Clinical Pearls: PDPA’s 5th Annual Keystone Dermatology Conference

Image Credit: © Samuel Lustig

CME Session: What’s Hot in the Journals

Hannah Rodriguez, MPAS, PA-C and current President of the Pennsylvania Dermatology Physician Assistants (PDPA), highlighted the conflicting meta-analysis data on 5-alpha reductase inhibitors (5-ARIs) for androgenetic alopecia and their association with sexual dysfunction (SD). She noted that the prevalence of obesity, nicotine dependence, diabetes mellitus, hypertension, mood, and anxiety disorder was much higher in those exposed to 5-ARI with SD. This raises the question if it is the drug itself or if comorbid conditions are contributing to SD.

Karen Limaye, FNP-C, DCNP highlighted the prevalence of delusions of parasitosis in those patients of female gender, advanced age, on polypharmacy (>5 drugs), ADHD medications, SSRIs, gabapentin, and opioids. She emphasized the importance of obtaining an accurate medication history when evaluating patients thought to be afflicted with this disorder. Limaye expressed that stimulants, SSRIs, and gabapentin may contribute to off-target effects on the brain, altering neural connectivity that may affect the process of fear conditioning and contribute to the disorder. She noted that reviewing the renal clearance of drugs is also critical as this is a debilitating disorder that requires a thoughtful management approach.

Psoriasis: Improving Outcomes and Cost-Effective Care

Joel Gelfand, MD, MSCE, a leading authority in psoriasis, asserted that phototherapy is cost-effective, safe, and can improve cardiovascular biomarkers. Randomized control trial data shows that phototherapy may have cardiovascular benefits by way of reducing IL-6 and improving HDL-P. This is a great reminder that while novel therapeutics have altered the way we treat psoriasis, we must consider that older treatments offer their own unique benefits as well.

Gelfand also reminded attendees that we should strive to aggressively and appropriately treat psoriasis in an effort to lower patients' risk of cardiovascular disease. He refers to hypertension as the “silent killer” and psoriasis as the “visible killer.” He educates patients and colleagues alike that inflammation manifested cutaneously mirrors internal inflammation, highlighting the need to treat psoriasis as more than skin deep.

Considering the constant evolution of novel therapeutics for the treatment of psoriasis, he stated that 4 agents have shown the best efficacy based on a Cochrane network meta-analysis consisting of 167 studies of 20 different agents. These therapies are infliximab (TNF), ixekizumab and bimekizumab (IL-17), and risankizumab (IL-23). When considering the plethora of options we have to treat psoriasis, he notes that IL-17 agents are likely the fastest while IL-23 agents are likely the best at 1 year. There are significant nuances in both safety and efficacy within and between the drug classes.

Procedural Dermatology: 5 Surgical Pearls to Improve Patient Outcomes

Theresa Talens, DNP, FNP-C, highlighted how employing the set-back buried dermal suture technique can optimize skin eversion, minimize wound inversion, and provide excellent scar cosmesis. She also detailed the utility of the cross pulley stitch when operating in areas of high tension, like the central chest or the lower extremities, to enhance patient outcomes.

Pearls for Pediatrics

Pediatric dermatologist, James Treat, MD, emphasized the importance of early detection and treatment of morphea. Linear morphea of the face in its early presentation may manifest as a subtle linear patch down the forehead, which can easily be mistaken for a nevus simplex. The notable difference between the two is time of presentation. Eliciting a careful history from parents and doing a thorough clinical examination is imperative to establish an accurate diagnosis and avoid ophthalmologic complications and seizures.

Treat also shared that dupilumab blocks TH2 cytokines but upregulates TH1. He highlighted a pediatric case in which a child with atopic dermatitis was burdened by a large number of verrucae. After initiating the patient on dupilumab, he noted a dramatic improvement in the patient's warts, demonstrating that TH1 immunologic response can help to clear verrucae.

Cosmetic Neurotoxin Injectables

Corinn Singletary, MS, PA-C, reviewed the many intricacies of injecting neurotoxins for cosmetic indications. She emphasized the importance of evaluating each patient and their unique anatomy rather than using “cookie cutter” techniques on all patients. The presence of dermatochalasis, for instance, must be considered when injecting the only elevator of the brows as injecting the frontalis can result in significant worsening of underlying eyelid hooding. She also reviewed the line of convergence as it relates to the elevation of the eyebrows and the depression of the scalp. This anatomic structure can be used to our advantage in order to produce the desired cosmetic outcome. 

Finance and Employee Contracts: Issues and Negotiation

Attorney Randall Gold, ESQ, presented the nuances of NP and PA employment contracts and considerations for negotiations. He emphasized the importance of having one's contract reviewed by a seasoned contract lawyer, prior to signing the document, and educated attendees on topics such as malpractice insurance, timely access to billing and collection figures, and restrictive covenants.

Infectious Diseases and Dermatology

Misha Rosenbach, MD, encouraged attendees to speak to patients about the utility of the HPV vaccine, not only as it relates to genital warts and certain cancers, but as it relates to common warts. He also reminded attendees that molluscum contagiosum is considered to be an STD in adult patients. As such, we should be mindful to check for other STDs like syphilis and HIV during treatment.

Decoding Dermatology: From Text to Diagnosis

Veronica Richardson, MSN, ANP-BC, DCNP, spoke about the unique challenges healthcare providers routinely face when friends and family members solicit medical advice. She reminded us that we should treat friends and family in the same way we treat our patients in the clinic. This means that we must ask “uncomfortable” questions to form an accurate diagnosis and appropriate treatment plan.

Common Nail Clinic Consults and How to Manage Them

Adam Rubin, MD, known for his expertise in nail disorders, stressed the importance of behavioral modification when treating pseudomonas of the nail, onycholysis, and chronic paronychia. He provided attendees with several recommendations, including;

• Limit physical trauma to the cuticles
• Avoid aggressive cleaning under the nails as this promotes onycholysis and invites the potential for organisms to invade the empty space
• Trim back a lifted nail plate if impacted by pseudomonas and onychomycosis
• Wear cotton gloves followed by heavy-duty vinyl gloves when doing “wet work”

Advanced Dermoscopy: Facial Lesions and Case Studies

Lori Fiessinger, MD, challenged attendees to accurately diagnose skin lesions based on their dermoscopic appearance. She reviewed algorithms for examining complex lesions, such as those encountered on the face. Actinic keratoses, for instance, tend to manifest with some degree of scale, enlarged follicular openings, and a “strawberry” pattern under dermoscopy. A clue for lentigo maligna on the face is the presence of multiple sizes of follicular openings rather than a uniform size as seen in actinic keratoses. In basal cell carcinomas, she noted that the arborizing vessels are “in camera focus” in contrast to vessels in the surrounding skin.

Jamie Restivo, MPAS, PA-C, graduated from Towson University’s CCBC Essex PA Program with a Master of Science in Physician Assistant Studies in 2017. She serves as the pioneer PA of Crumay Parnes Associates in Enola, Pennsylvania, and is the incoming president of the Pennsylvania Dermatology Physician Assistants (PDPA).