritation to the skin. Therefore, use of non-soap cleansers that have a low pH, fragrance free and hypoallergenic should be used.

Individuals with atopic dermatitis are predisposed to skin infections because of their compromised skin barriers. A common colonizer Staphylococcus aureus is the most prevalent bacteria present on the skin. Its presence, even without active infection, triggers multiple inflammatory cascades that further damage the epidermal barrier. A review of the literature found no support for use of oral or topical antibiotics, antiseptics, antibacterial soaps or bath additives in the setting of AD. One exception to this is the use of bleach baths in pateints with moderate to severe AD. The current recommendation is one-quarter cup plain bleach to a full bathtub of water twice per week for treatment resistant cases.

There are many treatment options available for atopic dermatitis. However, not all treatments work for all patients and finding the right mixture of treatments can be a daunting task. A through understanding of the mechanisms affecting atopic skin and a wide variety of treatment options will better prepare the nurse practitioner to effectively treat these patients. 

Arthurs' passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

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Eczema: An Itchy Nuisance
December 23, 2015 8:44 AM by Guest Blogger

By Darrel Arthurs, ARNP, DCNP

Eczema, or more specifically atopic dermatitis (AD), is one of the most common skin conditions affecting hundreds of thousands of individuals per year. It is most common in children, but can continue into adult hood becoming a life long nuisance.

The condition is genetic and associated with skin lipid and lipid production deficiencies, as well as filaggrin mutations. While there are entire studies conducted on the protein filaggrin and what it does within the skin it is most important to understand that without it the skin cannot hold onto water. Therefore, it is exceedingly difficult for people with eczema to maintain moisture within their skin. The mutation associated with decreased filaggrin production is present in approximately 50% of people with atopic dermatitis.

Atopic dermatitis usually begins in infancy, 3-6 months of age is most common, but it can develop, however, rare, later in life as well. Frequently, atopic dermatitis is associated with both asthma and allergies and the patient will have two or all three conditions. Itching is the most common symptom and will frequently keep the patient awake at night or even wake them from sleep in order to scratch. The itch is constant with no respite and quality of life is dramatically decreased with the patient constantly itching, scratching, bleeding, getting infections and losing sleep.  Staph infections are common with this condition.

The winter months are normally worse for patients with this condition however, some patients report issues with the summer months as well. Sun exposure especially those of UVB are a treatment for atopic dermatitis, but it could be that some allergens become more prominent that time of year, affecting the patient, or even just that the skin becomes dryer with sun exposure creating a worsening condition for some patients.

The rash of atopic dermatitis often will begin as papules and then coalesce and spread into erythematous plaques with excoriations. For children the rash develops on the cheeks, often sparing the mouth, extensor surfaces and the scalp. Older children and young adults will have the condition in the flexural folds of the neck, elbows, knees and ankles. Adults who have the condition will have involvement of the hands, wrists, feet, ankles and face, especially around the eyes and across the forehead. More mature patients will frequently have lichenification of the affected areas especially those that have had the condition for many years.

Atopic dermatitis is a debilitating condition for many people and it is important to recognize and diagnose the condition appropriately. The American Academy of Dermatology spearheaded a research project and developed criteria for the diagnosis of AD in infants, children and adults. It can be found at: http://dx.doi.org/10.1016/j.jaad.2013.10.010. In my next article I will discuss some treatment options for all severities of the atopic dermatitis.

Arthurs' passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

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Supporting Veterans
November 19, 2015 9:20 AM by Debra Shelby
It seems like every day we open up the newspaper or watch the news and see the negativity towards law officers and our military personnel. The National Academy of Dermatology Nurse Practitioners and the American College of Dermatology Nurse Practitioners want to recognize fallen soldiers and fallen law officers at our next conference. We want the world to know that there are thousands, if not millions, of nurses who support our military and law enforcement.

At the annual 2016 NADNP/ACDNP Dermatology Conference, we will be dedicating the week to honoring these fallen heroes. In addition, we will be hosting selected families of these fallen heroes as our guest for the week at the Sheraton Sand Key Resort.

We are also sponsoring a Wounded Warriors Project Beach Event to honor those who gave the ultimate sacrifice for our country. Proceeds from this event will help our soldiers and their families in need of help.

Please come show your support by attending the conference. Every year, we set aside scholarships for those who need help attending. NP or PA students have the opportunity to volunteer for a free main conference registration.

2016 NADNP/ACDNP Events

  • May 10, 2016: Clearwater Beach Marina Aquarium Exclusive After Hours Dinner Event. We will be sponsoring needy children for a fun visit at the marina to see Winter and Hope.
  • May 11, 2016: Opening Ceremony for Fallen Heroes is part of the main conference. Please come support our families as we have the University of Florida's Honor Guard performing a missing soldier military formation.
  • May 11, 2016: Exhibit Hall Party with Moffitt Cancer Center Cutaneous Program Charity Event to raise money for melanoma and other skin cancer research.
  • May 12, 2016: Wounded Warriors Beach Event with live music and food. Come spend time with our wounded warriors.
  • May 13, 2016: Dali Museum Psoriasis Event with live music, food and symposiums. This event is open to the conference registrants and the physician, NP and PA communities to help raise money for the National Psoriasis Foundation.

Please visit nadnp.enpnetwork.com or nadnp.net for more information!

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Skin Cancer Risk & Military Service
October 22, 2015 10:18 AM by Guest Blogger
By Dr. J. Michael Williamson, Lt Col, USAF, NC

Skin cancer is a risk for all persons. Within the military there is was found a higher incidence in melanoma in service members as compared to the general population.1 Service members are frequently required to work outside exposed to sunlight for long hours a day. 

Given the increased risk for melanoma nurse practitioners should consider extra focus on the increased risk for skin cancer for current service members and those who have served. "Skin Cancer Risk Factors and Preventative Behaviors among United States Military Veterans Deployed to Iraq and Afghanistan" is a recent article that reinforces this need.2

References

  1. Zhou J, et al. Melanoma incidence rates among whites in the U.S. military. Cancer Epidemiol Biomarkers Prev. 2011;20(2):318-323. doi:10.1158/1055-9965
  2. Powers JG, et al. Skin cancer risk factors and preventative behaviors among United States military veterans deployed to Iraq and Afghanistan. Journal of Investigative Dermatology. 2015. doi:10.1038/jid.2015.238
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Wet Wraps
September 28, 2015 2:35 PM by Guest Blogger

By Darrel Arthurs, ARNP, DCNP

Recently there has been a surge of information touting the effectiveness of wet wraps for childhood eczema. The treatment has been utilized for years by dermatology professionals but now it is becoming more of a main stream treatment. Researchers at the National Jewish Health in Denver, Colo., recently published a study on the effectiveness of wet wraps. They found that the treatment could reduce symptoms by as much as 71% if utilized correctly.

Some providers may not be aware of exactly what wet wraps are and how they are utilized. They are dressings that are often made of clothing that have been soaked in warm water and applied over a topical steroid or thick, creamy, moisturizer. After they are applied to the child a dry layer is added over the areas of treatment in order to entrap all of the moisture on the skin. The wet wraps can encompass large body areas such as the trunk and extremities or they can be used only over specific areas such as the antecubital or popliteal fossa's. In either case they are typically reserved for more severe cases of eczema. 

While this is an easy treatment which can be performed at home Mark Boquniewicz, MD, a pediatric allergist and immunologist who coauthored the study strongly recommends supervision by the family's dermatology provider in order to determine if the treatment is appropriate for their condition. He also states that more harm can be done to the child if the treatment is used incorrectly or overly used.

The exact details used in the study involves allowing the affected areas of the child to soak in lukewarm water for 20 minutes prior to applying creams and or prescribed topical steroid ointments.  The child is then immediately dressed with a wet cloth (gauze or surgical netting can also be used) which seals in the moisture. There is no drying performed after soaking the skin. Next a dry layer of clothing is applied and the patient is instructed to have minimal activity for two hours after which time the clothing is removed. As the water evaporates from the bandages the skin will cool thus decreasing inflammation. At the same time a significant amount of moisture will be absorbed by the skin allowing healing to occur.

Many of the patients in the study returned home and continued to have clearance of symptoms for nearly a month even without the use of topical steroids. During the study period the wet wraps were applied 2-3 times per day depending on severity of the child. After four days of treatment dramatic results were noted with the majority of children. With the numerous documented side effects of both oral and topical steroids wet wraps offer a workable alternative for those families that are concerned about possible side effects and their children's health.

Arthurs' passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs is on the NADNP Board of Directors.

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Which Biopsy Method is the Best for Pigmented Lesions?
August 14, 2015 7:26 AM by Guest Blogger

By Darrel Arthurs, ARNP, DCNP

 

A literature review was conducted to determine, "What is the best biopsy method for pathology diagnosis of malignant melanoma?"

There are three types of biopsies that can be performed in the office, which will aid in the diagnosis of melanoma. First, a wide local excisional biopsy is where an ellipse of skin is removed with the entire pigmented lesion intact. Second is a punch biopsy where a small circular piece of tissue is removed to the fatty layer. Finally a shave biopsy where a saucerization is performed around the lesion, within the dermis, and an attempt to obtain as much of the lesion as possible is performed.

The National Comprehensive Cancer Network guidelines recommend excisional biopsy as the preferred method. However, there may be a variety of reasons this type of biopsy cannot be performed. One of the most recognized reasons is clinician's level of expertise. For instance, some lesions may just be too large to remove safely depending on the skill level of the provider. Other lesions may be in an anatomically impractical location such as on the ear, face, or feet. For these reasons some providers may not be comfortable doing an excisional biopsy. Therefore, an alternative method is needed but which one is the best choice?

There are many concerns about doing either a punch or shave biopsy in place of performing an excision. If the entire depth of the lesion is not obtained it will be difficult if not impossible to measure the Breslows depth, which is used to grade the tumor stage. Without this information the treatment course may be more of a guess as opposed to using strong clinical guidelines based on studies and patient outcomes. A shave biopsy is concerning for not getting the entire depth of the lesion. Proper training can significantly improve the outcome of the shave biopsy and increase its clinical value however occasionally the base of the lesion is still missed.  A punch biopsy will only obtain a portion of the pigmented lesion however, it does take a full thickness of the skin. The obvious drawback to this biopsy is that it will only take a small area of the lesion. It was found that punch biopsies were best used in smaller lesions less than 1 cm diameter and that the punch used was nearly as large if not larger than the lesion itself.

Not surprisingly the findings concluded that both procedures resulted in more residual disease than wide local excisional biopsy. Punch biopsies were associated with even more residual disease than shave biopsies were. It was also found that both biopsies were frequently associated with upgrading in tumor severity on subsequent pathology in comparison to original biopsy. This was particularly true for the punch biopsy which frequently only takes a small portion of the lesion present. The shave biopsy was the least upgraded of the two methods however it was still, often times, upgraded as well. It was also found that training levels of the clinicians greatly impacted the upgrading of both biopsies.

Overall, the findings indicated that biopsy type did not impact the diagnosis of malignant melanoma. It also did not adversely impact the outcomes

of any diagnosed melanoma. The most important factor was getting the diagnosis of melanoma quickly and then referring the patient for the appropriate intervention. If a melanoma is suspected a biopsy needs to be done immediately. It is most preferable that biopsies of these lesions be completed at the time of initial findings and not at a later date. A provider may not be able to perform a wide local excisional biopsy immediately but either a shave or a punch biopsy can be safely used to diagnosis malignant melanoma as well.  If these biopsies are used in the correct situations and appropriate follow-up with a surgeon is adhered to the outcomes for the patients can be truly positive.

Arthurs' passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma. Arthurs' is on the NADNP Board of Directors

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2015 NADNP Conference Sponsors and Exhibitors
July 22, 2015 2:35 PM by Debra Shelby

                                                                           

NADNP is extremely grateful for all of our sponsors and exhibitors. Without them, our conference, scholarships, and charity work would not be possible! When they visit you in your practice setting, please thank them for their support to NP education.

 Sustainer Sponsors  

Allergan, Genentech, Lilly, Abbvie

Supporter Sponsors 

  DUSA, Galderma, 3Gen, Leo

Special Educational Support: PharmaDerm

2015 Exhibitors

Florida Specialty Medical Services LLC., Hill Pharma, L'dara, Bio-Oil, Smith-Nephew, Leo, Bayer Healthcare, Abbvie, 3Gen, Novartis, Genentech, PharmaDerm, Pharmaceuticals Specialties Inc., Allergan, Dusa, La Roche-Posay, Galderma, Prestium Pharma, Valeant, Janssen Biotech, Celgene, Castle Biosciences Inc., Florida Nurse Practitioner Network and Lasting Impressions Jewelers

Is your favorite company not on the list? Let them how important it is to support NP dermatology education through NADNP!

Please visit our website at www.nadnp.net

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