1VOLUME 7 • NUMBER 1 • WINTER 2013

Official Journal of the Society of Dermatology Physician Assistants

DERMATOLOGY PA NEWS & NOTESSDPA State Round Table 13

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CLINICAL DERMATOLOGYWhat's New in Dermoscopy 23

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SURGICAL DERMATOLOGYJournal Club 31

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COSMETIC DERMATOLOGYCosmetic Pearls 34

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PROFESSIONAL DEVELOPMENTDermatology Billing & Coding 37

V O L U M E 7 • N U M B E R 1 • W I N T E R 2 0 1 3 • www.jdpa.org

JDPAJournal of Dermatology for Physician Assistants

›› Earn CME credit with this issue CME A Review of Herpes Simplex Type 2 18

SUPPLEMENT

for the

Cutaneous Lymphoma

Foundation

Journal of Dermatology for Physician Assistants2

PUBLISHING STAFFPublisher Travis Hayden, MPAS, PA-CManaging Editor Jennifer M. Hayden, M.EdCopy Editor Douglas MorrisArt Director Angela Simiele Website Design Terry Scanlon

SALES OFFICEPhysician Assistant Communications, LLC P.O. Box 416, Manlius NY 13104-0416Phone (315) 663-4147 PAC@pacommunications.orgwww.pacommunications.orgEDITORIAL 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, practice-proven 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.

KEEP CURRENT:

EDITORIAL BOARDTravis Hayden, MPAS, PA-C, Editor in ChiefJoe R. Monroe, MPAS, PA-CPatricia Ferrer, MPAS, PA-CGordon Day, R.Ph., PA-CNancy Primo, MPAS, PA-CLauren Zajac, MHS, PA-CMichelle DiBaise, MPAS, PA-CP. Eugene Jones, Ph.D., PA-CMark Archambault, DHSc, PA-CKristine Kucera, DHS, MPAS, PA-CJennifer Winter, PA-CMark Hyde, MMS, PA-CJennifer Conner, MPAS, PA-CJeffrey LaDuca, Ph.D., MDAlan Menter, MD

DEPARTMENT EDITORSClinical Department Editors Susan E. King-Barry, MPAS, PA-C Karen Graham, MPAS, PA-CDermoscopy Q&A Editor John Burns, PA-CDrugs in Dermatology Editor Stephen Wolverton, MDSurgical Department Editor Christy Kerr, MPAS, PA-CCosmetic Department Editor Nancy Primo, MPAS, PA-CProf Dev Department Editor Abby Jacobson, MS, PA-C

SDPA BOARD OF DIRECTORSPRESIDENT John Notabartolo, MPAS, PA-CPRESIDENT-ELECT Jennifer Winter, PA-CIMMEDIATE PAST PRESIDENT Keri Holyoak, MPH, PA-CVICE PRESIDENT Jacki Kment, MPAS, PA-CSECRETARY / TREASURER Joleen Volz, MPAS, PA-CDIRECTORS AT LARGE Matthew Brunner, MHS, PA-C Greg Buttolph, MPAS, PA-C Jennifer Conner, MPAS, PA-C Vicki Roberts, MPAS, PA-C

THIS ISSUE IS SPONSORED BY

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 7, Number 1, Winter 2013. 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. © 2013 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., 4111 W. Alameda Ave. Suite 412, Burbank, CA 91505, 1-800-380-3992., email SDPA@dermpa.org, www.dermpa.org.

Journal of Dermatology for Physician Assistants

3VOLUME 7 • NUMBER 1 • WINTER 2013

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From The Patient’s PerspectiveMy CTCL Journey

It was a chilly morning in late October 2009. I had just arrived at the office of Doctor Williams, a local dermatologist. This was my first visit to a dermatologist, and I wasn't sure where this visit was going to take me.

The wait was short, and I was soon in an examination room ready to see the doctor. I looked around the examination room at the pictures on the walls showing various skin issues. Would this doctor be able to help with my problem? I thought about the red patches on my body and the years of applying creams to clear them up. The first patch on the inside of my left knee had appeared at least five years ago. Previous doctors assured me it was only eczema and that softer soaps and ointments would take care of the problem. I now had many red patches that extended from my knees to my shoulders, and some were on my upper arms.

I remembered a time in early 2005 when I had a three-month work assignment in Sydney, Australia. Because I had few distractions during that time, I was able to consistently apply an eczema ointment every day and night. The few patches became softer, and at times the red color would be lighter, but it didn't seem to make a long-term difference. I began to accept these patches as things that were going to stay around. They didn't seem to itch or hurt most of the time. They would occasionally get scaly, and I would apply some hand lotion for a few days.

I had recently changed my primary care physician and made a visit to get an annual physical examination. He asked about the patches. I told him they were part of my life and that they didn't seem to go away so I just accepted them. He suggested I have a dermatologist look at them to ensure they were not a concern. He recommended Doctor Williams and here I sat waiting for his opinion.

I was brought back to the present as the doctor entered the room, and we exchanged greetings. He looked at the red patches and asked a few questions about how long they had been there. After a few minutes, he stepped back and said, "I know what you have, and you will die with it."

I wasn't quite sure I heard him right. I must have had a puzzled look on my face because he explained further,

The mission of the Cutaneous Lymphoma Foundation is to support every person with cutaneous lymphoma by promoting awareness and education, advancing patient care, and facilitating research.

Contact information: www.clfoundation.org (248) 644-9014 info@clfoundation.org

PO Box 374, Birmingham, MI 48012

By Gary C. Robinson

"You will die with it but probably not from it." I wasn't sure that helped to calm my concern. He explained that it looked like I had cutaneous T-cell lymphoma, known as CTCL. The lymphoma word didn't sound good. He would need to take a biopsy to be sure. Looking around my body again, he chose an older patch on my lower back. He stated that this disease is often hard

to identify and that future biopsies might be needed. He told me I would be hearing back from his office within the week.

Several days later, I received a call and was

informed that my situation had been referred to the

Huntsman Cancer Institute and that they would be contacting me for an appointment. Within a very short time, I was sitting in another examination room waiting to see Doctor Glen Bowen. I now realize, as I reflect back to that day, that it was a turning point for several aspects of my life.

I had spent time researching CTCL on the Internet and saw pictures of patches like mine. Some of the stories were not very encouraging and I wondered what the future would bring. Just then, Doctor Bowen entered the room bringing a great amount of energy with him. He welcomed me and made me feel good to be there. He looked me over and then started to explain about this disease. He used some images and related descriptions that helped me to calm my concerns, to better comprehend what was going on, and to understand how we could treat this disease in the near term. I left feeling encouraged to fight the battle.

The battle has not always been easy. Ultraviolet light

“After a few minutes, he stepped back and said, ‘I know what you have, and you will die with it.‘ ”

...continued on page 28

Journal of Dermatology for Physician Assistants4

1. How do we deliver bad news? Bad news can be any health related news given to a patient that negatively affects how the person views his/her future, and it is often in the “eye of the beholder.” While it is often said about CTCL that you will "most likely die with it than from it," this statement can sound rather callous when it is the first piece of diagnostic information a patient receives from the clinician. The word lymphoma also suggests a bad diagnosis. We as clinicians understand why CTCL is labeled as such, but we must be sensitive to what patients hear and interpret. Notice the difference between saying “most likely you will die with it, than from it” vs. “I truly believe that you will live a healthy life despite this diagnosis?” We need to be gentle with our first words, since they may never be forgotten.

2. Who delivers the bad news? When this patient was called on the phone and was told that his “situation has been referred to the Huntsman Cancer Institute,” one wonders how he felt when he heard the word “cancer?” It seems to me that the clinician should have been involved with delivering this news and should have reiterated that more likely than not, the patient would live a healthy life despite the CTCL diagnosis.

3. How do you deal with patients with a chronic disease? I noticed that the patient recalled that Dr. Bowen, the CTCL specialist, made him feel good about seeing him. Dr. Bowen educated him, both visually and verbally, helped calm him down, and no doubt helped with the patient’s compliance over many months of treatment. The main themes in dealing with patients who have a chronic disease are to educate the patient and to be honest, caring, and available. I have used this expression before in this journal, but it is worth repeating, “To cure sometimes, to relieve often, to comfort always.”

Take Home Points for Derm PAs:By Steven K. Shama, MD, MPH

treatments began in mid December 2009. I made the trek to the clinic three times each week for two months. In the early stages, my skin would be on the edge of a sunburn and painful to the touch. Then the itching would wake me up at night. The frequent visits for light therapy and the tired feeling that followed were impacting my work ability. I had launched my own business while this was happening; it did give me some schedule flexibility, but productivity was impacted. The patches initially got redder, and the itching was unbearable. I wondered if the time and effort were really going to be worth it. My wife was my biggest supporter during this period; she gave me daily encouragement and was there when I needed her.

After the initial two months, I had a nice tan and the itching was greatly minimized. The patches had faded away. My February 2010 visit with Doctor Bowen revealed that the light treatments were working, and I could begin a slow decrease in the frequency. It was now a time to look towards the future and to ensure my daily efforts matched my health desires. I had become involved in a CTCL support group, which met monthly to help educate other people like me. Participation in this group helped to lift my spirits, to educate me on the possibilities, and to identify those areas of my life where I could make changes to improve my overall health and well-being.

These monthly meetings have brought the support and encouragement of Mark Hyde, PA-C (who works with Doctor Bowen) and Kellie Custen (a patient and family support specialist). I have been able to meet and associate with other CTCL patients and learn how they are dealing with this disease. The monthly support group meeting agenda includes topics on mindfulness meditation, proper diet, and physical exercise programs. These have helped me focus on my health improvement objectives. My CTCL diagnosis and the treatment journey since then have instilled in me an awareness of my overall health and the improvements I can make now to ensure a healthier future.

The journey is not over. I continue with light treatments every five weeks to maintain this disease. The patches are gone for now. The itching and the slight sunburn pain still follow each treatment. Continual watching and caring by my wife identified some spots on my face, which were identified as basal cell carcinoma and have been removed. My family health history shows other potential concerns for the future so my wife and I have made diet changes and increased our exercise efforts so that we can enjoy a future retirement in the years to come.

This refocus on what is most important is the result of a short statement from a dermatologist who said I will die with this CTCL disease but not from it. I am trying

to do what I can to make that a very long time from now. The continued support of my wife and my CTCL team at Huntsman Cancer Institute help make this journey possible and enjoyable.

Gary Robinson of Saratoga Spring, UT was diagnosed with CTCL in late 2009. He runs an elearning development company with his wife to help small businesses migrate their training effort to the online world and is expanding to provide self-improvement and leadership skill content for individuals and companies. Volunteer service with

the Boy Scouts of America continues to be a focus and Gary is preparing to serve as the president of a local Rotary Club.

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...continued from page 25From The Patient’s Perspective

5VOLUME 7 • NUMBER 1 • WINTER 2013

PAs are medical providers licensed to practice medicine with physician supervision. From patient care and education, to skin surgery, treatment of chronic skin conditions, and cosmetic procedures, PAs are dynamic members of the

healthcare team. PAs practice in every medical and surgical specialty and have been collaborating with dermatologists for 30 years, providing a wide variety of services. These include diagnosing, prescribing medications, ordering and interpreting lab tests, wound suturing, and medical or surgical treatment of a wide variety of clinical diseases. As with all PAs, dermatology PAs are legally and ethically bound to practice only under physician supervision.

Physician Assistants (PAs) in dermatology play a number of varied and vital roles.

Dermatology Physician Assistants

PAs are trained in intensive, accredited education programs.

More information can be found at www.dermpa.org and www.aapa.org.

Because of the close working relationship that PAs have with physicians, PAs are educated in the medical model designed to mirror and complement physician training. PAs take a national certification examination and to maintain their certification, they must complete 100 hours of continuing medical education every two years and take a recertification exam every six years. Graduation from an accredited PA program and passage of the national certifying exam are required for state licensure.

How a PA practices dermatology varies with training, experience, and state law. In addition, the scope of the PA’s responsibilities corresponds to the supervising physician’s scope of practice. In general, a PA will see many of the same types of patients as the physician. Referral to the physician, or close consultation between the PA and physician, is based on the dynamic relationship between the physician and PA.

The Society of Dermatology Physician Assistants (SDPA) is a non-profit professional organization, composed of members who provide dermatologic care or have an interest in the medical specialty of dermatology. Fellow members provide medical services under the supervision of a board certified dermatologist.