Are you ever intimidated when dermatology chief complaints appear on your schedule? If so, you are not alone. NP, PA, and MD new graduates consistently list dermatology as one of the top 3 areas of least confidence. After 12 years of working in an outpatient dermatology clinic, I want to share a few pearls to increase your comfort level when dermatology complaints walk into your exam rooms.
1. The advantage
You cannot feel a patient’s abdominal pain or experience their headaches, but you can see their skin problem. This already puts you ahead of the game compared with other types of visits.
2. Barrier Repair
Barrier repair is a hot topic in dermatology. What does it mean? It refers to restoring the outermost layer of the skin, the Stratum Corneum (SC). Picture the SC as a brick wall. In healthy skin, the bricks and mortar form a tight network and provide a solid fortress against moisture loss and entry of external irritants, allergens, and bacteria. When the SC is compromised due to dry skin, genetics, or skin diseases, the bricks become shrunken, creating gaps that allow passage into and out of the skin. This broken skin barrier is at the heart of many skin problems. The good news is that the SC can be repaired with the following recommendations:
Bathe daily with a mild, gentle cleanser. This washes away irritants, allergens, and bacteria. Pat dry.
Within 3 minutes of patting dry, apply a moisturizing cream. This is known as the “soak and seal” technique. The skin soaks in water while bathing, and the moisturizer seals it into the skin. It is very important to use a moisturizing cream that contains Ceramides, the building blocks of the SC. Ceramide-containing moisturizers are available OTC.
This simple routine can improve and even eliminate many skin problems. You should recommend this regimen to all patients, including children and infants, who suffer from skin diseases. If the patient has a steroid responsive condition, instruct them to layer topical steroid on top of the moisturizer after bathing. I teach patients to “layer the moisturizer and Rx like peanut butter and jelly”. This layering technique improves absorption and reduces the risk of steroid atrophy.
3. Vehicle selection
Have you worked with a colleague who has a favorite “go to” topical steroid cream regardless of the diagnosis? You can do better! Whether using OTC or Rx topicals, the vehicle, or delivery system for the active ingredient, makes all the difference. All vehicles are not created equal. Due to low water content among other factors, ointments are the most effective vehicle. Mometasone .1% ointment, for example, is a class II topical steroid. Mometasone .1% cream is a class III-IV topical steroid. The active ingredient is the same; the vehicle changes the potency. Think of vehicles in this way:
Ointment= tank. Cream= SUV. Lotion= small car. Solution= bicycle.
I infrequently see PCPs Rx ointments, but I almost always select an ointment when treating a dry condition, such as Atopic Dermatitis or Psoriasis. Ointments are also an excellent choice for raw, abraded areas, because they do not sting or burn. They are greasy, so some patients may be resistant for cosmetic reasons.
4. Topical Clindamycin
Never Rx topical Clindamycin as monotherapy for acne. P. acnes, the bacteria that contributes to breakouts, has a high rate of resistance to topical Clindamycin. In order to be effective, it must be used in combination with Benzoyl Peroxide (BPO). It is appropriate to Rx a combination Clindamycin/ BPO product or to have the patient use a BPO cleanser prior to applying Clindamycin.
5. Non-healing lesions
I frequently see patients with skin cancer who were treated with Mupirocin or oral antibiotics for many months prior to biopsy or referral. Skin cancer often looks like a sore that will not heal. If it is a true sore, it should heal within a 4-6 week period. If a lesion does not heal within 4-6 weeks, biopsy or refer for evaluation.
6. Medication reactions
Adverse skin reactions to medications are very common and come in many forms. Drug eruptions may be dramatic and appear as a maculopapular eruption that typically starts on the trunk or a blistering rash. They can also be more subtle and itch more than they rash- meaning that they often are very itchy and bothersome but may not look very dramatic. When you see a patient experiencing intense itching without dramatic skin findings, a medication reaction should be included in your differential. New medications, dosing changes, and manufacturer switches are all red flags that may uncover the culprit. Antibiotics are common causes and typically trigger a more abrupt onset and a more dramatic skin eruption. Other medications such as statins, NSAIDs and Proton Pump Inhibitors are some of the most common, less familiar, triggers of long-standing itching and rashes. Never underestimate the power of medications, including OTC meds, to cause itching and rashes. It is important to note that the symptoms may not resolve completely for 2-3 months after discontinuing the medication. Most patients, though, do notice an improvement in their symptoms within 1-2 weeks of stopping the trigger.
7. Dermatology resources
The following resources are great places to learn more about dermatology and improve your diagnostic and treatment skills.
Visual Dx: a “diagnostic clinical decisions support system” with a large dermatology database. www.visualdx.com
Learn Skin: a free podcast that “investigates the intersection of Eastern and Western medicine to inform an integrative approach to dermatology”.
Thrive AP: Our 12-month program includes dermatology lectures to help “fill in the skills gap” that NPs and PAs face with their first years of practice. For more information on how to enroll in ThriveAP, contact firstname.lastname@example.org.
Allison King, FNP-C, studied at the University of Mississippi undergraduate and then continued on to receive her Masters at Vanderbilt University School of Nursing. She has been practicing at Mid-South Dermatology in Memphis, TN since 2008, and is a frequent speaker for ThriveAP. Allison is a member of the Memphis Dermatology Society, the Nurse Practitioner Society of the Dermatology Nurses’ Association, and serves as the regional president of the Mid-South chapter of the National Academy of Dermatology Nurse Practitioners.