JDPA Fall 2017 by Angela Simiele

DPA J

V o l u m e 1 1 • n u m b e r 4 • F A LL 2 0 1 7 • www.jdpa.org

Journal of Dermatology for Physician Assistants

Dermatology PA News & Notes From the Desk of... 41 __________________________________

CLINIcal dermatology Clinical Snapshots

__________________________________

surgical dermatology Surgical Wisdom 26 _________________________________

cosmetic dermatology Cosmetic Pearls 31 __________________________________

professional development Notes From Your Office Manager

›› Earn CME credit with this issue CME Overview of Vitiligo

Anniversary Year

Official Journal of the Society of Dermatology Physician Assistants

Volume 11 • number 4 • FALL 2017

BRIEF SUMMARY OF FULL PRESCRIBING INFORMATION FOR LUZU (luliconazole) This Brief Summary does not include all the information needed to use LUZU safely and effectively. See full Prescribing Information for LUZU. LUZU (luliconazole) Cream, 1% for topical use Initial U.S. Approval: 2013 Rx Only INDICATIONS LUZUÂŽ (luliconazole) Cream, 1% is an azole antifungal indicated for the topical treatment of interdigital tinea pedis, tinea cruris, and tinea corporis caused by the organisms Trichophyton rubrum and Epidermophyton floccosum, in patients 18 years of age and older. DOSAGE AND ADMINISTRATION For topical use only. LUZU Cream, 1% is not for ophthalmic, oral, or intravaginal use. When treating interdigital tinea pedis, a thin layer of LUZU Cream, 1% should be applied to the affected area and approximately 1 inch of the immediate surrounding area(s) once daily for two (2) weeks. When treating tinea cruris or tinea corporis, LUZU Cream, 1% should be applied to the affected area and approximately 1 inch of the immediate surrounding area(s) once daily for one (1) week. ADVERSE REACTIONS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug, and may not reflect the rates observed in practice. In three Phase 3 clinical trials, 616 subjects were exposed to LUZU Cream, 1%: 305 with interdigital tinea pedis and 311 subjects with tinea cruris. Subjects with interdigital tinea pedis or tinea cruris applied LUZU Cream, 1% or vehicle cream once daily for 14 days or 7 days, respectively, to affected and adjacent areas. During clinical trials with LUZU Cream, 1% the most common adverse reactions were application site reactions which occurred in less than 1% of subjects in both the LUZU and vehicle arms. Most adverse reactions were mild in severity. Postmarketing Experience The following adverse reactions have been identified during postmarketing use of luliconazole cream, 1%: contact dermatitis and cellulitis. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. DRUG INTERACTIONS An in vivo study in adult subjects with moderate to severe interdigital tinea pedis and tinea cruris showed that LUZU Cream, 1% is a weak inhibitor of CYP2C19 [see Clinical Pharmacology in full Prescribing Information]. USE IN SPECIFIC POPULATIONS Pregnancy _____________ Risk Summary There are no available data with LUZU Cream, 1% use in pregnant women to inform a drug-associated risk for major birth defects and miscarriage. In animal reproduction studies with pregnant rats and rabbits, there were no adverse developmental effects observed with subcutaneous administration of luliconazole during organogenesis at doses up to 3 and 24 times, respectively, the maximum recommended human dose (MRHD) [see Data]. The background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. ____ Data Animal Data The animal multiples of human exposure calculations were based on daily dose body surface area (BSA) comparisons (mg/m2) for the reproductive toxicology studies described in this section and in Carcinogenesis, Mutagenesis, Impairment of Fertility. The maximum recommended human dose (MRHD) was set at 8 g 1% cream per day (1.33 mg/kg/day for a 60 kg individual, which is equivalent to 49.2 mg/m2/day).

Systemic embryofetal development studies were conducted in rats and rabbits. Subcutaneous doses of 1, 5 and 25 mg/kg/day luliconazole were administered during the period of organogenesis (gestational days 7-17) to pregnant female rats. No treatment-related effects on maternal toxicity or malformations were noted at 25 mg/kg/day (3 times the MRHD based on BSA comparisons). Increased incidences of skeletal variation (14th rib) were noted at 25 mg/kg/day. No treatment-related effects on skeletal variation were noted at 5 mg/kg/day (0.6 times the MRHD based on BSA comparisons). Subcutaneous doses of 4, 20 and 100 mg/kg/day luliconazole were administered during the period of organogenesis (gestational days 6-18) to pregnant female rabbits. No treatment-related effects on maternal toxicity, embryofetal toxicity or malformations were noted at 100 mg/kg/day (24 times the MRHD based on BSA comparisons). In a pre- and postnatal development study in rats, subcutaneous doses of 1, 5 and 25 mg/kg/day luliconazole were administered from the beginning of organogenesis (gestation day 7) through the end of lactation (lactation day 20). In the presence of maternal toxicity, embryofetal toxicity (increased prenatal pup mortality, reduced live litter sizes and increased postnatal pup mortality) was noted at 25 mg/kg/day. No embryofetal toxicity was noted at 5 mg/kg/day (0.6 times the MRHD based on BSA comparisons). No treatment effects on postnatal development were noted at 25 mg/kg/day (3 times the MRHD based on BSA comparisons). Lactation

_____________ Risk Summary

It is not known whether luliconazole is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when LUZU Cream, 1% is administered to women who are breastfeeding. Pediatric Use The safety and effectiveness of LUZU Cream, 1% in pediatric patients have not been established. Geriatric Use Of the total number of subjects in clinical studies of LUZU Cream, 1%, 8 percent were 65 and over, while 1.4 percent were 75 and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term studies to evaluate the carcinogenic potential of LUZU Cream, 1% have not been conducted. Luliconazole revealed no evidence of mutagenic or clastogenic potential based on the results of two in vitro genotoxicity tests (Ames assay and Chinese hamster lung cell chromosomal aberration assay) and one in vivo genotoxicity test (mouse bone marrow micronucleus test). In a fertility study in rats, subcutaneous doses of 1, 5 and 25 mg/kg/day luliconazole were administered prior to and during mating and through early pregnancy. Treatment related effects on reproductive function were noted in females (decreased live embryos and decreased corpus luteum) at 5 and 25 mg/kg/day and males (decreased sperm counts) at 25 mg/kg/day. No treatment related effects on fertility or reproductive function were noted at 1 mg/kg/day (0.1X MRHD based on BSA comparisons). PATIENT COUNSELING INFORMATION See FDA-approved patient labeling (Patient Information) Inform patients that LUZU Cream, 1% is for topical use only. LUZU Cream, 1% is not intended for intravaginal or ophthalmic use. Manufactured for: Valeant Pharmaceuticals North America LLC Bridgewater, NJ 08807 USA Manufactured by: Valeant Pharmaceuticals International, Inc. Laval, Quebec H7L 4A8, Canada Issued: 6/2017 Based on 9438801 Luzu is a trademark of Valeant Pharmaceuticals International, Inc. or its affiliates. ÂŠValeant Pharmaceuticals North America LLC LUZ.0030.USA.17

For the topical treatment of tinea pedis, tinea cruris, and tinea corporis due to Trichophyton rubrum and Epidermophyton floccosum in adults1

STRIKE NOW. TREAT FAST.

1 week, 7 doses for tinea cruris and tinea corporis; efficacy seen at 3 weeks post-treatment1 2 weeks, 14 doses for tinea pedis; efﬁcacy seen at 4 weeks post-treatment1

Indications and Usage LUZU (luliconazole) Cream, 1% is indicated for the topical treatment of interdigital tinea pedis, tinea cruris, and tinea corporis caused by the organisms Trichophyton rubrum and Epidermophyton floccosum in patients 18 years of age and older. Important Safety Information LUZU is indicated for topical use only and is not indicated for ophthalmic, oral or intravaginal use. LUZU should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Caution should be exercised when LUZU is prescribed for nursing mothers. The most common adverse reactions in clinical trials were application site reactions, which occurred in less than 1% of subjects in both LUZU and vehicle arms. Most adverse reactions were mild in severity. To report SUSPECTED ADVERSE REACTIONS contact Valeant Pharmaceuticals North America LLC at 1-800-321-4576 or FDA at 1-800-FDA-1088 or visit fda.gov/medwatch. Please see Brief Summary of full Prescribing Information for LUZU on adjacent page. Reference: 1: LUZU [prescribing information]. Bridgewater, NJ: Valeant Pharmaceuticals North America LLC.

Volume 11 • number 4 • FALL 2017

Journal of th Dermatology for Anniversary Physician Assistants Year

EDITORIAL BOARD

Travis Hayden, MPAS, PA-C, Editor in Chief Joe R. Monroe, MPAS, PA Patricia Ferrer, MPAS, PA-C Gordon Day, R.Ph, PA-C Lauren Zajac, MHS, PA-C Michelle DiBaise, MPAS, PA-C Mark Archambault, DHSc, PA-C Kristine Kucera, DHS, MPAS, PA-C Jennifer Winter, PA-C Mark Hyde, MMS, PA-C Jennifer Conner, MPAS, PA-C Jeffrey LaDuca, PhD, MD Alan Menter, MD

DEPARTMENT EDITORS Clinical Department Editors Susan E. King-Barry, MPAS, PA-C Karen Graham, PhD, MPAS, PA-C Dermatology Grand Rounds Editor Cynthia F. Griffith, MPAS, PA-C Dermoscopy Editor John Burns, MSPA, PA-C Drugs in Dermatology Editor Stephen Wolverton, MD Surgical Department Editor Christy Kerr, MPAS, PA-C Cosmetic Department Editor Travis Hayden, MPAS, PA-C Prof Dev Department Editor Abby Jacobson, MS, PA-C

2017-18 SDPA Board of Directors PRESIDENT Jane Mast, MPAS, PA-C PRESIDENT-ELECT Joleen Volz, MPAS, PA-C IMMEDIATE PAST PRESIDENT Jennifer Conner, MPAS, PA-C VICE PRESIDENT John Notabartolo, MPAS, PA-C SECRETARY / TREASURER Gina Mangin, MPAS, PA-C DIRECTORS AT LARGE Renata Block, MHS, PA-C Travis Hayden, MPAS, PA-C Archana Sangha, MMS, PA-C Martha Sikes, MS, RPh, PA-C

editorial missioN: The JDPA is the official clinical journal of the Society of Dermatology Physician Assistants. The mission of the JDPA is to improve dermatological patient care by publishing the most innovative, timely, practiceproven educational information available for the physician assistant profession. PUBLISHED CONTENT IN THE JDPA: Statements and opinions expressed in the articles and communications herein are those of the authors and not necessarily those of the Publisher or the Society of Dermatology Physician Assistants (SDPA). The Publisher and the SDPA disclaim any responsibility or liability for such material, including but not limited to any losses or other damage incurred by readers in reliance on such content. Neither Publisher nor SDPA verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damage incurred by readers in reliance on thereon. Neither Publisher nor SDPA guarantees, warrants, or endorses any product or service advertised in this publication, nor do they guaranty any claim made by the manufacturer of such product or service. This Issue: The JDPA includes articles that have been reviewed and approved for Category I (Preapproved) CME credit by the American Academy of Physician Assistants. Approval is valid for 1 year from the issue date, and participants may submit the self-assessment at any time during that period. Category I CME articles included in JDPA are planned and developed in accordance with AAPA’s CME Standards for Journal Articles and for Commercial Support of Journal Articles. going green: Since its inception, the JDPA has utilized eco-friendly printing practices. The JDPA is printed on paper obtained from sustainable forests that meet strict environmental standards. Soy-based inks that have a low environmental impact are used during printing of the journal and the journal is printed using 100% renewable energy. SDPA members may join us in our efforts and opt to receive the JDPA in digital format.

Publishing Staff Managing Editor Jennifer M. Hayden, M.Ed Copy Editor Douglas Morris Art Director Angela Simiele Website Design Terry Scanlon SALES Office Physician Assistant Communications, LLC P.O. Box 416, Manlius NY 13104-0416 Phone (315) 663-4147 PAC@pacommunications.org www.pacommunications.org Cover Source Image: GNU Free Documentation License

To read the JDPA publication’s Ethics and Malpractice Statement, please visit www.jdpa.org/write.html. keep current with the SDPA:

JDPA/Journal of Dermatology for Physician Assistants (ISSN 1938-9574) is published quarterly (4 issues per volume, one volume per year) by Physician Assistant Communications, LLC, P.O. Box 416, Manlius NY 13104-0416. Volume 11, Number 4, Fall 2017. One year subscription rates: $40 in the United States and Possessions. Single copies (prepaid only): $10 in the United States (Include $6.50 per order plus $2 per additional copy for US postage and handling). Periodicals postage rate paid at New York, NY 10001 and additional mailing offices. © 2017 Physician Assistant Communications, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including by photocopy, recording, or information storage and retrieval system, without permission in writing from the publisher. Postmaster: Send address changes to Society of Dermatology Physician Assistants, Inc., 8400 Westpark Drive, 2nd Floor, McLean, VA 22102 1-800-380-3992., email SDPA@dermpa.org, www.dermpa.org.

Journal of Dermatology for Physician Assistants

Editor’s Message

very issue as I sit down to write for the upcoming issue of the JDPA, I often find myself gravitating back to similar messages: how rewarding it is to be a dermatology PA, what a great organization the SDPA is, why it is so important to volunteer with the SDPA and the DPAF and what makes them so special. This issue is no different. I am beyond words proud to be a part of an organization that continues to put the needs of patients and others before itself. We have all seen the sheer devastation that many of our dermatology colleagues, fellow SDPA members, family, and friends have been faced with in the wake of Hurricanes Irma and Maria. I know that the decision to cancel the conference in Puerto Rico was made with concern and compassion not only for the SDPA members but also for the communities of Puerto Rico that were affected by the disaster. The SDPA working along with the DPAF created an opportunity for our members to give back and help those in the affected areas. The Puerto Rico Disaster Relief Fund is the result of this level of commitment by both the SDPA and DPAF to help those in need. Our supervising physicians have also teamed up through the AAD’s efforts and created funding opportunities for those affected by Hurricane Harvey in Houston, Texas. As PAs we make a commitment to help our patients and provide top quality healthcare. What makes me most proud to be a part of our dermatology PA community is the many members who look to go above and beyond and help others (colleagues and patients alike) in any way that they can. Please read this issue’s Outside & Inside 9 to 5 article, as well as the Collaborating Physician Corner to learn more about how the SDPA, DPAF, and the AAD have helped those in most need and continue to make a difference in the lives of those affected by the recent natural disasters. J

Travis Hayden, MPAS, PA-C JDPA Editor in Chief editor@jdpa.org

Volume 11 • number 4 • FALL 2017

table of contents SDPA Members Only Content

A complimentary subscription to the JDPA is provided to the members of the SDPA. Please visit www.dermpa.org today to join the SDPA and gain full access to the valuable content of the JDPA.

By Jaspreet Bachra, MPAS, PA-C and Kristen Grippe, MPAS, PA-C

Overview of Vitiligo

›› CME

GNU Free Documentation License

12 Derm PA News & Notes – part one • Certification Review

15 Clinical Dermatology • CME Article: Overview of Vitiligo

26 Surgical Dermatology • Surgical Wisdom: Dermcast.tv Blog

Departments 04 Editorial Board 05 Editor’s Message 08 SDPA News & Current Affairs 12 Dermatology Market Watch 19 From The Patient’s Perspective 23 Clinical Snapshots 26 Surgical Wisdom 31 Cosmetic Pearls 32 Notes from your Office Manager 39 Listening to Patients 45 JDPA Information for Authors 46 Professional Opportunities and Development

29 Cosmetic Dermatology • Act Your Age When It Comes To Skin Care

32 Professional Development • Outside & Inside the 9 to 5…

35 Derm PA News & Notes – part two

Go Green & Read On the Go 6

Journal of Dermatology for Physician Assistants

• Workplace Excellence • From the Desk of… • Collaborating Physician Corner: Hurricane Harvey Response

dermpa.org

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Volume 11 • number 4 • FALL 2017

FROM THE SDPA

News & Current Affairs

CALENDAR OF EVENTS 2018 JUNE SDPA Summer Dermatology Conference June 27 – July 1, 2018 The Westin Seattle Seattle, WA JULY AAD Summer Meeting July 26 - 29, 2018 Chicago, IL NOVEMBER SDPA 16th Annual Fall Dermatology Conference November 1 - 4, 2018 Loews Portofino Bay Hotel Orlando, FL

Sometimes a thank you goes a long way. Being a dermatology PA is awesome. Helping patients feel and look better is a reward onto itself. Still I would venture out to say that one of the greatest gifts a dermatology PA can get is a thank you. If you’re anything like me when I get a card at the office from a patient thanking me it goes a long way. In fact, I keep those cards and look back on them on the tough days of clinical practice. I’ve been hearing from quite a few PAs recently who are trying to navigate the art of negotiating their worth within a practice. Of course every practice is different, however an overwhelming theme seems to be appreciation. I wonder how many PAs just want to be appreciated for the work they do. Appreciation goes a long way in the workplace. In fact many studies show that employees who feel appreciated work harder. A study by the online career site Glassdoor showed that more than 80 percent of employees say they are motivated to work harder when their boss shows appreciation for their work. Of course appreciation comes in different forms from monetary rewards to even a simple “job well done.” Non-cost appreciation can even include being involved in the decision making process, career development opportunities, or some form of special recognition. On a national level we as PAs also seek recognition for the work we do. This is why AAPA is pursuing Optimal Team Practice (OTP). Part of OPT is recognizing the vital role that PAs play in the healthcare system and making sure the laws support PAs. Part of OTP ensures PAs are included in the decision making process by creating PA licensing boards or ensuring that the state medical boards include PAs. So in lieu of my own advice, I want to thank each and every one of you for being a member of the SDPA. Thank you for taking amazing care of patient’s dermatological needs. Thank you for working to make our profession better and the lives of our patients better. Thank you! J

Jane Mast, MPAS, PA-C SDPA President

Journal of Dermatology for Physician Assistants

FOR MODERATE TO SEVERE INFLAMMATORY ACNE

MATCH THE POWER TO THE PATIENT TREAT INFLAMMATORY LESIONS WITH CUSTOMIZED DOSING1 FIVE CUSTOMIZED, WEIGHT-BASED STRENGTHS DELIVER ~1 MG/KG/DAY1

GIVE PATIENTS YOU SEE THE MOST ONLY WHAT THEY NEED1 Indication and Usage SOLODYN ® is indicated to treat only inflammatory lesions of non-nodular moderate to severe acne vulgaris in patients 12 years of age and older. SOLODYN did not demonstrate any effect on non-inflammatory acne lesions. Safety of SOLODYN has not been established beyond 12 weeks of use. This formulation of minocycline has not been evaluated in the treatment of infections. To reduce the development of drug-resistant bacteria as well as to maintain the effectiveness of other antibacterial drugs, SOLODYN should be used only as indicated.

Important Safety Information for SOLODYN Tablets • This drug is contraindicated in persons who have shown hypersensitivity to any of the tetracyclines • MINOCYCLINE, LIKE OTHER TETRACYCLINE-CLASS DRUGS, CAN CAUSE FETAL HARM WHEN ADMINISTERED TO A PREGNANT WOMAN. Should not be used during pregnancy or by individuals of either gender who are attempting to conceive a child; concurrent use of tetracyclines with oral contraceptives may render oral contraceptives less effective. • TETRACYCLINE DRUGS SHOULD NOT BE USED DURING TOOTH DEVELOPMENT (LAST HALF OF PREGNANCY AND UP TO 8 YEARS OF AGE) AS THEY MAY CAUSE PERMANENT DISCOLORATION OF TEETH.

• Pseudomembranous colitis has been reported with nearly all antibacterial agents and may range from mild to life-threatening; therefore, it is important to consider this diagnosis in patients who present with diarrhea subsequent to the administration of antibacterial agents • Dose adjustments may be necessary in patients with renal impairment to avoid liver toxicity • Central nervous system side effects, including light-headedness, dizziness, and vertigo, have been reported with minocycline therapy • Pseudotumor cerebri (benign intracranial hypertension) and autoimmune syndromes have been associated with the use of tetracyclines • Cases of anaphylaxis, serious skin reactions, erythema multiforme, and drug rash with eosinophilia and systemic symptoms have been reported postmarketing with minocycline use. Discontinue SOLODYN immediately if symptoms occur. In rare cases, photosensitivity has been reported. • The most commonly observed adverse reactions are headache, fatigue, dizziness, and pruritus To report SUSPECTED ADVERSE REACTIONS contact Valeant Pharmaceuticals North America LLC at 1-800-321-4576 or FDA at 1-800-FDA-1088 or visit www.fda.gov/medwatch. Please see Brief Summary of Prescribing Information on the following pages.

Reference: 1. SOLODYN Tablets Package Insert. Valeant Pharmaceuticals North America LLC. Solodyn is a trademark of Valeant Pharmaceuticals International, Inc. or its affiliates. © 2017 Valeant Pharmaceuticals North America LLC. SDN.0029.USA.17

Volume 11 • number 4 • FALL 9 Visit2017 Solodyn.com

SUMMARY OF PRESCRIBING INFORMATION This Brief Summary does not include all the information needed to use SOLODYN safely and effectively. See full Prescribing Information. SOLODYNÂŽ (minocycline HCl, USP) Extended Release Tablets Rx Only KEEP OUT OF REACH OF CHILDREN INDICATIONS AND USAGE Indication SOLODYN is indicated to treat only inflammatory lesions of non-nodular moderate to severe acne vulgaris in patients 12 years of age and older. Limitations of Use SOLODYN did not demonstrate any effect on non-inflammatory acne lesions. Safety of SOLODYN has not been established beyond 12 weeks of use. This formulation of minocycline has not been evaluated in the treatment of infections. To reduce the development of drug resistant bacteria as well as to maintain the effectiveness of other antibacterial drugs, SOLODYN should be used only as indicated (see Warnings and Precautions). CONTRAINDICATIONS This drug is contraindicated in persons who have shown hypersensitivity to any of the tetracyclines. Warnings and Precautions Teratogenic Effects A. MINOCYCLINE, LIKE OTHER TETRACYCLINE-CLASS DRUGS, CAN CAUSE FETAL HARM WHEN ADMINISTERED TO A PREGNANT WOMAN. IF ANY TETRACYCLINE IS USED DURING PREGNANCY OR IF THE PATIENT BECOMES PREGNANT WHILE TAKING THESE DRUGS, THE PATIENT SHOULD BE APPRISED OF THE POTENTIAL HAZARD TO THE FETUS. SOLODYN should not be used during pregnancy or by individuals of either gender who are attempting to conceive a child (see Nonclinical Toxicology & Use in Specific Populations). B. THE USE OF DRUGS OF THE TETRACYCLINE CLASS DURING TOOTH DEVELOPMENT (LAST HALF OF PREGNANCY, INFANCY, AND CHILDHOOD UP TO THE AGE OF 8 YEARS) MAY CAUSE PERMANENT DISCOLORATION OF THE TEETH (YELLOW-GRAY-BROWN). This adverse reaction is more common during long-term use of the drug but has been observed following repeated short-term courses. Enamel hypoplasia has also been reported. TETRACYCLINE DRUGS, THEREFORE, SHOULD NOT BE USED DURING TOOTH DEVELOPMENT. C. All tetracyclines form a stable calcium complex in any bone-forming tissue. A decrease in fibula growth rate has been observed in premature human infants given oral tetracycline in doses of 25 mg/kg every 6 hours. This reaction was shown to be reversible when the drug was discontinued. Results of animal studies indicate that tetracyclines cross the placenta,

of which is papilledema. Clinical manifestations include headache and blurred vision. Bulging fontanels have been associated with the use of tetracyclines in infants. Although signs and symptoms of pseudotumor cerebri resolve after discontinuation of treatment, the possibility for permanent sequelae Pseudomembranous Colitis such as visual loss that may be Clostridium difficile associated diarrhea permanent or severe exists. Patients (CDAD) has been reported with nearly should be questioned for visual all antibacterial agents, including disturbances prior to initiation of minocycline, and may range in severity treatment with tetracyclines. If visual from mild diarrhea to fatal colitis. disturbance occurs during treatment, Treatment with antibacterial agents alters patients should be checked for the normal flora of the colon leading to papilledema. Concomitant use of overgrowth of C. difficile. isotretinoin and minocycline should be C. difficile produces toxins A and B which avoided because isotretinoin, a systemic contribute to the development of CDAD. retinoid, is also known to cause Hypertoxin producing strains of pseudotumor cerebri. C. difficile cause increased morbidity and mortality, as these infections can be Autoimmune Syndromes Tetracyclines have been associated with refractory to antimicrobial therapy and the development of autoimmune may require colectomy. CDAD must be syndromes. The long-term use of considered in all patients who present minocycline in the treatment of acne has with diarrhea following antibiotic use. been associated with drug-induced Careful medical history is necessary since CDAD has been reported to occur lupus-like syndrome, autoimmune over two months after the administration hepatitis and vasculitis. Sporadic cases of serum sickness have presented of antibacterial agents. shortly after minocycline use. Symptoms If CDAD is suspected or confirmed, may be manifested by fever, rash, ongoing antibiotic use not directed arthralgia, and malaise. In symptomatic against C. difficile may need to be patients, liver function tests, ANA, CBC, discontinued. Appropriate fluid and and other appropriate tests should be electrolyte management, protein performed to evaluate the patients. Use supplementation, antibiotic treatment of of all tetracycline-class drugs should be C. difficile, and surgical evaluation should discontinued immediately. be instituted as clinically indicated. Photosensitivity Hepatotoxicity Photosensitivity manifested by an Post-marketing cases of serious liver exaggerated sunburn reaction has been injury, including irreversible drug-induced observed in some individuals taking hepatitis and fulminant hepatic failure tetracyclines. This has been reported (sometimes fatal) have been reported with rarely with minocycline. Patients should minocycline use in the treatment of acne. minimize or avoid exposure to natural Metabolic Effects or artificial sunlight (tanning beds or UVA/B treatment) while using The anti-anabolic action of the minocycline. If patients need to be tetracyclines may cause an increase in BUN. While this is not a problem in those outdoors while using minocycline, they should wear loose-fitting clothes that with normal renal function, in patients protect skin from sun exposure and with significantly impaired function, higher serum levels of tetracycline-class discuss other sun protection measures with their physician. drugs may lead to azotemia, hyperphosphatemia, and acidosis. If Serious Skin/Hypersensitivity renal impairment exists, even usual oral Reaction or parenteral doses may lead to Cases of anaphylaxis, serious skin excessive systemic accumulations of the reactions (e.g. Stevens Johnson drug and possible liver toxicity. Under syndrome), erythema multiforme, and such conditions, lower than usual total drug rash with eosinophilia and systemic doses are indicated, and if therapy is symptoms (DRESS) syndrome have been prolonged, serum level determinations of reported postmarketing with minocycline the drug may be advisable. use in patients with acne. DRESS Central Nervous System Effects syndrome consists of cutaneous reaction (such as rash or exfoliative dermatitis), Central nervous system side effects eosinophilia, and one or more of the including light-headedness, dizziness following visceral complications such as: or vertigo have been reported with hepatitis, pneumonitis, nephritis, minocycline therapy. Patients who myocarditis, and pericarditis. Fever and experience these symptoms should be lymphadenopathy may be present. In cautioned about driving vehicles or some cases, death has been reported. If using hazardous machinery while on this syndrome is recognized, the drug minocycline therapy. These symptoms should be discontinued immediately. may disappear during therapy and usually rapidly disappear when the drug Tissue Hyperpigmentation is discontinued. Tetracycline-class antibiotics are known Benign Intracranial Hypertension to cause hyperpigmentation. Tetracycline Pseudotumor cerebri (benign intracranial therapy may induce hyperpigmentation hypertension) in adults and adolescents in many organs, including nails, bone, skin, eyes, thyroid, visceral tissue, oral has been associated with the use of cavity (teeth, mucosa, alveolar bone), tetracyclines. Minocycline has been sclerae and heart valves. Skin and oral reported to cause or precipitate pigmentation has been reported to occur pseudotumor cerebri, the hallmark are found in fetal tissues, and can cause retardation of skeletal development on the developing fetus. Evidence of embryotoxicity has been noted in animals treated early in pregnancy (see Use in Specific Populations).

10 Journal of Dermatology for Physician Assistants

independently of time or amount of drug administration, whereas other tissue pigmentation has been reported to occur upon prolonged administration. Skin pigmentation includes diffuse pigmentation as well as over sites of scars or injury. Development of Drug Resistant Bacteria Bacterial resistance to the tetracyclines may develop in patients using SOLODYN, therefore, the susceptibility of bacteria associated with infection should be considered in selecting antimicrobial therapy. Because of the potential for drug-resistant bacteria to develop during the use of SOLODYN, it should be used only as indicated. Superinfection As with other antibiotic preparations, use of SOLODYN may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection occurs, SOLODYN should be discontinued and appropriate therapy instituted. Laboratory Monitoring Periodic laboratory evaluations of organ systems, including hematopoietic, renal and hepatic studies should be performed. Appropriate tests for autoimmune syndromes should be performed as indicated. ADVERSE REACTIONS Clinical Trial Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials cannot be directly compared to rates in the clinical trials of another drug, and may not reflect the rates observed in practice. The following table summarizes selected adverse reactions reported in clinical trials at a rate of â&#x2030;Ľ1% for SOLODYN. Selected Treatment-Emergent Adverse Reactions in at least 1% of Clinical Trial Subjects Adverse Reactions

SOLODYN PLACEBO (1 mg/kg) N=364 N=674 (%) (%)

At least one treatment-emergent 379 (56) 197 (54) event Headache 152 (23) 83 (23) Fatigue 62 (9) 24 (7) Dizziness 59 (9) 17 (5) Pruritus 31 (5) 16 (4) Malaise 26 (4) 9 (3) Mood alteration 17 (3) 9 (3) Somnolence 13 (2) 3 (1) Urticaria 10 (2) 1 (0) Tinnitus 10 (2) 5 (1) Arthralgia 9 (1) 2 (0) Vertigo 8 (1) 3 (1) Dry mouth 7 (1) 5 (1) Myalgia 7 (1) 4 (1) Postmarketing Experience Adverse reactions that have been reported with minocycline hydrochloride use in a variety of indications include: Skin and hypersensitivity reactions: fixed drug eruptions, balanitis, erythema multiforme, Stevens-Johnson syndrome, anaphylactoid purpura, photosensitivity, pigmentation of skin and mucous membranes, hypersensitivity reactions, angioneurotic edema, anaphylaxis, DRESS syndrome (see Warnings and Precautions).

HOW SUPPLIED/STORAGE AND HANDLING How Supplied SOLODYN (minocycline HCl, USP) Extended Release Tablets are supplied as aqueous film coated tablets containing minocycline hydrochloride equivalent to 55 mg, 65 mg, 80 mg, 105 mg or 115 mg minocycline, are supplied as follows. The 55 mg extended release tablets are pink, unscored, coated, and debossed with “DYN-055” on one side. Each tablet contains minocycline hydrochloride OVERDOSAGE equivalent to 55 mg minocycline, In case of overdosage, discontinue supplied as follows: medication, treat symptomatically and Bottle of 30 institute supportive measures. Minocycline NDC 99207-465-30 is not removed in significant quantities by The 65 mg extended release tablets are hemodialysis or peritoneal dialysis. blue, unscored, coated, and debossed with “DYN-065” on one side. Each tablet NONCLINICAL TOXICOLOGY contains minocycline hydrochloride Carcinogenesis, Mutagenesis, equivalent to 65 mg minocycline, Impairment of Fertility supplied as follows: NDC 99207-463-30 Bottle of 30 Carcinogenesis—In a carcinogenicity study in which minocycline HCl was orally The 80 mg extended release tablets are administered to male and female rats once dark gray, unscored, coated, and daily for up to 104 weeks at dosages up debossed with “DYN-080” on one side. to 200 mg/kg/day, minocycline HCl was Each tablet contains minocycline associated in both genders with follicular hydrochloride equivalent to 80 mg cell tumors of the thyroid gland, including minocycline, supplied as follows: increased incidences of adenomas, NDC 99207-466-30 Bottle of 30 carcinomas and the combined incidence The 105 mg extended release tablets are of adenomas and carcinomas in males, purple, unscored, coated, and debossed and adenomas and the combined incidence with “DYN-105” on one side. Each tablet of adenomas and carcinomas in females. In contains minocycline hydrochloride a carcinogenicity study in which minocycline equivalent to 105 mg minocycline, HCl was orally administered to male and supplied as follows: female mice once daily for up to 104 weeks NDC 99207-467-30 Bottle of 30 at dosages up to 150 mg/kg/day, exposure The 115 mg extended release tablets are to minocycline HCl did not result in a green, unscored, coated, and debossed significantly increased incidence of with “DYN-115” on one side. Each tablet neoplasms in either males or females. contains minocycline hydrochloride Mutagenesis—Minocycline was not equivalent to 115 mg minocycline, mutagenic in vitro in a bacterial reverse supplied as follows: mutation assay (Ames test) or CHO/ NDC 99207-464-30 Bottle of 30 HGPRT mammalian cell assay in the Storage presence or absence of metabolic Store at 25ºC (77ºF); excursions are activation. Minocycline was not permitted to 15º-30ºC (59º-86ºF) clastogenic in vitro using human [See USP Controlled Room Temperature]. peripheral blood lymphocytes or in vivo in a mouse micronucleus test. Handling Keep out of reach of children Impairment of Fertility—Male and female reproductive performance in rats Protect from light, moisture, and was unaffected by oral doses of excessive heat. minocycline of up to 300 mg/kg/day Dispense in tight, light-resistant (which resulted in up to approximately container with child-resistant closure. 40 times the level of systemic exposure Revised: 06/2016 to minocycline observed in patients as a U.S. Patents 5,908,838; 7,790,705; result of use of SOLODYN). However, oral 7,919,483; 8,252,776; 8,268,804; administration of 100 or 300 mg/kg/day and other Patents Pending* of minocycline to male rats (resulting in *55 mg, 80 mg, and 105 mg are also approximately 15 to 40 times the level covered by U.S. Patents 8,722,650 of systemic exposure to minocycline *65 mg and 115 mg are also covered by observed in patients as a result of use U.S. Patent 9,119,793 of SOLODYN) adversely affected Manufactured for: spermatogenesis. Effects observed at Valeant Pharmaceuticals the fluorescence test. Pediatric Use 300 mg/kg/day included a reduced North America LLC SOLODYN is indicated to treat only USE IN SPECIFIC POPULATIONS number of sperm cells per gram of inflammatory lesions of non-nodular epididymis, an apparent reduction in the Bridgewater, NJ 08807 USA Pregnancy By: moderate to severe acne vulgaris in percentage of sperm that were motile, WellSpring Pharma Services Inc. Teratogenic Effects: Pregnancy category D patients 12 years and older. Safety and (at 100 and 300 mg/kg/day) Oakville, Ontario L6H 1M5 Canada and effectiveness in pediatric (see Warnings and Precautions) increased numbers of morphologically Based on 9387301 patients below the age of 12 has SOLODYN should not be used during abnormal sperm cells. Morphological not been established. pregnancy. If the patient becomes abnormalities observed in sperm Use of tetracycline-class antibiotics below samples included absent heads, pregnant while taking this drug, the the age of 8 is not recommended due to patient should be apprised of the misshapen heads, and abnormal flagella. ®/TMs are trademarks of Valeant the potential for tooth discoloration (see potential hazard to the fetus and stop Pharmaceuticals International, Inc. Limited human studies suggest that Warnings and Precautions). treatment immediately. or its affiliates. All other product or minocycline may have a deleterious There are no adequate and well-controlled Geriatric Use brand names are trademarks of their effect on spermatogenesis. studies on the use of minocycline in respective owners. Clinical studies of SOLODYN did not SOLODYN should not be used by pregnant women. Minocycline, like other include sufficient numbers of subjects individuals of either gender who are © 2016 Valeant Pharmaceuticals tetracycline-class drugs, crosses the aged 65 and over to determine whether attempting to conceive a child. North America LLC. SDN.0053.USA.16 placenta and may cause fetal harm when administered to a pregnant woman. Rare spontaneous reports of congenital anomalies including limb reduction have been reported with minocycline use in pregnancy in post-marketing experience. Only limited information is available regarding these reports; therefore, no conclusion on causal association can be established. Minocycline induced skeletal malformations (bent limb bones) in fetuses when administered to pregnant rats and rabbits in doses of 30 mg/kg/day and 100 mg/kg/day, respectively, (resulting in approximately 3 times and 2 times, respectively, the systemic exposure to minocycline observed in patients as a result of use of SOLODYN). Reduced mean fetal body weight was observed in studies in which minocycline was administered to pregnant rats at a dose of 10 mg/kg/day (which resulted in approximately the DRUG INTERACTIONS same level of systemic exposure to minocycline as that observed in patients Anticoagulants Because tetracyclines have been shown who use SOLODYN). to depress plasma prothrombin activity, Minocycline was assessed for effects on peri- and post-natal development patients who are on anticoagulant of rats in a study that involved oral therapy may require downward adjustment of their anticoagulant dosage. administration to pregnant rats from day 6 of gestation through the period Penicillin of lactation (postpartum day 20), at Since bacteriostatic drugs may interfere dosages of 5, 10, or 50 mg/kg/day. with the bactericidal action of penicillin, it In this study, body weight gain was is advisable to avoid giving tetracycline- significantly reduced in pregnant class drugs in conjunction with penicillin. females that received 50 mg/kg/day (resulting in approximately 2.5 times Methoxyflurane the systemic exposure to minocycline The concurrent use of tetracycline and observed in patients as a result of use methoxyflurane has been reported to of SOLODYN). No effects of treatment result in fatal renal toxicity. on the duration of the gestation period Antacids and Iron Preparations or the number of live pups born per Absorption of tetracyclines is impaired litter were observed. Gross external by antacids containing aluminum, anomalies observed in F1 pups calcium or magnesium and iron(offspring of animals that received containing preparations. minocycline) included reduced body size, improperly rotated forelimbs, Low Dose Oral Contraceptives and reduced size of extremities. No In a multi-center study to evaluate the effects were observed on the physical effect of SOLODYN on low dose oral development, behavior, learning ability, contraceptives, hormone levels over one or reproduction of F1 pups, and there menstrual cycle with and without was no effect on gross appearance of SOLODYN 1 mg/kg once-daily were F2 pups (offspring of F1 animals). measured. Based on the results of this trial, minocycline-related changes in Nursing Mothers estradiol, progestinic hormone, FSH and Tetracycline-class antibiotics are LH plasma levels, of breakthrough excreted in human milk. Because of bleeding, or of contraceptive failure, cannot the potential for serious adverse effects be ruled out. To avoid contraceptive failure, on bone and tooth development in female patients are advised to use a nursing infants from the tetracyclinesecond form of contraceptive during class antibiotics, a decision should be treatment with minocycline. made whether to discontinue nursing or discontinue the drug, taking into account Drug/Laboratory Test Interactions False elevations of urinary catecholamine the importance of the drug to the mother levels may occur due to interference with (see Warnings and Precautions). Autoimmune conditions: polyarthralgia, pericarditis, exacerbation of systemic lupus, pulmonary infiltrates with eosinophilia, transient lupus-like syndrome. Central nervous system: pseudotumor cerebri, bulging fontanels in infants, decreased hearing. Endocrine: brown-black microscopic thyroid discoloration, abnormal thyroid function. Oncology: thyroid cancer. Oral: glossitis, dysphagia, tooth discoloration. Gastrointestinal: enterocolitis, pancreatitis, hepatitis, liver failure. Renal: reversible acute renal failure. Hematology: hemolytic anemia, thrombocytopenia, eosinophilia. Preliminary studies suggest that use of minocycline may have deleterious effects on human spermatogenesis (see Nonclinical Toxicology).

they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and concomitant disease or other drug therapy.

Volume 11 • number 4 • FALL 2017 11

Dermatology PA news & notes

Dermatology Market Watch

Psoriatic Arthritis Screening Tool For Providers Early diagnosis of psoriatic arthritis leads to better long-term health. Patients who wait even as little as six months before getting diagnosed and starting treatment typically have worse clinical outcomes. As a health care provider, it’s up to you to ensure your patients get the care they need as quickly as possible. The Psoriasis Epidemiology Screening Tool, or PEST, is a screening tool that can help you recognize signs of psoriatic arthritis in your psoriasis patients.1 Patients answer five questions and fill out a diagram. If patients check “yes” to three or more of the questions, they may have psoriatic arthritis. You should speak with them about their symptoms, their options and possibly refer them to a rheumatologist.

The PEST resource can help you get started talking to your patients about psoriatic arthritis. We encourage you to download the printable PDF, including five-question quiz and diagram (see Figure opposite page), and provide it to your psoriasis patients as part of their pre-appointment paperwork. This will help them—and you—understand if they’re showing symptoms of psoriatic arthritis and whether they should be referred to a rheumatologist. J REFERENCE: 1. Ibrahim, G. H., et al. "Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire." Clinical & Experimental Rheumatology 27.3 (2009): 469.

Ortho Dermatologics Announces U.S. FDA Filing Acceptance for IDP-118, Novel Plaque Psoriasis Treatment Ortho Dermatologics, a division of Valeant Pharmaceuticals International, Inc. recently announced that the U.S. Food and Drug Administration (FDA) has accepted the New Drug Application (NDA) for IDP118 (halobetasol propionate and tazarotene) lotion, an investigational topical treatment for plaque psoriasis. If approved, IDP-118 will be the first and only topical lotion that contains a unique combination of halobetasol 12 Journal of Dermatology for Physician Assistants

propionate and tazarotene in one formulation for the treatment of plaque psoriasis in adult patients, allowing for a potentially expanded duration of use. The most common adverse events were contact dermatitis (7.4%) and application site pain (2.6%). J

Screening Tool for Psoriatic Arthritis Psoriatic arthritis is a form of arthritis that can affect almost one-third of people with psoriasis and lead to lasting damage to your joints and bones. But getting diagnosed and treated as soon as possible can prevent that damage and help you stay healthy. Answer the following five questions to find out if you’re at risk for psoriatic arthritis. Then put a check mark next to the places on the diagram where your body feels tender or sore. Bring this handout with you to your doctor’s appointment. 1. Have you ever had a swollen joint (or joints)? Yes No 2. Has a doctor ever told you that you have arthritis? Yes No 3. Do your fingernails or toenails have holes or pits? Yes No

Neck Shoulder

Elbow

Lower Back

4. Have you had pain in your heel? Yes No 5. Have you had a finger or toe that was completely swollen and painful for no apparent reason? Yes No

Shoulder

Upper Back

Wrist Thumb Hand/ Fingers

This validated screening tool was approved for use by the National Psoriasis Foundation (NPF). For more information on psoriasis and psoriatic arthritis, and to learn about NPF’s Patient Navigation Center and the many services it offers, visit www.psoriasis.org.

Hip

Knee

Wrist Thumb Hand/ Fingers

Hip

Knee

Ankle Ankle Ibrahim GH, Buch MH, Lawson C, Waxman R, Helliwell PS. Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire. Clin Exp Rheumatol. 2009 May-June; 27(3): 469-474.

Foot/ Toes

Foot/ Toes Volume 11 • number 4 • FALL 2017 13

Certification Review

All Those Things Inside the Skin You Might Have Forgotten By James A. Van Rhee, MS, PA-C

QUESTION: A 24-year-old female presents to the office for a routine health maintenance visit. She asks about screening for cervical cancer. She denies any family history of cancer. Review of systems reveals no vaginal discharge or pain. According to the United States Preventive Services Task Force, which of the following is the recommended screening for cervical cancer in this patient? A. Screen with cytology every three years B. Screen with HPV testing every five years C. Screen with cytology and HPV testing every three years D. Screen with cytology and HPV testing every five years E. No screening needed until age 25 EXPLANATION: The United States Preventive Services Task Force (USPSTF) recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. The USPSTF further recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology,

in women younger than age 30 years; recommends against screening for cervical cancer in women younger than age 21 years; recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer; and recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. J The correct answer is A.

DERmatology pa news & notes

Are you recertifying soon? Start your board review early. Each issue of the JDPA features one board question accompanied by a brief explanation of the answer along with any pertinent test taking tips. Best of luck!

James A. Van Rhee, MS, PA-C, is the Program Director for the Yale University School of Medicine Physician Assistant Program. Mr. Van Rhee has been involved in physician assistant education for over 20 years. He has served as project director and test item writer for the Physician Assistant Education Associationâ&#x20AC;&#x2122;s (PAEA) Physician Assistant Clinical Knowledge Rating Assessment Tool (PACKRAT) and is the author of the Physician Assistant: Certification and Re-certification Review Book, published by Elsevier. For the last fifteen years he has been course director and presenter of the Physician Assistant Board Review, which is now being produced live online by Kaplan Medical.

What Do You Want To Read About In The JDPA? Weâ&#x20AC;&#x2122;re interested in knowing what kind of articles SDPA members would be interested in reading more about in order to help improve their practice of dermatology. Share your content ideas today. Email them to editor@jdpa.org

JDPA Journal of Dermatology for Physician Assistants

14 Journal of Dermatology for Physician Assistants

Clinic al Dermatology

Overview of Vitiligo By Jaspreet Bachra, MPAS, PA-C and Kristen Grippe, MPAS, PA-C

SDPA Members Only Content A complimentary subscription to the JDPA is provided to the members of the SDPA. Please visit www.dermpa.org today to join the SDPA and gain full access to the valuable content of the JDPA.

›› CME

This program has been reviewed and is approved for a maximum of .5 hours of AAPA Category I CME credit by the Physician Assistant Review Panel.

Approval is valid for 1 year from the issue date of December 2017. Participants may submit the selfassessment exam at any time during that period. This program was planned in accordance with AAPA’s CME Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs.

SDPA members may access the posttest at www.jdpa.org

Learning Objectives: At the conclusion of this activity, participants should be able to: • Define the term “vitiligo” and explain its etiology and epidemiology. • Differentiate possible risk factors that may contribute to the development of vitiligo. • Describe the cutaneous manifestations of vitiligo and differentiate them from other skin lesions. • Describe diagnostic techniques for vitiligo. • Prescribe or administer appropriate treatments for vitiligo. Volume 11 • number 4 • FALL 2017 15

Overview of Vitiligo

SDPA Members Only Content

CLINIC AL Dermatology

A complimentary subscription to the JDPA is provided to the members of the SDPA. Please visit www.dermpa.org today to join the SDPA and gain full access to the valuable content of the JDPA.

16 Journal of Dermatology for Physician Assistants

Overview of Vitiligo

SDPA Members Only Content

CLINIC AL Dermatology

A complimentary subscription to the JDPA is provided to the members of the SDPA. Please visit www.dermpa.org today to join the SDPA and gain full access to the valuable content of the JDPA.

Volume 11 • number 4 • FALL 2017 17

Overview of Vitiligo

CLINIC AL Dermatology

Jaspreet Bachra, MPAS, PA-C is a recent graduate of Gannon Universityâ&#x20AC;&#x2122;s Master of Physician Assistant Science program. She has indicated no relationships to disclose relating to the content of this article. Kristen Grippe, MPAS, PA-C has practiced in dermatology for 10 years and family medicine for 2 years. She is currently a full-time assistant professor at Gannon Universityâ&#x20AC;&#x2122;s Physician Assistant program in Erie, PA. She has indicated no relationships to disclose relating to the content of this article.

Allison Arthur, M.D., Libby Edwards, M.D., Steven Feldman, M.D., Francisco Kerdel, M.D., Pearl Kwong, M.D., Maahew Leavii, D.O., Raymond Ramirez, D.O., eodore Rosen, M.D., Heather Woolery-Lloyd, M.D., Maahew Zirwas, M.D.

18 Journal of Dermatology for Physician Assistants

From The Patient’s Perspective

Adventuring for a Cure

It all began with a dime-sized patch of scaly skin on my shin that itched pretty bad. This was several years ago when I was in my mid-20s. At that point in my life, I didn’t have health insurance, but I wasn’t overly concerned with my health. I was more concerned with having a good time. I had self-diagnosed this patch of skin as a fungus. I tried a few anti-fungal over-the-counter creams, but nothing helped. The patch grew in size and after two years of hoping it would just go away I decided I needed to see a dermatologist. I learned I had plaque psoriasis. Now it all made sense. By this time, my psoriasis had surfaced in my ears, some areas of my hands and both legs in my shin area.

The itching in my ears was really bad and about 30 percent of my lower legs were covered. I tried a few medications – Topicort spray, Otezla (apremilast), cortisone injections – and a few natural remedies, but I was not happy with the results. On top of that, I was hesitant to use some of these medications due to the potential side effects. This is when my psoriasis started to get the best of me. I felt like things were only getting worse. I would scratch my skin until I bled and I wouldn’t do any activities where I had to put on shorts and deal with people looking at my legs. I turned to drinking to cope. I couldn’t help but feel that my psoriasis was going to spread and there was nothing I could do about it. I was overweight, unhealthy and I felt isolated. My primary care physician informed me that due to my weight and lifestyle I had early signs of fatty liver disease, diabetes and reactive airway disease. I was smoking cigarettes, eating whatever I wanted and drinking way too much. While we are at it, let’s go ahead and add depression to that list.

Kicking Off The Comeback The Mentor Program connects newly practicing physicians and researchers with members of the NPF Medical Board and Emeritus Medical Board – experts with ample experience treating psoriatic disease. The early career providers will have access to these leaders for feedback on how to treat complex cases and for general career guidance. The Mentor Program is open to all early career professional members of NPF, including nurse practitioners and physician assistants, dermatologists, rheumatologists and researchers in their first three years of practice. Distance and in-person mentorships are available. CME credit and a stipend is also available for in-person mentorships. Visit https://www.psoriasis.org/mentor-program to learn more.

Right around this time I joined a couple of psoriasis support groups on Facebook. I quickly realized that I wasn’t alone. On top of that, I realized it’s pretty common and there are folks out there who are way worse off than I was. This was the first of a few turning points in my life. Here I was feeling sorry for myself, but not doing anything to improve my situation. In December 2015 I was heavier than I had ever been at 235 pounds. I’m only 5’ 7”. By now I was married to my awesome wife and we had a beautiful little girl. What kind of example was I setting for them? I wanted to make some changes because I wanted to be around as long as possible for my family. I had let my psoriasis define me, and I wasn’t going to allow that any more. I started off with some exercising and dieting. I cut out 99 percent of sugars and carbs from my diet Volume 11 • number 4 • FALL 2017 19

CLINIC AL Dermatology

Wise words from his 5-year-old daughter sets guest blogger Gene Griffin on a better path

CLINIC AL Dermatology

and dropped to 205 pounds in about a month and a half. I started doing those outdoor activities I loved and missed like kayaking, swimming, hiking and biking. I maintained this weight for all of 2016 and the beginning of 2017. Even with this weight loss I still had those health issues. I was still drinking and smoking. My doctor explained that if I got down to my target weight, stopped smoking and stopped drinking excessively, these health issues might go away completely.

The Tipping Point Everything changed in one moment. My sweet little 5-year-old daughter looked me in the eyes and said, “Daddy, will you please stop smoking? It’s not

Driving Discovery, Creating Community This year, we’re celebrating 50 years of driving efforts to cure psoriatic disease and improve the lives of those affected. See how far we’ve come with this timeline of NPF’s history. But there’s still plenty to do, and we can’t do it without you! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise 20 Journal of Dermatology for Physician Assistants

good for you and I don’t want you to be sick.” Man, that hurt. That hurt really bad. I teared up, gathered my thoughts, kneeled down to her and said, “Yes baby. I will stop smoking.” This was about four months ago and that short conversation changed my path, goals and priorities in life. I stopped drinking excessively, stopped smoking, got more serious about my diet and got a gym membership. I also needed to find something to occupy my time so I took those outdoor activities I enjoyed to the next level: kayaking. You can follow me as I kayak to connect with other people with psoriasis, inspire people to get out there and live their life, raise awareness and raise funds for NPF. Follow me on Facebook and on my Team NPF page, where I’ll be “Adventuring for a Cure” in the Texas Junior Water Safari on Sept. 16 and other competitions in my home state of Texas and maybe in your state, too! J Gene Griffin has had psoriasis for roughly eight years. He is a true adventurer who loves to hike, bike, backpack and most of all kayak. He is the creator of “Adventuring for a Cure,” where he aims to inspire others with psoriasis to get outside, enjoy nature and break the constraints of psoriasis. Gene is not afraid to show off his psoriasis and use it as an opportunity to educate and empower others.

Content provided as a courtesy from the National Psoriasis Foundation. For more information, visit www.psoriasis.org.

funding to promote research into better treatments and a cure by joining Team NPF, where you can walk, run, cycle, play bingo or even create your own DIY event. Contact our Patient Navigation Center for free, personalized support for living a healthier life with psoriatic disease. And keep the National Psoriasis Foundation going strong by making a donation today! Together, we will find a cure. The opinions expressed by NPF Blog contributors are their own and do not reflect the opinions or positions of the National Psoriasis Foundation. The information posted on the NPF Blog is not intended as, and is not, a substitute for professional medical advice.

YEARS

Celebrati ng

gs! tin ee

BEAUTIFUL BLOWN GLASS BY SEATTLE ARTIST DALE CHIHULY.

SDPA

Y r 15 ears of ve M O

ANNUAL SUMMER DERMATOLOGY CONFERENCE

2018

êêê REGISTER TODAY!

SEATTLE PRE-CONFERENCE:

JUNE 27TH, 2018

GENERAL CONFERENCE:

JUNE 28TH - JULY 1ST, 2018 The Westin Seattle – Seattle, WA Mark your calendar now and plan to join us in Seattle in June 2018 for the leading CME conference for Derm PAs. You especially won’t want to miss our special dual track pre-conference day offering dermoscopy in the morning and an all new professional development track in the afternoon.

SDPAConferences.org s 844-DERM-PAS, Ext. 1 s conferences@dermpa.org

#SDPAsummer

Volume 11 • number 4 • FALL 2017 21

GOING 80 MPH DOWNHILL -

EXTREME? NOT WEARING SUNSCREEN,

NOW THAT’S CRAZY

I’m Julia Mancuso, Olympic medalist and professional skier, and I apply sunscreen every day. I’m wearing orange to help put a spotlight on skin cancer.

Did you know snow reflects and intensifies the damaging rays of the sun? Sun exposure is the most preventable risk factor for skin cancer. To protect your skin apply sunscreen, seek shade, and wear protective clothing. Visit SpotSkinCancer.org.

22 Journal of Dermatology for Physician Assistants

Clinical snapshots Radiation Dermatitis By Bill Jones, RT (R)(CV), RRA, PA-C

SDPA Members Only Content

Image A

Macule at diagnosis on 03-25-15.

CLINIC AL Dermatology

A complimentary subscription to the JDPA is provided to the members of the SDPA. Please visit www.dermpa.org today to join the SDPA and gain full access to the valuable content of the JDPA.

Image B

There is subtotal resolution (between arrows) after 6 weeks with no treatment.

Volume 11 • number 4 • FALL 2017 23

SDPA Members Only Content

CLINIC AL Dermatology

A complimentary subscription to the JDPA is provided to the members of the SDPA. Please visit www.dermpa.org today to join the SDPA and gain full access to the valuable content of the JDPA.

Bill Jones, RT (R)(CV), RRA, MMS, PA-C completed his undergraduate degree in radiology at Weber State University and his Masters in Medical Sciences at Nova Southeastern Universityâ&#x20AC;&#x2122;s Physician Assistant Program in Orlando, Florida. He works for Watson Clinic, LLP and practices in radiology at Lakeland Regional Medical Center. Bill is an associate member of the SDPA, Florida Society of Dermatology Physician Assistants (FSDPA), and the Society of Interventional Radiology (SIR). He is also a member of the Florida Society of Physician Assistants (FAPA), American Registry of Radiologic Technologists (ARRT), and the American Society of Radiologic Technologists (ASRT). He has indicated no relationships to disclose relating to the content of this article.

24 Journal of Dermatology for Physician Assistants

REINTRODUCING

DISCOVER OUR RENEWED PURPOSE Building lasting relationships in the dermatology community through meaningful 1:1 connections with you and your peers.

1:1

Derm cоnectiоs Douglas DiRuggiero, PA-C, Physician Assistant

Andy Cobb, Executive Sales Representative, Ortho Dermatologics

Connect with us one to one at: www.ortho-dermatologics.com

Volume 11 • number 4 • FALL 2017 25

SURGICAL wisdom Dermcast.tv Blog Zinc Oxide Dressing Offers Improved Post-OP Healing Compared to Standard Wound Care By Martha L. Sikes, MS, RPh, PA-C

SURGIC AL Dermatology

Dermcast.tv is the official online media resource of the SDPA and is your free source for the latest SDPArelated audio podcasts, current dermatology news and research, and videos featuring thought-leaders, procedures, conference highlights, and much more. In addition, Dermcast is the #1 dermatology-related podcast on iTunes! To read more Dermcast.tv Blogs and/or to follow the next live blog from an upcoming SDPA dermatology conference, please visit the Dermcast.tv website at www.dermcast.tv and subscribe today.

26 Journal of Dermatology for Physician Assistants

ONEXTON.COM

TOLERABILITY YOU WANT RESULTS THEY CAN SEE1 ALSO FIND INSTANT SAVINGS FOR ELIGIBLE PATIENTS AT ORTHORXACCESS.COM TERMS AND CONDITIONS APPLY

INDICATION ONEXTON (clindamycin phosphate and benzoyl peroxide) Gel, 1.2%/3.75% is indicated for the topical treatment of acne vulgaris in patients 12 years of age or older.

IMPORTANT SAFETY INFORMATION • ONEXTON Gel is contraindicated in patients with a known hypersensitivity to clindamycin, benzoyl peroxide, any component of the formulation, or lincomycin. • ONEXTON Gel is contraindicated in patients with a history of regional enteritis, ulcerative colitis, or antibiotic-associated colitis. • Diarrhea, bloody diarrhea, and colitis (including pseudomembranous colitis) have been reported with the use of topical and systemic clindamycin. ONEXTON Gel should be discontinued if significant diarrhea occurs. • Orally and parenterally administered clindamycin has been associated with severe colitis, which may result in death. • Anaphylaxis, as well as other allergic reactions leading to hospitalizations, has been reported in postmarketing use of products containing clindamycin/benzoyl peroxide. If a patient develops symptoms of an allergic reaction such as swelling and shortness of breath, they should be instructed to discontinue use and contact a physician immediately.

• The most common local adverse reactions experienced by patients in clinical trials were mild and moderate erythema, scaling, itching, burning and stinging. • ONEXTON Gel should not be used in combination with erythromycin-containing products because of its clindamycin component. • ONEXTON Gel should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. A decision should be made whether to use ONEXTON Gel while nursing, taking into account the importance of the drug to the mother. • Patients should be advised to avoid contact with the eyes or mucous membranes. • Patients should minimize exposure to natural and avoid artificial sunlight (tanning beds or UVA/B treatment) while using ONEXTON Gel. To minimize exposure to sunlight, protective clothing should be worn and a sunscreen with SPF 15 rating or higher should be used. To report SUSPECTED ADVERSE REACTIONS, contact Ortho Dermatologics at 1-800-321-4576 or FDA at 1-800-FDA-1088 or visit www.fda.gov/medwatch. Please see Brief Summary of full Prescribing Information on the following page.

Reference: 1. ONEXTON [prescribing information]. Bridgewater, NJ: Valeant Pharmaceuticals North America LLC.

Volume 11 • number 4 • FALL 2017 27

BRIEF SUMMARY OF FULL PRESCRIBING INFORMATION

Neuromuscular Blocking Agents

This Brief Summary does not include all the information needed to use ONEXTON Gel safely and effectively. See full prescribing information for ONEXTON Gel.

Clindamycin has been shown to have neuromuscular blocking properties that may enhance the action of other neuromuscular blocking agents. ONEXTON Gel should be used with caution in patients receiving such agents.

ONEXTONâ&#x201E;˘ (clindamycin phosphate and benzoyl peroxide) Gel, 1.2%/3.75%, for topical use Initial U.S. Approval: 2000 CONTRAINDICATIONS Hypersensitivity ONEXTON Gel is contraindicated in those individuals who have shown hypersensitivity to clindamycin, benzoyl peroxide, any components of the formulation, or lincomycin. Anaphylaxis, as well as allergic reactions leading to hospitalization, has been reported in postmarketing use with ONEXTON Gel [see Adverse Reactions] WARNINGS AND PRECAUTIONS Colitis Systemic absorption of clindamycin has been demonstrated following topical use of clindamycin. Diarrhea, bloody diarrhea, and colitis (including pseudomembranous colitis) have been reported with the use of topical and systemic clindamycin. If significant diarrhea occurs, ONEXTON Gel should be discontinued. Severe colitis has occurred following oral and parenteral administration of clindamycin with an onset of up to several weeks following cessation of therapy. Antiperistaltic agents such as opiates and diphenoxylate with atropine may prolong and/or worsen severe colitis. Severe colitis may result in death. Studies indicate toxin(s) produced by Clostridia is one primary cause of antibiotic-associated colitis. The colitis is usually characterized by severe persistent diarrhea and severe abdominal cramps and may be associated with the passage of blood and mucus. Stool cultures for Clostridium difficile and stool assay for C. difficile toxin may be helpful diagnostically. Ultraviolet Light and Environmental Exposure Minimize sun exposure (including use of tanning beds or sun lamps) following drug application [see Nonclinical Toxicology]. ADVERSE REACTIONS The following adverse reaction is described in more detail in the Warnings and Precautions section of the label: Colitis [see Warnings and Precautions]. Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of a drug cannot be directly compared to rates observed in the clinical trials of another drug and may not reflect the rates observed in clinical practice. These adverse reactions occurred in less than 0.5% of subjects treated with ONEXTON Gel: burning sensation (0.4%); contact dermatitis (0.4%); pruritus (0.4%); and rash (0.4%). During the clinical trial, subjects were assessed for local cutaneous signs and symptoms of erythema, scaling, itching, burning and stinging. Most local skin reactions either were the same as baseline or increased and peaked around week 4 and were near or improved from baseline levels by week 12. The percentage of subjects that had symptoms present before treatment (at baseline), during treatment, and the percent with symptoms present at week 12 are shown in Table 1. Table 1: Local Skin Reactions - Percent of Subjects with Symptoms Present. Results from the Phase 3 Trial of ONEXTON Gel 1.2%/3.75% (N = 243) Before Treatment (Baseline)

Maximum During Treatment

End of Treatment (Week 12)

Mild

Mod.*

Severe

Mild

Mod.*

Severe

Mild

Mod.*

Severe

Erythema

Scaling

Itching

Burning

Stinging

*Mod. = Moderate

Postmarketing Experience Because postmarketing adverse reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Anaphylaxis, as well as allergic reactions leading to hospitalizations, has been reported in postmarketing use of products containing clindamycin phosphate/benzoyl peroxide. DRUG INTERACTIONS Erythromycin Avoid using ONEXTON Gel in combination with topical or oral erythromycin-containing products due to its clindamycin component. In vitro studies have shown antagonism between erythromycin and clindamycin. The clinical significance of this in vitro antagonism is not known. Concomitant Topical Medications Concomitant topical acne therapy should be used with caution since a possible cumulative irritancy effect may occur, especially with the use of peeling, desquamating, or abrasive agents. If irritancy or dermatitis occurs, reduce frequency of application or temporarily interrupt treatment and resume once the irritation subsides. Treatment should be 28 Journal of Dermatology for Physician Assistants discontinued if the irritation persists.

USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C. There are no adequate and well-controlled studies in pregnant women treated with ONEXTON Gel. ONEXTON Gel should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Animal reproductive/developmental toxicity studies have not been conducted with ONEXTON Gel or benzoyl peroxide. Developmental toxicity studies of clindamycin performed in rats and mice using oral doses of up to 600 mg/kg/day (240 and 120 times amount of clindamycin in the highest recommended adult human dose based on mg/m2, respectively) or subcutaneous doses of up to 200 mg/kg/day (80 and 40 times the amount of clindamycin in the highest recommended adult human dose based on mg/m2, respectively) revealed no evidence of teratogenicity. Nursing Mothers It is not known whether clindamycin is excreted in human milk after topical application of ONEXTON Gel. However, orally and parenterally administered clindamycin has been reported to appear in breast milk. Because of the potential for serious adverse reactions in nursing infants, a decision should be made whether to use ONEXTON Gel while nursing, taking into account the importance of the drug to the mother. Pediatric Use Safety and effectiveness of ONEXTON Gel in pediatric patients under the age of 12 have not been evaluated. Geriatric Use Clinical trials of ONEXTON Gel did not include sufficient numbers of subjects aged 65 and older to determine whether they respond differently from younger subjects. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity, mutagenicity and impairment of fertility testing of ONEXTON Gel have not been performed. Benzoyl peroxide has been shown to be a tumor promoter and progression agent in a number of animal studies. Benzoyl peroxide in acetone at doses of 5 and 10 mg administered topically twice per week for 20 weeks induced skin tumors in transgenic Tg.AC mice. The clinical significance of this is unknown. Carcinogenicity studies have been conducted with a gel formulation containing 1% clindamycin and 5% benzoyl peroxide. In a 2-year dermal carcinogenicity study in mice, treatment with the gel formulation at doses of 900, 2700, and 15000 mg/kg/day (1.8, 5.4, and 30 times amount of clindamycin and 2.4, 7.2, and 40 times amount of benzoyl peroxide in the highest recommended adult human dose of 2.5 g ONEXTON Gel based on mg/m2, respectively) did not cause any increase in tumors. However, topical treatment with a different gel formulation containing 1% clindamycin and 5% benzoyl peroxide at doses of 100, 500, and 2000 mg/kg/ day caused a dose-dependent increase in the incidence of keratoacanthoma at the treated skin site of male rats in a 2-year dermal carcinogenicity study in rats. In an oral (gavage) carcinogenicity study in rats, treatment with the gel formulation at doses of 300, 900 and 3000 mg/kg/day (1.2, 3.6, and 12 times amount of clindamycin and 1.6, 4.8, and 16 times amount of benzoyl peroxide in the highest recommended adult human dose of 2.5 g ONEXTON Gel based on mg/m2, respectively) for up to 97 weeks did not cause any increase in tumors. In a 52-week dermal photocarcinogenicity study in hairless mice, (40 weeks of treatment followed by 12 weeks of observation), the median time to onset of skin tumor formation decreased and the number of tumors per mouse increased relative to controls following chronic concurrent topical administration of the higher concentration benzoyl peroxide formulation (5000 and 10000 mg/ kg/day, 5 days/week) and exposure to ultraviolet radiation. Clindamycin phosphate was not genotoxic in the human lymphocyte chromosome aberration assay. Benzoyl peroxide has been found to cause DNA strand breaks in a variety of mammalian cell types, to be mutagenic in S. typhimurium tests by some but not all investigators, and to cause sister chromatid exchanges in Chinese hamster ovary cells. Fertility studies have not been performed with ONEXTON Gel or benzoyl peroxide, but fertility and mating ability have been studied with clindamycin. Fertility studies in rats treated orally with up to 300 mg/kg/day of clindamycin (approximately 120 times the amount of clindamycin in the highest recommended adult human dose of 2.5 g ONEXTON Gel, based on mg/m2) revealed no effects on fertility or mating ability. PATIENT COUNSELING INFORMATION See FDA-approved patient labeling (Patient Information). Manufactured for: Valeant Pharmaceuticals North America LLC Bridgewater, NJ 08807 USA By: Valeant Pharmaceuticals International, Inc. Laval, Quebec H7L 4A8, Canada U.S. Patent 8,288,434 Onexton is a trademark of Valeant Pharmaceuticals International, Inc. or its affiliates. ÂŠValeant Pharmaceuticals North America LLC Rev 10/2016 9432702 ONX.0075.USA.17

COSMETIC Dermatology

Act Your Age When It Comes To Skin Care Dermatologists Share Tips for Women in Their 20s, 30s, and 40s The JDPA will feature this three part series from the American Academy of Dermatology (AAD) about skin care tips for women in their twenties, thirties, and forties. This third article will address those skin care issues faced by women in their forties.

Volume 11 â&#x20AC;˘ number 4 â&#x20AC;˘ FALL 2017 29

COSMETIC Dermatology

Anne M. Chapas, MD, FAAD, is a clinical instructor of dermatology at Mount Sinai Medical Center in New York. She is a frequent lecturer and has been widely published on advances in cutaneous oncology, laser surgery, and cosmetic dermatology. Dr. Chapas earned a medical degree with honors from Harvard Medical School in Boston. In addition to her dermatology residency, she also completed fellowships in Mohs surgery and procedural, cosmetic, and laser dermatology.

Reprinted with permission from the American Academy of Dermatology

30 Journal of Dermatology for Physician Assistants

Cosmetic pearls

Dermcast.tv Blog Evaluating Fractional Laser Treatments to Improve Skin Elasticity By Martha L. Sikes, MS, RPh, PA-C

SDPA Members Only Content

COSMETIC Dermatology

A complimentary subscription to the JDPA is provided to the members of the SDPA. Please visit www.dermpa.org today to join the SDPA and gain full access to the valuable content of the JDPA.

Volume 11 • number 4 • FALL 2017 31

Professional development

Notes from your Office Manager Promoting Adherence to a Medication Regimen The Risk: Patient nonadherence to a prescribed medication regimen is a common problem that healthcare providers in all specialties encounter. Some factors that may influence medication adherence include the complexity of the regimen, the age of the patient, and the cost of medications. Patients and/or caregivers should be advised of the importance of taking medications exactly as directed. Educating patients regarding the use of medications should include information about potential drug interactions, side effects, and other related problems that may warrant medical intervention. Recommendations: 1. Prescribing providers should educate patients about each medication, including its name, appearance, purpose, and effect. This education should include any potential side effects and/or interactions associated with the medication regimen. It should also stress the importance of contacting a healthcare provider should any reactions, questions or concerns arise. 2. Query patients regarding any underlying issues with medication selection in order to resolve any concerns. 3. The importance of using only one pharmacy to obtain all medications should be emphasized to patients or their representatives. 4. Patients should also be advised to: ● Keep an accurate list of all medications including generic and brand names,

over-the-counter medications, and herbal supplements, which includes dosages, dosing frequency, and the reasons for taking the medication; ● Maintain a complete list of medical providers and their contact information; ● Post the name and telephone number of their local pharmacy in a prominent location along with the name and phone number of their physician; ● Establish a daily routine when taking their medications; and ● Bring a list of all medications that they are taking to each and every appointment. 5. Make patients aware of the various medication adherence aids and devices available, such as dosing reminders, pill boxes, and refill reminder programs. 6. Provide useful written information in plain language that clearly explains how patients can correctly manage their medications. 7. Consider utilizing the “teach back method” when explaining medications to patients. First teach the information, then ask patients to repeat it back in their own words. 8. Physicians should help patients manage their medications, caution them to not share medications, and advise them to follow storage recommendations and dispose of old medications properly. J

These Risk Management Tips have been reprinted with permission from: MLMIC Dateline, published by Medical Liability Mutual Insurance Company, 2 Park Avenue, Room 2500, New York, NY 10016. Copyright ©2017 by Medical Liability Mutual Insurance Company. All Rights Reserved. No part of this article may be reproduced or transmitted in any form or by any means, electronic, photocopying, or otherwise, without the written permission of MLMIC.

32 Journal of Dermatology for Physician Assistants

As many of you know by now, The SDPA had to make the difficult decision to cancel their 15th Annual Fall Dermatology Conference in San Juan, Puerto Rico, due to the tragic hurricanes that have devastated the island. With the majority of the island still enduring the lack of electricity, unsafe roads and infrastructure, the SDPA and DPAF have decided to unite and contribute to the recovery efforts in Puerto Rico. We asked our members to join the SDPA and DPAF in giving back to the Puerto Rican community as they continue their path to recovery. The campaign fundraising came to an end on November 12, 2017. We are happy to report that we had a fantastic total contribution from our members of $7,125. The JDPA pitched in an additional $2,875 to bring us to the full $10,000 original fundraising goal. The SDPA and DPAF will each contribute $5,000 matching as pledged,

which brings our total combined donation to $20,000 for Americares. Thanks to everyone for a wonderful and much needed campaign! We are so proud that we can contribute and support Puerto Rico at a time when it is so desperately needed. We appreciate everyone who supported, spread the word, and pushed to make this a reality. One hundred percent of your contribution and the matching funds will go towards the nonprofit organization Americares. Americares specializes in emergency programs, which prepare for and respond to natural disasters. Americares is on the ground in Puerto Rico delivering shipments of medicine and supplies, providing aid, and assessing the needs of health facilities in communities struggling to re-establish basic services. The organization has airlifted more than $3 million worth of medicine and supplies to Puerto Rico and the Dominica including antibiotics, woundcare supplies, intravenous fluids, mental health medications and treatments for chronic disease. Of funds donated to Americares, 97% will be used for relief efforts while only 3% will go to administrative fees and overhead charges. J

Opportunities to Volunteer While the DPAF and SDPA do not endorse any of the below volunteer opportunities or organizations, many members have asked if there are ways that they can contribute in person. Below are some volunteer opportunities that we know of and which individuals can explore. Individuals looking to volunteer with a chosen nonprofit or disaster relief organization should do their due diligence in researching each opportunity and organization prior to commitment. NVOAD (National Voluntary Organizations Active in Disaster) is accepting applications for those who want to volunteer in Puerto Rico. They will match you with groups who need you according to your expertise. Many SDPA members might, for example, be useful working in hospitals, clinics, shelters (providing these venues provide umbrella malpractice insurance). Anyone interested can find, complete and submit a volunteer application at https://www.nvoad.org. Other organizations that could assist with volunteering opportunities are the American Red Cross and Americares.

Volume 11 â&#x20AC;˘ number 4 â&#x20AC;˘ FALL 2017 33

professional development

Outside & Inside the 9 to 5... Helping Puerto Rico

Their success is your success

Help patients transition to the world of dermatology with VELTIN® Gel Please see full Prescribing Information at www.aquapharm.com/veltin.php VELTIN is a registered trademark of LEO Pharma. © 2017 Aqua Pharmaceuticals, Exton, PA 19341 aquapharm.com 9/17 AQ-181b

34 Journal of Dermatology for Physician Assistants

#I MyDerm

Dermatology PA news & notes

Workplace Excellence

Coaching on Grow-and-Let-Go Strategies In The Workplace By Matthew Davidson, PhD

In my work as President of the Institute for Excellence & Ethics (IEE) I have had the opportunity to work with diverse individuals and organizations in their quest to achieve excellence. This column dedicated to workplace excellence explores the organizational, interpersonal, and ethical issues that contribute to (or detract from) individual or organizational excellence within the physician assistant profession. If you have any workplace topics you would like to see covered in the JDPA please feel free to share them with us. Email editor@ jdpa.org with any topic ideas or questions concerning the workplace. You can grow, improve, and change. You’re born with amazing mental, physical, and emotional capacity - far greater than what most of us are aware. This is the foundational message for healthcare providers/ supervisors as they can function as coaches to help instill the Grow-and-Let-Go Strategies. Research on fixed and growth mindset shows that a growth mindset is a powerful factor in the pursuit of optimal performance and one that many healthcare providers/supervisors and staff members/students overlook. Our approach to new skills, challenges, adversity, and transitions begins with how we frame them. The Grow-and-Let-Go Strategies are mental habits underlying our reaction to new challenges, difficult situations, and failure. These habits help us to reframe setbacks as learning situations, and to see challenges as opportunities. The mindset formed by the Grow-and-Let-Go Strategies helps us to forget about perfection (because nobody’s perfect) and perception (because what others think doesn’t really matter). This mindset is all about letting go of the past and the things we can’t change, focusing on what we’ll do better or different in the future, and asking for help when we need it. Even with a focus on the things that are within our control there are still plenty of things we can’t change or do anything about. These are the things we just need to let go. When we won’t let go, we often experience anxiety, embarrassment, shame, frustration, isolation, and less than optimal performance. Communication Coaching/training for a growth mindset means continuously framing and reframing obstacles as opportunities. Never held this specific position before? Learning a new skill, strategy, or schema? Performing in a new clinical situation or environment?

The best coaches/supervisors communicate continuously about the mindset needed for and developed from any new challenge, situation, or set of circumstances. Coaching means communicating these situations as opportunities to learn and grow because it is in and through these experiences that our mindset muscles grow, just as our physical muscles do when put to the test. Every great staff member has struggled, failed, and then improved. We get better after these challenges if our coaches/supervisors continuously communicate the message that our mindset is as important (if not more than) as our current skillset. Communication for optimal performance means clarifying expectations to ensure that performers work hard and smart. Sometimes the message is to simply hang on and keep doing it until it becomes a comfortable, familiar habit. Sometimes the message is to make a change in strategy. It’s all about growth, and teaching optimal performance means communicating the message: Forget perfect, find optimal! Keep growing, failing forward, building on strengths, targeting weaknesses, focusing on what you’ll do better or differently, and quickly flushing mistakes. It takes continuous dialogue and ongoing action and reflection to define and refine what optimal looks, sounds, and feels like, and, therefore, communication about and around growth mindset is essential and never-ending. Habit Research indicates that we all have areas in our life where the growth mindset comes more easily, and areas where our mindset tends to be more fixed. Educating staff members for this mindset requires the development of mindset habits, specific ways of thinking and Volume 11 • number 4 • FALL 2017 35

DERmatology pa news & notes

responding. Knowledge about what mindset is and why it matters isn’t enough; developing a Grow-andLet-Go mindset requires intensive, deliberate practice and real-world simulation. Supervising or overseeing staff members presents numerous opportunities to get comfortable being uncomfortable. Optimal performers practice being uncomfortable through targeted training; then they practice the skill in numerous situations until they have grown new mindset muscles, along with the mental confidence to improve on what was once uncomfortable if not impossible for them. If you’ve never (or rarely) been in uncomfortable situations (situations where you didn’t excel, weren’t the best, where it didn’t come easy, where you weren’t successful); then when you encounter these situations your mind is usually the first to give in and give up. Teaching about this habit means exposing the way the mind can turn on a staff member and what this negative selftalk sounds like: “You’re no good at this, and nothing can change that.” “You should quit or quickly hide this weakness and never show it to anyone again.” “You’re going to fail, get cut, or be put on the bench.” Coaching means helping to develop the habit of responding to uncomfortable situations by letting go of the outcome and simply focusing on the process and those things in our control. At some point every staff member and supervisor will encounter a situation where they are uncomfortable, where they struggle, or are not achieving their set goals. Encouraging staff members to adopt a growth mindset means instilling a way of thinking, practicing, and emotionally responding so that members quickly learn to grow and let go. Examples of Grow-and-Let-Go habits include dusting off your shoulder, taking a deep breath between patient encounters to put the last disgruntled patient behind you, stepping out into the hallway after a challenging case, not becoming frazzled when taking a patient history using a new electronic medical 36 Journal of Dermatology for Physician Assistants

record system, and resetting yourself by focusing your eyes on the next patient and thinking about the next appointment instead of the last. These are specific strategies that form a ritual linked to the formation of mindset. The same can be applied to phone encounters between staff members and patients. Accountability Accountability is vital for shaping a growth mindset. Accountability needs to focus on process as much as outcome. It’s important that supervisors not simply praise ability, talents, and giftedness. This type of praise reinforces a fixed mindset: “I’m good at X; “I’m not good at Y skills or Z situations” Instead, offer praise and polish for effort and attitude, growth and improvement, persistence, and courage. In addition, a c c ou nt a bi l it y coaching for growth mindset should offer praise that is specific and process-directed (“Good effort at the end of the day when we were running a bit off schedule,” “Great attention to detail in the way you followed t hrough,” “Excellent professionalism, even though the patient wasn’t pleasant”) as well as specific polish (“I like...” or “To improve it try...”) General praise feedback (eg, “Nice job” or “Great” or “Way to go”) and general polish feedback (“Do it over” or “That’s not good enough”) fail to provide accountability for specific things to work on in the future or specific things to do better or differently. One essential part of accountability is defining the optimal performance indicators and then measuring and monitoring progress through 180- and 360-degree type assessments. Measuring indicators include: openness to feedback, ability to respond quickly to failure, willingness to try new and different skills, strategy, roles, and responsibilities. Accountability is measuring what we do want to see, but also holding staff/key players accountable for efforts to avoid such fixed-mindset habits as the follwong: • Worrying about failing or making mistakes

Many supervisors and workplaces use quotes. The key is to connect them to growth mindset strategies and to the specific situations when and where we want staff members to put them into action. Quotes like these provide optimal performance truths that go to the heart of the Grow-and-Let-Go Strategies. As supervisors it is essential that we know what’s working and what needs improvement in the mindset of our staff members. This isn’t easy to achieve; using sentence-completion stems can help. For example: • Something you feel proud of or good about from today... • Something you’re worrying about.... • Something to target for improvement... • Negative things your mind tells you when you’re struggling... When it comes to forming a Grow-and-Let-Go mindset it’s essential to teach and reflect about the process and product, the journey, and the destination. When we only celebrate the end-product, we miss out on all the learning that took place on the way to it and that is a result in and of itself. What did you learn from this challenge? How are you different as a result? What would you do better or differently the next time you have a new transition to make? How could you improve that outcome? What would you do differently? The Grow-And-Let-Go Strategies help us all to use adversity to expand our strengths and abilities mentally, physically, and emotionally. J Matthew L. Davidson, Ph.D. is the Founder, President, and Director of Education for the Institute for Excellence & Ethics (IEE), a 501(c)3 nonprofit corporation dedicated to helping individuals and organizations achieve excellence. He is a National Spokesperson for the Business Bureau National Center for Character Ethics. The IEE specializes in the development and dissemination of research-based tools for developing the culture and competencies of excellence and ethics in schools, athletics, the workplace, and the home; this is done through professional development workshops & academies, teaching & learning resources, assessment, and consulting services. He is a frequent national presenter and is available for keynote lectures, professional development, retreats, and organizational consulting. He has indicated no relationships to disclose relating to the content of this article. For additional information or to contact the IEE, please visit www.excellenceandethics.org.

Volume 11 • number 4 • FALL 2017 37

DERmatology pa news & notes

• Worrying about how we compare to others • Trying to hide our struggles or weaknesses • Feeling embarrassed if something doesn’t come easily • Being afraid to ask for help • Worrying about the past or the future • Learning from and letting go of past mistakes or failures Mindset Fostering a Grow-and-Let-Go mindset means helping staff members to prepare mentally and emotionally through emotional visualization. Each new circumstance, situation, or challenge is different, but in general these often trigger the same kinds of emotions. Preparing oneself emotionally is half the battle. Prior to engaging in a transition, one needs to visualize the likely range of emotions and physical symptoms (eg, anxious mind, upset stomach, sweaty palms, or fidgety legs). Visualizing these prepares staff members to not be overwhelmed, but to recognize the feelings and then choose their response. Once they have the feeling that you’ve been here before, it’s less scary. They realize, “Hey, I’ve felt this before, and I made it through just fine!” A beneficial response to these emotions includes teaching skills like taking deep breaths, using positive self-talk, and simply focusing on what is most in the staff member’s control. Fostering a Grow-and-Let-Go mindset in the workplace can be enhanced through the use of quotes, movies, books, and similar other study examples that model what a growth mindset looks like. With movies you might use an entire movie (eg, Unbroken), but short clips can be even more powerful. You’re looking to highlight the adversity, the growth opportunity, and the mental approach and response. The more specific the example is to your circumstances and your staff development, the better. Quotes can be used to reinforce important ideas in bit-sized nuggets. A few growth mindset quotes to consider are the following: Success is not final. Failure is not fatal. It is the courage to continue that counts. ~ Winston Churchill You must do the thing you think you cannot do. ~ Eleanor Roosevelt You can’t stop the waves, but you can learn to surf. ~ Jon Kabot Zinn The harder you work, the luckier you get. ~ Gary Player Opportunities are usually disguised as hard work, so most people don’t recognize them. ~ Ann Landers

REINTRODUCING

OUR RENEWED PURPOSE:

YOU

We’re dedicated to building meaningful 1:1 connections with you and your peers and a ing value to every interaction by:

1:1 Derm

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Find out who we are: www.ortho-dermatologics.com Ortho Dermatologics is a trademark of Valeant Pharmaceuticals International, Inc. or its affiliates. © Valeant Pharmaceuticals North America LLC. NPR.0262.USA.17

38 Journal of Dermatology for Physician Assistants

Listening to Patients The Unforgiven By Alan Rockoff, MD

and told me that Leila’s father had called twice and that, “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.” Sighing inwardly, I sat down during a break and called her. “This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.” “That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.” “I’m sorry,” I said. “What questions did you forget to ask me?” She said, “I have marks on my back where the acne used to be, and they haven’t gone away.” “I see,” I said. “I thought we had covered that in connection with the marks left over on your face, but I’m sorry if I didn’t make that clear. All these marks need to fade on their own, and they will, though it will probably take a few more months.” “You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt. So I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.” “I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.” “I gave you a second chance,” Leila said, “and again you failed to spend adequate time or deliver satisfactory service.” (I bet you can guess what I really wanted to say, but of course I didn’t say it.) “Again, my apologies,” I said. I wished her luck and ended the call. Volume 11 • number 4 • FALL 2017 39

DERmatology pa news & notes

I like to be liked. Don’t you? Most patients like me. Some of them like me because I’m nice. Some of them like me because they got better, and they think I deserve the credit. Sometimes I even deserve it. Sometimes patients don’t like me, whether I deserve that or not. Overall, I think I come out ahead. You will too. But sometimes we don’t. When that happens, we learn what we can, if there is anything to learn, and move on. Leila’s visit seemed uneventful enough. She was back for the semester break of her senior year, and she came in for an acne follow-up. Leila seemed to be doing pretty well since she had just a couple of active papules on each cheek and some residual fading red marks from old lesions. Still, Leila was not happy with her situation. “I’ve been taking minocycline since September,” she said, “and I’m still breaking out.” “Some of the marks you have just haven’t had time to fade away yet,” I told her. “But since you’re still getting new ones, maybe we should change antibiotics. After four months on the old one, it’s not likely that you are going to clear up as fully as you want. Total clearing can be a hard goal to reach.” I discussed alternative choices with her and we settled on one as being most likely to help and least likely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on because she had had “reactions” to several previous topical agents, to contact me with any problems, and to come back in May. As I wrote up her prescriptions, I asked about her academic major. “Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to combine both disciplines in a business context.” I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they are headed after graduation. I wished her well and left the room. Since the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later

DERmatology pa news & notes

After all these years, I think I am pretty good at picking up physical and verbal cues of anger and dissatisfaction, but I obviously missed them all in Leila’s case. Like everyone else, I have had my share of unhappy patients, but I am hard pressed to remember being laid out in lavender with such gusto before. When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being chastised by a self-righteous and unforgiving youngster less than a third my age will not be one of them. When you get your chance, you will be able to look back on many pleasant and gratifying interactions with patients. With skill, caring, and luck there won’t be too many of the other kind. But you will remember those. I guarantee it. J

Alan Rockoff, MD practices dermatology in Boston, MA. He graduated with his medical degree in 1972 from the Albert Einstein College of Medicine in New York and then completed a pediatric internship and residency at Bronx Municipal Hospital Center. Continuing his education, Dr. Rockoff completed a dermatology residency program at the combined program at Boston University and Tufts University. Dr. Rockoff is a Clinical Assistant Professor of Dermatology at Tufts University School of Medicine. He has taught senior medical students and other trainees for over thirty-five years. Dr. Rockoff has been named one of Boston’s Top Doctors by Boston Magazine for five years. Dr. Rockoff is board certified by the American Board of Pediatrics and the American Board of Dermatology. Dr. Rockoff is a Fellow of the American Academy of Dermatology and a member of the Massachusetts Medical Society and the Massachusetts Academy of Dermatology. Dr. Rockoff’s publications have appeared in a number of journals. He writes a monthly column for his dermatologic colleagues in Dermatology News as well as a blog for the magazine Psychology Today. His first book, “Under My Skin: A Dermatologist Looks at His Profession and His Patients” is available on Amazon and is his second book, “Act Like a Doctor, Think Like a Patient: Teaching Patient-focused Medicine” is available on Amazon and at Barnes and Noble. Profession and His Patients” is available on Amazon and is his second book, “Act Like a Doctor, Think Like a Patient: Teaching Patient-focused Medicine” is available on Amazon and Barnes and Noble.

Let them know they’re not alone... Share a story with your patients. Visit the Patient’s Perspective library of articles at www.jdpa.org/advocacy.html

JDPA Journal of Dermatology for Physician Assistants

If you know a patient who would like to share his/her story, please contact us at editor@jdpa.org 40 Journal of Dermatology for Physician Assistants

From the Desk of... In a time where there are so many CME conferences, how do you decide which one to attend? Is there a benefit of one over the other? The answer is easy and clear-yes! Since many meetings are now for profit, the biggest question to be answered is, will the organizers of the meeting advocate for me if something happens to my career? Your professional membership is so much more than just a conference, dues, and education; it also provides a synergy within your dermatology community. SDPA members obtain not only tangible benefits and returns on their investments, but also the SDPA’s advocacy and support for the entire dermatology community. We wanted to take a moment to explain both tangible and intangible benefits that SDPA members gain from their memberships. 1. Education (CME) As a member of the SDPA, you will benefit from our most coveted member benefit: CME opportunities and training. The SDPA offers over 150 hours of Category 1 CME courses at any given time. Our two yearly conferences average more than 25 CME hours each and our journal, the JDPA, offers 1 CME opportunity per quarterly issue. The SDPA recently rolled out two Performance Improvement (PI) courses each worth 40 CME hours due to NCCPA’s decision to no longer require PI CME, but to double weight credits for completed performance improvement projects. We now offer video recorded sessions from our yearly conferences for those unable to travel to our meetings. Lastly, SDPA members receive a discount on conference registration fees for both our summer and fall conferences. 2. Advocacy Beyond education, this is the most

important reason to become a member! Our wonderful leaders are busy advocating for you with the AAD and their members, state and federal legislators, industry leaders, patient advocacy groups, and your local communities. As an individual, you may not have the time or energy to devote to political action, but your SDPA leadership team remains alert and proactively involved in issues that have the potential to affect your career. By supporting our society you are helping us advocate for reform of antiquated PA licensing regulations and for a reduction in restrictive regulations, thus helping to advance your career. This alone should be why you join and continue to renew. There are plenty of well-respected dermatology meetings, but those involved in for-profit meetings do not advocate for you as a PA. In addition, we monitor the national and local publications for articles that may contain inaccurate information about PAs in dermatology and work to post replies and defend the profession in multiple print and online arenas. 3. Relationship with AAD The SDPA has been advocating for our profession with AAD leadership and their dermatologist members for many years. Over the past decade we have made great strides towards PA acceptance in the dermatology community, yet there is still much work to be done. SDPA leadership continuously works to maintain a collegial relationship with the AAD, while upholding our mission to advance the PA profession. Over the past couple of years, the AAD has embarked on a mission to develop their DermCare team model for practice. The SDPA has maintained an open dialogue regarding the DermCare team, but we firmly believe that PAs who forego SDPA membership to join the DermCare team will

Volume 11 • number 4 • FALL 2017 41

DERmatology pa news & notes

Strength in Numbers: Rally for Members

DERmatology pa news & notes

find themselves at a substantial disadvantage compared to SDPA members who have a whole team of dermatology PA leaders to advocate for the profession. 4. Training In June 2017, the SDPA launched the new Diplomate Fellowship program designed to become the gold standard in dermatology PA education and training. The Diplomate Fellowship program has been built with psychometricians and over 90 subject matter experts to cover the full range of knowledge every dermatology PA should have to best care for patients in the dermatology clinic. The completed program will consist of over 72 hours of CME (spread out over modules with video, didactic training, and proficiency testing.ctic recorded lectures) and testing at program completion The SDPA is proud to lead the way in PA dermatology education and training. We work tirelessly to ensure our programs provide cutting edge training and education. 5. Publications The SDPA boasts its own publication, the Journal of Dermatology for PAs (JDPA), which provides further education to our members. Content of the JDPA is written predominantly by dermatology PAs, and the journal was developed and is edited by a dermatology PA. It offers a great avenue for our members to publish and build their resumes. SDPA members also receive access to additional journals to provide further information on the most current dermatological innovations and news. 6. Community and Networking The SDPA provides you with unique opportunities to network with colleagues across the country at our two annual meetings and within our website social community. The website offers access to a fully functioning social community and multiple tools to connect with other members and SDPA thought leaders. Creating a network of colleagues can be catalyst to enhancing your career. The website’s functionality also allows members to post clinical and non-clinical questions and to

42 Journal of Dermatology for Physician Assistants

communicate with other members privately. The Membership Committee also highlights fellow members in a monthly “member spotlights” to showcase the amazing work being done by dermatology PAs across the country. 7. Jobs You can use our career center to post your resume and find/apply to job postings. New jobs are regularly posted and are searchable by a number of criteria. Don’t want to look? Set up an alert to get instant email as soon as a new job is posted! There is also an area where you can submit your resume for view by those looking to hire. 8. Discounts Everyone loves discounts! We offer them on dermatology relevant products such as dermatoscopes, lab coats, and compression socks for your patients. Your SDPA Membership Committee is continuously working to provide our members with professional discounts and member benefits to further enhance your experience as an SDPA member. 9. Leadership Opportunities The SDPA helps members create new networks throughout the country and grow professionally and personally by developing and using their leadership skills. Our profession depends on leadership. Why not become a force for positive change and get involved in leadership today? Visit our website for further information. For your next contract year, make it a priority to pay your SDPA membership dues. We are an organization made up of dermatology PAs fighting for dermatology PAs in an ever-changing healthcare landscape. J Sincerely, Sara M. Wilchowski, PA-C Chair, SDPA Constituent Relations Committee

Dermatology PAs [or those PAs interested in dermatology]

Should Become a Member of the SDPA 4

Training

➊

Education (CME)

Advocacy

➐

➑

Jobs

Discounts!

➏

Community & Networking

➒

A Career Boost

The largest of 26 specialty organizations under the American Academy of Physician Assistants (AAPA), the Society of Dermatology Physician Assistants (SDPA) is a non-profit professional association focused on empowering, educating and advancing PAs currently working in the field of dermatology and those who would like to work in the field.

Volume 11 • number 4 • FALL 2017 43

Collaborating Physician CORNER

DERmatology pa news & notes

Hurricane Harvey Response In August, our country witnessed the devastating flooding and destruction in southeastern Texas and along the gulf coast that will have lasting effects for residents in that region. Hurricane Harvey has overwhelmed these communities and there is much work to be done. There are several programs the Academy’s Board of Directors have enacted to come to the aid of the region and certainly our colleagues and their patients who are impacted by this devastation, and we hope you will contribute – as the Academy has the ability to match your donations and make them go even further for the cause. Donate to Humanitarian Efforts The Academy is providing a matching fund donation program to allow all of us – Academy staff and members alike – share in helping those who are affected by this hurricane. Funds will be distributed to the American Red Cross, United Way, and local food banks to help those in need. For every donation you make through the Academy through the end of September, the Academy will match these funds, up to $100,000. You can make your donation directly at www.donate.aad.org/harvey. DONATE NOW If you have already contributed to a qualified organization for the Hurricane Harvey relief effort, you may provide the AAD proof of your contribution, and it will be included in the amount to be matched. Qualified organizations include: • Gulf Coast United Way • American Red Cross • Houston Food Bank • Greater Houston Community Foundation Member Loan Assistance If you’ve been impacted, help is available through the Academy in the form of low interest loans. AAD member licensed dermatologists and dermatology residents who sustained physical damage not covered by insurance may apply for a loan at www.aad.org/ members/aad-disaster. Dermatologists can apply for up 44 Journal of Dermatology for Physician Assistants

to $25,000 and graduate members (residents and fellows) may apply for up to $5,000 each. The Academy has set aside up to $300,000 for this effort. APPLY FOR A LOAN The Academy is sensitive to the suffering and damage such an event as Hurricane Harvey has caused, and although we still do not know the full effect of this storm, we know that it will take all of us to help this region recover. As vicepresident elect, Ted Rosen, MD, FAAD recently wrote to us from his post in Houston: “Your matched contribution will help relieve the unfathomable suffering which has afflicted my colleagues, neighbors, friends, and fellow Texans. I know the AAD will use these contributions to support efforts by reputable charities who are, at this very moment, actively trying to bring shelter, sustenance, medical care, disaster counseling and comfort to those in dire need. Be generous! Every dollar counts! Thanks for proving that WE care.” Ted Rosen, MD, FAAD, AAD Vice-PresidentElect Houston, Texas Please consider a donation that the Academy can help extend with matching funds, and thank you for supporting these relief efforts. J Henry Lim, MD Academy President Henry W. Lim, MD, FAAD President, American Academy of Dermatology Association Dr. Lim is chair emeritus of the department of dermatology and senior vice president for Academic Affairs at Henry Ford Health System in Detroit, Michigan. He previously served as Chief of Staff of the New York VA Medical Center.

th Journal of Anniversary Dermatology for Year Physician Assistants Information for Authors – The JDPA is a peer-reviewed publication that delivers innovative clinical, surgical, cosmetic, and professional content exclusively for dermatology PAs. Submissions to the JDPA are peer-reviewed by a panel of experienced dermatology PAs, educational PAs, and dermatologists before articles are accepted for publication. Manuscripts submitted for publication will be reviewed with the understanding that they are original and have not been submitted elsewhere nor are being considered by other journals. Electronic submissions are accepted and should be sent to editor@ jdpa.org. The five main sections featured in each issue of the JDPA are listed below along with a brief description of the various topics that authors can contribute to. Regardless of the section, all articles must follow the following criteria: • Formatting - Times New Roman font, 12 point, double-spaced, left aligned. • Article Order - Title, Author(s), Author bios (including disclosures), Text of Article, References, Tables, and Figures • Reference Citations - Utilize the AMA Manual of Style, 10th Edition. Dermatology PA News and Notes Feature Articles

Write a review about a new or innovative dermatological procedure, device, and/or approach to patient care (500-1000 words).

From The Desk Of…

Write an opinion essay sharing your insight regarding a current “hot item” issue (e.g., specialty PA credentialing, dermatology access to care, supervising physician relationships, etc.) or any other topic regarding the field of dermatology (250-1000 words).

Clinical Dermatology CME articles

Content should be specific to the field of dermatology following any of the following formats: Study – Original research (clinical or basic science). Professional issues or health policy papers. Review – Scholarly review of a topic. Content length: 6 pages (requires 4 self-assessment Q&A) = .5hr of Cat. I CME. 12 pages (requires 8 self-assessment Q&A) = 1hr of Cat. I CME. Article should include written learning objectives (3-4 required).

Dermatology Case Report

Write a report and discuss a case(s) that illustrate an important or interesting observation (500-1500 words).

Journal Club: Dermatology PA Perspectives

Write a review of an already published article from an established dermatology journal (e.g., JAAD, Cos Dermatol, Dermatol Surg, etc.), summarizing the practical thoughts and clinical issues (250-1000 words).

From the Patient’s Perspective

Patients’ stories published in their own words. JDPA staff can even assist patients with writing their stories (250-1000 words).

Clinical Snapshots

Write a brief written description and clinical facts about an interesting cutaneous anomaly (250-500 words).

Drugs in Dermatology

Write about the current information regarding a particular dermatological medication, drug interaction, or medication side effect/adverse reaction (250-1000 words).

Dermatology Evidence-Based Medicine (derm EBM)

Write a brief, evidence-based assessment of the one or two most relevant studies retrieved to answer a focused clinical question that may have arisen from a real-life situation. A derm EBM is not a comprehensive review of a subject or a synthesis of all the available knowledge (500–1500 words).

Surgical Dermatology Feature Articles

Write a review about a new or innovative surgical procedure, device, and/or approach to patient care (500-1000 words).

Surgical Wisdom

Write a brief article on a fact or pearl for the surgical setting (250-500 words).

Surgical Dermatology Case Report

Write a report and discuss a case(s) that illustrate an important or interesting observation (500-1500 words).

Journal Club: Dermatology PA Perspectives

Cosmetic Dermatology Feature Articles

Write a review about a new or innovative cosmetic procedure, device, and/or approach to patient care (500-1000 words).

Cosmetic Pearls

Write a brief article on a fact or pearl for the cosmetic setting (250500 words).

Cosmetic Dermatology Case Report Write a report and discuss a case(s) that illustrate an important or interesting observation (500-1500 words). Journal Club: Dermatology PA Perspectives

Professional Development Feature Articles

Write an article that explores the professional issues dermatology PAs face such as reimbursement, education, medical trends, contracts, office management, etc. (500-1500 words).

Outside & Inside the 9 to 5

Allow us to share your story of the good work that you do either outside or inside your practice of dermatology. You can write this article yourself or the JDPA staff can interview you to write the article (250-1000 words). Notes From Your Office Manager Write a brief article on a fact or pearl for the office setting (250-500 words).

Judicial and Ethical Affairs

Write an article that explores the complex or multifaceted ethical or judicial professional issues that affect the practice of dermatology for PAs (250-1000 words).

To read the JDPA publication’s Ethics and Malpractice Statement, please visit www.jdpa.org/write.html.

Volume 11 • number 4 • FALL 2017 45

Professional Opportunities and Development

A dver tiser INDE X • Valeant - Luzu..................................Pages 2, 3 • GDPA – CME Conference.....................Page 7 • Valeant - Solodyn.............................Pages 9-11 • FSDPA - CME Conference................... Page 18 • Ortho Dermatologics.......................... Page 25 • Ortho Dermatologics - Onexton... Pages 27, 28 • Aqua Pharmaceuticals – Veltin............Page 34 • Ortho Dermatologics..........................Page 38 • Valeant - Jublia............................. Pages 47, 48 For more information on advertising opportunities in the JDPA, please log on to www.jdpa.org

HELP YOUR PATIENTS WITH ALOPECIA AREATA! Encourage Them to Contact the

National Alopecia Areata Foundation

Your patients with alopecia areata are our community.

Just one phone call connects them to us & others who share their experiences to help them realize they are not alone. Our staff provides personal support, educational materials, a network of caring people who understand & research updates.

Let us help YOU help THEM! www.NAAF.org/JDPA (415)472-3780

DEFENSE

Prevent. Detect. Live. Skin cancer is the most diagnosed cancer in the United States. Your best defense is to prevent skin cancer by seeking shade, covering up, and wearing sunscreen.

46 Journal of Dermatology for Physician Assistants

BRIEF SUMMARY OF PRESCRIBING INFORMATION This Brief Summary does not include all the information needed to use JUBLIA safely and effectively. See full prescribing information for JUBLIA.

JUBLIA® (efinaconazole) topical solution, 10% For topical use Initial U.S. Approval: 2014 INDICATIONS AND USAGE JUBLIA (efinaconazole) topical solution, 10% is an azole antifungal indicated for the topical treatment of onychomycosis of the toenail(s) due to Trichophyton rubrum and Trichophyton mentagrophytes. DOSAGE AND ADMINISTRATION Apply JUBLIA to affected toenails once daily for 48 weeks, using the integrated flowthrough brush applicator. When applying JUBLIA, ensure the toenail, the toenail folds, toenail bed, hyponychium, and the undersurface of the toenail plate, are completely covered. JUBLIA is for topical use only and not for oral, ophthalmic, or intravaginal use. CONTRAINDICATIONS None. ADVERSE REACTIONS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In two clinical trials, 1227 subjects were treated with JUBLIA, 1161 for at least 24 weeks and 780 for 48 weeks. Adverse reactions reported within 48 weeks of treatment and in at least 1% of subjects treated with JUBLIA and those reported in subjects treated with the vehicle are presented in Table 1. Table 1: Adverse Reactions Reported by at Least 1% of Subjects Treated for up to 48 Weeks Adverse Event, n (%)

JUBLIA N = 1227

Vehicle N = 413

Ingrown toenail

28 (2.3%)

3 (0.7%)

Application site dermatitis

27 (2.2%)

1 (0.2%)

Application site vesicles

20 (1.6%)

0 (0.0%)

Application site pain

13 (1.1%)

1 (0.2%)

DRUG INTERACTIONS In vitro studies have shown that JUBLIA, at therapeutic concentrations, neither inhibits nor induces cytochrome P450 (CYP450) enzymes. USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C There are no adequate and well-controlled studies with JUBLIA in pregnant women. JUBLIA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Systemic embryofetal development studies were conducted in rats and rabbits. Subcutaneous doses of 2, 10 and 50 mg/kg/day efinaconazole were administered during the period of organogenesis (gestational days 6-16) to pregnant female rats. In the presence of maternal toxicity, embryofetal toxicity (increased embryofetal deaths, decreased number of live fetuses, and placental effects) was noted at 50 mg/kg/day [559 times the Maximum Recommended Human Dose (MRHD) based on Area Under the Curve (AUC) comparisons]. No embryofetal toxicity was noted at 10 mg/kg/day (112 times the MRHD based on AUC comparisons). No malformations were observed at 50 mg/kg/day (559 times the MRHD based on AUC comparisons).

Subcutaneous doses of 1, 5, and 10 mg/kg/day efinaconazole were administered during the period of organogenesis (gestational days 6-19) to pregnant female rabbits. In the presence of maternal toxicity, there was no embryofetal toxicity or malformations at 10 mg/kg/day (154 times the MRHD based on AUC comparisons). In a pre- and post-natal development study in rats, subcutaneous doses of 1, 5 and 25 mg/kg/day efinaconazole were administered from the beginning of organogenesis (gestation day 6) through the end of lactation (lactation day 20). In the presence of maternal toxicity, embryofetal toxicity (increased prenatal pup mortality, reduced live litter sizes and increased postnatal pup mortality) was noted at 25 mg/kg/day. No embryofetal toxicity was noted at 5 mg/kg/day (17 times the MRHD based on AUC comparisons). No effects on postnatal development were noted at 25 mg/kg/day (89 times the MRHD based on AUC comparisons). Nursing Mothers It is not known whether efinaconazole is excreted in human milk. After repeated subcutaneous administration, efinaconazole was detected in milk of nursing rats. Because many drugs are excreted in human milk, caution should be exercised when JUBLIA is administered to nursing women. Pediatric Use Safety and effectiveness of JUBLIA in pediatric subjects have not been established. Geriatric Use Of the total number of subjects in clinical trials of JUBLIA, 11.3% were 65 and over, while none were 75 and over. No overall differences in safety and effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and the younger subjects, but greater sensitivity of some older individuals cannot be ruled out. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility A 2-year dermal carcinogenicity study in mice was conducted with daily topical administration of 3%, 10% and 30% efinaconazole solution. Severe irritation was noted at the treatment site in all dose groups, which was attributed to the vehicle and confounded the interpretation of skin effects by efinaconazole. The high dose group was terminated at week 34 due to severe skin reactions. No drug-related neoplasms were noted at doses up to 10% efinaconazole solution (248 times the MRHD based on AUC comparisons). Efinaconazole revealed no evidence of mutagenic or clastogenic potential based on the results of two in vitro genotoxicity tests (Ames assay and Chinese hamster lung cell chromosome aberration assay) and one in vivo genotoxicity test (mouse peripheral reticulocyte micronucleus assay). No effects on fertility were observed in male and female rats that were administered subcutaneous doses up to 25 mg/kg/day efinaconazole (279 times the MRHD based on AUC comparisons) prior to and during early pregnancy. Efinaconazole delayed the estrous cycle in females at 25 mg/kg/day but not at 5 mg/kg/day (56 times MRHD based on AUC comparisons). PATIENT COUNSELING INFORMATION See FDA-Approved Patient Labeling (Patient Information).

Manufactured for: Valeant Pharmaceuticals North America LLC, Bridgewater, NJ 08807 USA Manufactured by: Valeant Pharmaceuticals International, Inc., Laval, Quebec H7L 4A8, Canada JUBLIA is a trademark of Valeant Pharmaceuticals International, Inc. or its affiliates. © Valeant Pharmaceuticals North America LLC U.S. Patents 8,039,494; 7,214,506 Based on 9462903 JUB.0130.USA.16 Issued: 09/2016

Volume 11 • number 4 • FALL 2017 47

ONYCHOMYCOSIS* Your patient’s dirty secret?

TIME TO CLEAN IT UP AT THE SITE OF INFECTION1

*For the treatment of onychomycosis of the toenail(s) due to Trichophyton rubrum and Trichophyton mentagrophytes.

JUBLIA allows some patients to have clearer toenails grow back.1 Individual results may vary.

PRESCRIBED

BRAND FOR TOENAIL FUNGUS2

INDICATION JUBLIA (efinaconazole) topical solution, 10% is indicated for the topical treatment of onychomycosis (tinea unguium) of the toenail(s) due to Trichophyton rubrum and Trichophyton mentagrophytes.

• The most common adverse reactions (incidence >1%) were (vs vehicle): ingrown toenail (2.3% vs 0.7%), application-site dermatitis (2.2% vs 0.2%), application-site vesicles (1.6% vs 0%), and application-site pain (1.1% vs 0.2%).

IMPORTANT SAFETY INFORMATION

• JUBLIA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus, and should be used with caution in nursing women. The safety and effectiveness in pediatric patients have not been established.

• JUBLIA is for topical use only and is not for oral, ophthalmic, or intravaginal use. • Patients should be instructed to contact their health care professional if a reaction suggesting sensitivity or severe irritation occurs. References: 1. JUBLIA [prescribing information]. Bridgewater, NJ: Valeant Pharmaceuticals North America LLC; 2016. 2. Toenail fungus market summary—current 12 week TRx count: April 2017. Symphony Health Solutions Integrated Dataverse.

To report SUSPECTED ADVERSE REACTIONS contact Valeant Pharmaceuticals North America LLC at 1-800-321-4576 or FDA at 1-800-FDA-1088 or visit www.fda.gov/medwatch. Please see Brief Summary of full Prescribing Information on the adjacent page. Find out more by visiting www.JubliaRx.com.

48 Journal of Dermatology for Physician Assistants