The Role of Dermatology Advanced Practice Providers With Shanna Miranti, PA-C

In an interview with Dermatology Times®, Shanna Miranti, MPAS, PA-C, a board-certified physician assistant at Riverchase Dermatology in Naples, Florida, discusses her role as a dermatology physician assistant and how fellow advanced practice providers (APPs) can enhance a clinic’s team by improving patient care. Miranti also discusses the race-to-the-finish between Verrica Pharmaceuticals and Novan Inc. to produce the first molluscum contagiosum treatment approved by the US Food and Drug Administration.

Regarding APPs just starting out in their career, Miranti noted, “I want to really edify a lot of the new APPs out there to find mentors; find those of us in this space that have been in dermatology a long time because there's so many of us out there that are truly passionate about teaching. We would be happy to help you and collaborate with you to figure out what's going to be a phenomenal way to get your knowledge of dermatology built up to a comfort level where you feel confident seeing patients, providing wonderful diagnoses, and being able to see your patients with competence.”

Transcript

Shanna Miranti, MPAS, PA-C: Hi, my name is Shanna Miranti. I'm a physician assistant with Riverchase Dermatology in Naples, Florida. And I have been practicing dermatology for over 20 years.

Dermatology Times: What is your role as a dermatology physician assistant at Riverchase Dermatology?

Miranti: I'm very, very proud to be a dermatology PA for over 20 years. I was one of the founding providers for this great practice Riverchase Dermatology, which is now operating under the umbrella of Aqua Dermatology in the southeastern United States. And I've had the privilege to see this you know, amazing practice go from just one doctor and myself to now a practice of over 95 offices within the southeastern United States, and that has given me the perspective of being able to allow to see the growth of a lot of my colleagues in this space. I am like I said, a proud dermatology PA, I'm a physician assistant, and the APPs in dermatology have been doing such amazing work. Really, they are truly advancing patient care and providing access to patient care.

Dermatology Times: How do advanced practice providers help enhance a clinic's team?

Miranti: So, a lot of people ask me what is a PA? What is an NP? What are the differences between the 2 of us? So now we go by the title APP: advanced practicing providers. And we are all proud to work in dermatology. So, we are dermatology APPs. I am a physician assistant, I went to the College of Medicine at the University of Florida. Most physician assistants study under a medical school type of curriculum, where nurse practitioners are actually trained within the nursing school model. And most nurse practitioners are actually getting the designation of DNP which is a doctorate of nurse practitioner. So, we're extremely proud of our colleagues for that. We really work collaboratively with physicians and we are able to provide a lot of care and see more patients than a physician could see on their own. In my practice, I work side by side with physicians all day long. There are physicians in the building at all times. And we are there to provide additional care whether we work with Mohs surgeons or cosmetic dermatologists or medical dermatologists, dermatology APPs are able to somewhat spread our wings a little bit, and depending upon our level of education and comfort level in this space of dermatology, can really truly do quite a bit within this space. I practice in a very large practice. And it is a practice that I'm so proud of having been there to kind of build a lot of it along the way. And we have a lot of doctors that collaborate along with APPs. The APPs in my practice are sometimes the ones doing the complex medical derm just because dermatologists in our area are so busy working on skin cancers and doing Mohs or they maybe do not have the bandwidth or the space in their schedule to see these complex cases. So, we have some phenomenal nurse practitioners within our practice that are our complex medical derm experts. I myself am more of the pediatric dermatology and more general dermatology space. I do a little bit of lasers, so we are able to dabble in some cosmetics and cosmetic dermatology. I work with our dermatology APPs that just specialize in cosmetics and they do lasers, fillers, neurotoxins and what have you. So it's a really incredibly fun industry to be involved with because you can find your passion as an APP. You can decide what you really want to see and what you love to see and keep kind of chasing that dream and carve out your own type of practice along with a collaborating physician. I've always had amazing physicians that were there for me the entire time that edified me and educated me in the space of dermatology. And I know that there are still a lot of doctors out there that want to do the same thing for their APPs.

But some APPs come into dermatology with very little experience in dermatology, and they're just thrown in and expected to start doing biopsies and seeing a ton of patients. So, there are actually some organizations out there through the SDPA, the Society for Dermatology Physician Assistants, through the DNA organizations and the Dermatology Nurse Practitioner organizations, and even some nationwide organizations that are APP focused and truly dedicated toward education. I'm on the board of diversity in dermatology, which is an all-dermatology APP organization nationwide. And we actually have an Achieve program which is a year-long curriculum that new APPs to the space of dermatology, whether you've been practicing in emergency medicine for 19 years or whether you are brand new right out of PA school or right out your nurse practitioner program, you can actually join this program and get phenomenal education, live web-based education seminars from some of the top key opinion leaders, the doctors in this country that are truly wonderful educators. So, there are some programs that are like that, I know that a number of practices have dermatology PA residency programs. So, there was a lot of education in this space, because we know that the doctors sometimes don't have the time to train all of us and put all of us through a true residency. So, a lot of times it's trial by fire. And if you talk to a number of dermatology APPs, they'll tell you just that, they might have been thrown into a situation where they just had to learn on their own and they had to study on their own. But I want to really edify a lot of the new APPs out there to find mentors; find those of us in this space that have been in dermatology a long time because there are so many of us out there that are truly passionate about teaching. And we would be happy to help you know, kind of collaborate with you, and figure out what's going to be a phenomenal way to get your knowledge of dermatology built up to a comfort level where you feel confident seeing patients and providing wonderful diagnoses and being able to see your patients with competence. Certainly, we always want that collaborative relationship. We want to have that side-by-side relationship with our doctors and make sure that our doctors are confident in our ability to see their patients and our patients as well.

Dermatology Times: Verrica Pharmaceuticals and Novan Inc. are currently competing for the first FDA-approved treatment of molluscum contagiosum. What is your experience with treating this disease state?

Miranti: So it is a very exciting time in pediatric dermatology right now. We have 2 pharmaceutical companies essentially in a race to the finish, to get the very first FDA-approved treatment for molluscum contagiosum. Verica Pharmaceuticals has Ycanth or VP-102 that has been in development for a number of years, and it is a drug-device combo with cantharidin in a precise, small, very fine-tipped pen that will be able to be applied in the office by providers to our patients directly to the molluscum lesions. This will be a stained violet, like a purple-colored stain, that will be able to precisely apply a very distinct amount and a very small amount of cantharidin to each individual molluscum. Right now, we are actually utilizing compounded cantharidin from usually multiple sources, sometimes Canada, and it's not always the same, you know, we want consistency, we want to make sure that the patients we treated a year ago, six months ago, last month, last week, are given the exact same consistent treatment. And right now, it's kind of all over the place. So, we really do need consistency, and it will be so nice to have an FDA-approved option to use in the office.

The other competitor in this race to the finish is Novan Inc., which will be coming out with a topical prescription called berdazimer gel. And this is a topical that will be used by patients at home. So even though this has turned into more of a marathon than a sprint, we've been waiting for these medicines to come out, and believe me, no one is more excited about them coming out than the companies themselves. They are truly chomping at the bit to be the first one FDA approved. Berdazimer will be, if it is first, the first take-home topical medication that patients can actually apply that has been FDA approved. Again, in that space right now, we are using compounds that sometimes work wonderfully but they can have some variation from pharmacy to pharmacy, there's not always one consistent compound that's used nationwide. So it will be again very nice to have consistency and to have very appropriate results that are able to be achieved and recreated from the clinical trials. So again, this may be a very exciting next year. They believe and anticipate that both of these may be released by the very end of 2023 or even early 2024. And I'm sure that a lot of dermatology APPs like myself will be extremely excited to get our hands on these products. Because right now there's nothing FDA-approved for molluscum. It's amazing to think about that, molluscum affects 6 million Americans and over 70% go untreated because they just think that they're bumps or they think they're cosmetic or because they're not causing any pain, maybe they're not such a problem, but it is a contagious condition. It's something that because I work in pediatric dermatology and general dermatology I see every single day. I think I had 3 or 4 cases of molluscum today on my schedule. So, it's something that it will be wonderful to have an FDA-approved drug in our armament. Again, we want to make sure that we have proven safe medications that we are able to provide for our patients. So, we are extremely excited to finally get our hands on some of these medicines.

[Transcript edited for clarity]