Top Tips for Optimizing Patient Care

In a presentation at the 2022 Fall Clinical Dermatology Conference for PAs & NPs, held June 3 to 5, in Scottdale, Arizona, expert panelists shared their best-practice strategies for delivering top-tier patient care.¹

The session presenters included James Q. Del Rosso, DO, research director of JDR Dermatology Research in Las Vegas, Nevada and senior vice president of clinical research and strategic development at Advanced Dermatology & Cosmetic Surgery in Maitland, Florida; April Armstrong, MD, MPH, professor of dermatology, associate dean of clinical research, University of Southern California; and Mark Lebwohl, MD, FAAD, dean for clinical therapeutics and Waldman professor and chairman emeritus of the Kimberly and Eric J. Waldman Department of Dermatology, Icahn School of Medicine at Mount Sinai in New York, New York, and a member of the Dermatology Times® editorial advisory board.

Armstrong’s tips included:

Tip 1: Isotretinoin and Laboratory Monitoring

Is it ok to change this to: Reports have associated isotretinoin use with complete blood count, comprehensive metabolic panel, and lipid panel abnormalities, according to the presentation. Should Additionally be changed to however, since the first sentence is about adverse outcomes but this seems to say the outcomes weren’t uncommonly bad. Additionally, meta-analysis has shown that mean changes in white blood cell count, lipid levels, and liver function tests were not abnormal or common enough to warrant monthly laboratory testing.

According to Armstrong, isotretinoin abnormalities usually arise in the first 2 months of use. Since the next two sentences would need some clarification, can we just skip to her quote? She suggested that continuous laboratory monitoring is unlikely to affect or is she saying that patient management if the dose remains the same.² You need some transition here to make this flow from the other points—or leave it out.”

“Check labs at baseline, month 1, and month 2,” she recommended. “With that process of checking, if abnormalities were to occur, you can detect and treat it.”

Tip 2: Potassium Testing in Healthy Young Women Taking Spironolactone

Spironolactone historically has been thought to cause occult hyperkalemia. However, according to Armstrong, there has been no increase in the incidence of hyperkalemia among young women taking spironolactone for acne. Therefore, she noted that potassium testing is unnecessary in healthy young women—characterized in the study as those under 40—taking spironolactone, according to a sited study by the Journal of American Medical Association Dermatology (JAMA Dermatology).³

“Obviously if you’re in doubt, check baseline potassium levels,” she said. “Ask for a history of kidney problems in family history.”

Del Rosso added, “You can never be faulted for checking at baseline.”

Tip 3: Patients with Suspected Pyoderma Gangrenosum

Armstrong stressed the importance of checking differential diagnosis when pyoderma gangrenosum (PG) is suspected.

“40% of [cases] biopsied were not PG,” she said. “We want to widen our differential diagnosis.”

Differential diagnosis for PG includes:

• Infectious: Bacterial, fungal, parasitic, viral, and mycobacterial
• Vascular: Venous, arterial, and Martorell’s ischemic hypertensive leg ulcer
• Malignancy: Basal cell carcinoma, squamous cell carcinoma, and lymphoma
• Exogenous: Factitial and tissue injury from spider bites

For skin biopsy, she suggested biopsy at the edge of the lesion, ideally in an early lesion prior to initiation of treatment. When cutting, incise down to the subcutaneous fat and look for special stains indicating diagnosis—Brown and Brenn (B&B), Grocott’s Methenamine silver, periodic acid-Schiff, and acid-fast bacilli.

Lebwohl added, “Biopsy is almost never helpful [unless] it’s for exclusion. [And] If it’s on the hand alone, it’s not pyoderma gangrenosum.”

Tip 4: Reduced Vulvar SCC Recurrence in Patients with Vulvar Lichen Sclerosus

To help prevent a reoccurrence of vulvar squamous cell carcinoma (vSCC), Armstrong suggested the use of daily topical corticosteroids after primary excision of vSCC or differential vulvar intraepithelial neoplasia (dVIN). She advised that patients continue daily use until there is a normal texture with a loss of white discoloration. According to a sited study in JAMA Dermatology, patients who used topical corticosteroids had a vSCC and dVIN rate of 27% compared to a 5-year recurrence rate of 44%-47%. Additionally, topical corticosteroid therapy may reduce vSCC and dVIN recurrence rates in patients with vulvar sclerosus.⁴

“For vSCC, we should not be afraid to treat that with topical corticosteroids,” Armstrong said.

References

1. Armstrong A. 10 things you need to know to optimize patient care. Presented at: 2022 Fall Clinical Dermatology Conference for PAs & NPs. June 3-5, 2022. Scottsdale, Arizona and virtual.
2. Lee YH, Scharnitz TP, Muscat J, Chen A, Gupta-Elera G, Kirby JS. Laboratory monitoring during isotretinoin therapy for acne: a systematic review and meta-analysis. JAMA Dermatol. 2016;152(1):35.
3. Plovanich M, Weng QY, Mostaghimi A. Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. JAMA Dermatol. 2015;151(9):941.
4. Chin S, Scurry J, Bradford J, Lee G, Fischer G. Association of topical corticosteroids with reduced vulvar squamous cell carcinoma recurrence in patients with vulvar lichen sclerosus. JAMA Dermatol. 2020;156(7):813.