Spring 2010 Journal of Dermatology for Physician Assistants

Volume 4 number 2 SPRING 2010

SDPA News and Current Affairs

dermatology pa news and notes

clinical dermatology

surgical dermatology

cosmetic dermatology

Professional development

Official Journal of the Society of Dermatology Physician Assistants

Vol. 4, No. 2 SPRING 2010

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RETIN-A MICRO® (tretinoin gel) microsphere, 0.04% and 0.1% are indicated for topical application in the treatment of acne vulgaris.

Important Safety Information: RETIN-A MICRO (tretinoin gel) microsphere, 0.04% and 0.1% is contraindicated in individuals with a history of sensitivity reactions to any of its components. The skin of certain individuals may become excessively dry, red, swollen or blistered. If warranted, these individuals should temporarily reduce the amount or frequency of application, or discontinue use temporarily or altogether. Patients should be encouraged to minimize exposure to sunlight, including sunlamps, and to use a sunscreen with a SPF of 15 or higher and protective clothing.

The most common adverse reactions to RETIN-A MICRO 0.04% and 0.1% were limited to mild or moderate irritation of the skin. 1.3% of patients using RETIN-A MICRO 0.04% and 6% of patients using RETIN-A MICRO 0.1% discontinued due to irritation. RETIN-A MICRO 0.04% and 0.1% showed a visible reduction in total mean lesion count in as little as 2 weeks with full benefits seen after 7 weeks.

Please see brief summary of prescribing information on the next page. *Reported at the end of the 12-week P.U.M.P. Study. † Data based on a consumer preference study designed to evaluate preference of Pump versus tube delivery. 104 male and female acne sufferers between the ages of 13 and 36 completed the study.3 References: 1. RETIN-A MICRO 0.04%/0.1% [prescribing information]. Los Angeles, Calif: Ortho Dermatologics; May 2006. 2. Eichenfield LF, Nighland M, Rossi AB, et al; PUMP Study Group. Phase 4 study to assess tretinoin pump for the treatment of facial acne. J Drugs Dermatol. 2008;7(12):1129-1136. 3. Data on file, Ortho Dermatologics. 4. Embil K, Nacht S. The Microsponge ® Delivery System (MDS): a topical delivery system with reduced irritancy incorporating multiple triggering mechanisms for the release of actives. J Microencapsul.

1996;13(5):575-588.

RETIN-A MICRO ® is a brand of Ortho Dermatologics division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. © Ortho Dermatologics division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. 2009 09DD0217 10/09 Printed in the USA

FOR TOPICAL USE ONLY. NOT FOR OPHTHALMIC, ORAL, OR INTRAVAGINAL USE. Brief Summary Retin-A Micro® (tretinoin gel) microsphere, 0.1% and 0.04% is a formulation containing 0.1% or 0.04%, by weight, tretinoin for topical treatment of acne vulgaris. This formulation uses patented methyl methacrylate/glycol dimethacrylate crosspolymer porous microspheres (MICROSPONGE® System) to enable inclusion of the active ingredient, tretinoin, in an aqueous gel.

IMPORTANT NOTE: This information is a BRIEF SUMMARY of the complete prescribing information provided with the product and therefore should not be used as the basis for prescribing the product. This summary has been prepared by deleting information from the complete prescribing information such as certain text, tables, and references.

The physician should be thoroughly familiar with the complete prescribing information before prescribing the product.

INDICATIONS AND USAGE: Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%, is indicated for topical application in the treatment of acne vulgaris. The safety and efficacy of the use of this product in the treatment of other disorders have not been established.

CONTRAINDICATIONS: This drug is contraindicated in individuals with a history of sensitivity reactions to any of its components. It should be discontinued if hypersensitivity to any of its ingredients is noted.

PRECAUTIONS: General: • The skin of certain individuals may become excessively dry, red, swollen, or blistered. If the degree of irritation warrants, patients should be directed to temporarily reduce the amount or frequency of application of the medication, discontinue use temporarily, or discontinue use all together. Efficacy at reduced frequencies of application has not been established.

If a reaction suggesting sensitivity occurs, use of the medication should be discontinued.

Excessive skin dryness may also be experienced; if so, use of an appropriate emollient during the day may be helpful.

• Unprotected exposure to sunlight, including sunlamps, should be minimized during the use of Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%, and patients with sunburn should be advised not to use the product until fully recovered because of heightened susceptibility to sunlight as a result of the use of tretinoin. Patients who may be required to have considerable sun exposure due to occupation and those with inherent sensitivity to the sun should exercise particular caution. Use of sunscreen products (SPF 15) and protective clothing over treated areas are recommended when exposure cannot be avoided.

• Weather extremes, such as wind or cold, also may be irritating to patients under treatment with tretinoin.

• Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%, should be kept away from the eyes, the mouth, paranasal creases of the nose, and mucous membranes.

• Tretinoin has been reported to cause severe irritation on eczematous skin and should be used with utmost caution in patients with this condition.

Information for Patients: A Patient Information Leaflet has been prepared and is included with each package of Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%.

Drug Interactions: Concomitant topical medication, medicated or abrasive soaps and cleansers, products that have a strong drying effect, products with high concentrations of alcohol, astringents, or spices should be used with caution because of possible interaction with tretinoin. Avoid contact with the peel of limes. Particular caution should be exercised with the concomitant use of topical over-the-counter acne preparations containing benzoyl peroxide, sulfur, resorcinol, or salicylic acid with Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%. It also is advisable to allow the effects of such preparations to subside before use of Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%, is begun.

Carcinogenesis, Mutagenesis, Impairment of Fertility: In a 91-week dermal study in which CD-1 mice were administered 0.017% and 0.035% formulations of tretinoin, cutaneous squamous cell carcinomas and papillomas in the treatment area were observed in some female mice. These concentrations are near the tretinoin concentration of these clinical formulations (0.04% and 0.1%). A dose-related incidence of liver tumors in male mice was observed at those same doses. The maximum systemic doses associated with the administered 0.017% and 0.035% formulations are 0.5 and 1.0 mg/kg/day, respectively. These doses are two and four times the maximum human systemic dose applied topically, when normalized for total body surface area. The biological significance of these findings is not clear because they occurred at doses that exceeded the dermal maximally tolerated dose (MTD) of tretinoin and because they were within the background natural occurrence rate for these tumors in this strain of mice. There was no evidence of carcinogenic potential when 0.025 mg/kg/day of tretinoin was administered topically to mice (0.1 times the maximum human systemic dose, normalized for total body surface area). For purposes of comparisons of the animal exposure to systemic human exposure, the maximum human systemic dose applied topically is defined as 1 gram of Retin-A Micro (tretinoin gel) microsphere, 0.1% applied daily to a 50 kg person (0.02 mg tretinoin/kg body weight).

Dermal carcinogenicity testing has not been performed with Retin-A Micro (tretinoin gel) microsphere, 0.04% or 0.1%.

Studies in hairless albino mice suggest that concurrent exposure to tretinoin may enhance the tumorigenic potential of carcinogenic doses of UVB and UVA light from a solar simulator. This effect has been confirmed in a later study in pigmented mice, and dark pigmentation did not overcome the enhancement of photocarcinogenesis by 0.05% tretinoin. Although the significance of these studies to humans is not clear, patients should minimize exposure to sunlight or artificial ultraviolet irradiation sources.

The mutagenic potential of tretinoin was evaluated in the Ames assay and in the in vivo mouse micronucleus assay, both of which were negative.

The components of the microspheres have shown potential for genetic toxicity and teratogenesis.

EGDMA, a component of the excipient acrylates copolymer, was positive for induction of structural chromosomal aberrations in the in vitro chromosomal aberration assay in mammalian cells in the absence of metabolic activation, and negative for genetic toxicity in the Ames assay, the HGPRT forward mutation assay, and the mouse micronucleus assay.

In dermal Segment I fertility studies of another tretinoin formulation in rats, slight (not statistically significant) decreases in sperm count and motility were seen at 0.5 mg/kg/day (4 times the maximum human systemic dose applied topically, and normalized for total body surface area), and slight (not statistically significant) increases in the number and percent of nonviable embryos in females treated with 0.25 mg/kg/day (2 times the maximum human systemic dose applied topically and normalized for total body surface area) and above were observed. In oral Segment I and Segment III studies in rats with tretinoin, decreased survival of neonates and growth retardation were observed at doses in excess of 2 mg/kg/day (17 times the human topical dose normalized for total body surface area).

Dermal fertility and perinatal development studies with Retin-A Micro (tretinoin gel) microsphere, 0.1% or 0.04%, have not been performed in any species.

Pregnancy: Teratogenic Effects: Pregnancy Category C. In a study of pregnant rats treated with topical application of Retin-A Micro (tretinoin gel) microsphere, 0.1%, at doses of 0.5 to 1 mg/kg/day on gestation days 6-15 (4 to 8 times the maximum human systemic dose of tretinoin normalized for total body surface area after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%) some alterations were seen in vertebrae and ribs of offspring. In another study, pregnant

New Zealand white rabbits were treated with Retin-A Micro (tretinoin gel) microsphere, 0.1%, at doses of 0.2, 0.5, and 1.0 mg/kg/day, administered topically for 24 hours a day while wearing Elizabethan collars to prevent ingestion of the drug. There appeared to be increased incidences of certain alterations, including domed head and hydrocephaly, typical of retinoid-induced fetal malformations in this species, at 0.5 and 1.0 mg/kg/day. Similar malformations were not observed at 0.2 mg/kg/day, 3 times the maximum human systemic dose of tretinoin after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%, normalized for total body surface area. In a repeat study of the highest topical dose (1.0 mg/kg/day) in pregnant rabbits, these effects were not seen, but a few alterations that may be associated with tretinoin exposure were seen. Other pregnant rabbits exposed topically for six hours to 0.5 or 0.1 mg/ kg/day tretinoin while restrained in stocks to prevent ingestion, did not show any teratogenic effects at doses up to 17 times (1.0 mg/kg/day) the maximum human systemic dose after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%, adjusted for total body surface area, but fetal resorptions were increased at 0.5 mg/kg. In addition, topical tretinoin in non Retin-A Micro (tretinoin gel) microsphere formulations was not teratogenic in rats and rabbits when given in doses of 42 and 27 times the maximum human systemic dose after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%, normalized for total body surface area, respectively, (assuming a 50 kg adult applied a daily dose of 1.0 g of 0.1% gel topically).

At these topical doses, however, delayed ossification of several bones occurred in rabbits. In rats, a dose-dependent increase of supernumerary ribs was observed.

Oral tretinoin has been shown to be teratogenic in rats, mice, rabbits, hamsters, and subhuman primates. Tretinoin was teratogenic in Wistar rats when given orally or topically in doses greater than 1 mg/kg/day (8 times the maximum human systemic dose normalized for total body surface area). However, variations in teratogenic doses among various strains of rats have been reported. In the cynomolgus monkey, which metabolically is more similar to humans than other species in its handling of tretinoin, fetal malformations were reported for doses of 10 mg/kg/day or greater, but none were observed at 5 mg/kg/day (83 times the maximum human systemic dose normalized for total body surface area), although increased skeletal variations were observed at all doses. Dose-related increases in embryolethality and abortion also were reported. Similar results have also been reported in pigtail macaques.

Topical tretinoin in animal teratogenicity tests has generated equivocal results. There is evidence for teratogenicity (shortened or kinked tail) of topical tretinoin in Wistar rats at doses greater than 1 mg/kg/day (8 times the maximum human systemic dose normalized for total body surface area). Anomalies (humerus: short 13%, bent 6%, os parietal incompletely ossified 14%) have also been reported when 10 mg/kg/day was topically applied. Supernumerary ribs have been a consistent finding in rats when dams were treated topically or orally with retinoids.

There are no adequate and well-controlled studies in pregnant women. Retin-A Micro should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

With widespread use of any drug, a small number of birth defect reports associated temporally with the administration of the drug would be expected by chance alone. Thirty human cases of temporally associated congenital malformations have been reported during two decades of clinical use of Retin-A. Although no definite pattern of teratogenicity and no causal association has been established from these cases, five of the reports describe the rare birth defect category holoprosencephaly (defects associated with incomplete midline development of the forebrain). The significance of these spontaneous reports in terms of risk to the fetus is not known.

Non-Teratogenic Effects: Topical tretinoin has been shown to be fetotoxic in rabbits when administered 0.5 mg/kg/day (8 times the maximum human systemic dose applied topically and normalized for total body surface area), resulting in fetal resorptions and variations in ossification. Oral tretinoin has been shown to be fetotoxic, resulting in skeletal variations and increased intrauterine death in rats when administered 2.5 mg/kg/day (21 times the maximum human systemic dose applied topically and normalized for total body surface area).

There are, however no adequate and well-controlled studies in pregnant women.

Animal Toxicity Studies: In male mice treated topically with Retin-A Micro (tretinoin gel) microsphere 0.1%, at 0.5, 2.0, or 5.0 mg/kg/day tretinoin (2, 8, or 21 times the maximum human systemic dose after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%, normalized for total body surface area) for 90 days, a reduction in testicular weight, but with no pathological changes were observed at the two highest doses. Similarly, in female mice there was a reduction in ovarian weights, but without any underlying pathological changes, at 5.0 mg/kg/day (21 times the maximum human dose). In this study there was a dose-related increase in the plasma concentration of tretinoin 4 hours after the first dose. A separate toxicokinetic study in mice indicates that systemic exposure is greater after topical application to unrestrained animals than to restrained animals, suggesting that the systemic toxicity observed is probably related to ingestion. Male and female dogs treated with Retin-A Micro (tretinoin gel) microsphere, 0.1%, at 0.2, 0.5, or 1.0 mg/kg/day tretinoin (5, 12, or 25 times the maximum human systemic dose after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%, normalized for total body surface area, respectively) for 90 days showed no evidence of reduced testicular or ovarian weights or pathological changes.

Nursing Mothers: It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Retin-A Micro (tretinoin gel) microsphere, 0.1% or 0.04%, is administered to a nursing woman.

Pediatric Use: Safety and effectiveness in children below the age of 12 have not been established.

Geriatric Use: Safety and effectiveness in a geriatric population have not been established.

Clinical studies of Retin-A Micro did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.

ADVERSE REACTIONS: The skin of certain sensitive individuals may become excessively red, edematous, blistered, or crusted. If these effects occur, the medication should either be discontinued until the integrity of the skin is restored, or the medication should be adjusted to a level the patient can tolerate.

However, efficacy has not been established for lower dosing frequencies.

True contact allergy to topical tretinoin is rarely encountered. Temporary hyper- or hypopigmentation has been reported with repeated application of tretinoin. Some individuals have been reported to have heightened susceptibility to sunlight while under treatment with tretinoin.

OVERDOSAGE: Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%, is intended for topical use only. If medication is applied excessively, no more rapid or better results will be obtained and marked redness, peeling, or discomfort may occur. Oral ingestion of large amounts of the drug may lead to the same side effects as those associated with excessive oral intake of Vitamin A. Rx only.

Patent Nos.: 4,690,825; 5,145,675 & 5,955,109

Distributed by: OrthoNeutrogena DIVISION OF ORTHO-MCNEIL PHARMACEUTICAL, INC. Los Angeles, CA 90045 © OMP 2006 06DD0123 7/06 RETIN-A MICRO® is a registered trademark of Ortho-McNeil Pharmaceutical, Inc. MICROSPONGE® is a registered trademark of Cardinal Health, Inc., Dublin, OH.

Publishing Staff

EDITORIAL BOARD

Travis Hayden, MPAS, PA-C, Editor in chief Joe R. Monroe, MPAS, PA-C Patricia Ferrer, MPAS, PA-C Gordon Day, R.Ph., PA-C Nancy Primo, MPAS, PA-C Lauren Zajac, MHS, PA-C Michelle DiBaise, MPAS, PA-C P. Eugene Jones, Ph.D., PA-C Kristine Kucera, DHS, MPAS, PA-C Mark Hyde, MMS, PA-C Alan Menter, MD

DEPARTMENT EDITORS

Clinical Department Editor Susan E. King-Barry, MPAS, PA-C Drugs in Dermatology Editor Stephen Wolverton, MD Surgical Department Editor Christy Kerr, MPAS, PA-C Cosmetic Department Editor Nancy Primo, MPAS, PA-C Prof Dev Department Editor Abby Jacobson, MS, PA-C

SDPA Board of Directors

PrESiDEnT Kristine Kucera, DHS, MPAS, PA-C PrESiDEnT-ElECT Abby Jacobson, MS, PA-C iMMEDiATE PAST PrESiDEnT Bethany Grubb, MPAS, PA-C ViCE PrESiDEnT CaSondra Soto, PA-C SECrETAry / TrEASurEr Sharon Swartz, PA-C DirECTors AT lArGE Mark Hyde, MMS, PA-C Lauren R. Zajac, MHS, PA-C John Notabartolo, PA-C Casey Croes, PA-C

Society of Dermatology Physician Assistants, Inc P.O. Box 701461 San Antonio, Texas 78270 1-800-380-3992 SDPA@dermpa.org www.dermpa.org

Publisher Travis Hayden, MPAS, PA-C 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 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: of 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.

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, please join us in our efforts and opt to receive the JDPA in digital format.

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 4, Number 2, Spring 2010. 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).

TM Periodicals postage rate paid at New York, NY 10001 and additional mailing offices. Š 2010 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. P.O. Box 701461, San Antonio, Texas 78270; 1-800-380-3992.

THIS ISSUE IS SPONSORED BY

Journal of Dermatology for Physician Assistants

Editor’s Message

Getting Lost in Conversation Journal of Dermatology for Physician Assistants

The Official Journal of the SDPA

Journal Club Interested in starting a dermatology PA journal club?

I

have had many patients recently comment about how they would never be able to find their way around without their smart phones. I have yet to use such a gadget to get around as I actually enjoy finding my own way to places, even if it means getting a little lost along the way. If I only stayed on the recommended direct route I never would have stumbled upon the best cup of coffee in town or my kids favorite little playground that sits just off the beaten path. Being told how to directly get to a destination might be nice when I need to get somewhere in a hurry, otherwise I am all for taking my time and wandering off course.

Getting lost in conversation is an equally important way to stumble upon unexpected destinations. For example, when taking a patient’s history, if I were only to focus on the recommended and most direct way of obtaining answers, I could miss out on having a casual conversation with a patient. One of my most memorable casual conversations with a patient actually ended up helping me to solve the most perplexing case of stasis dermatitis I have had to manage. This particular case was not perplexing in regards to the difficulty of diagnosis or its management, but rather because the patient’s symptoms continued to worsen despite my best efforts and the patient’s strict compliance with the recommended treatments. At a follow-up visit with the patient, while applying yet another pair of Unna boots, our discussion drifted away from the stasis dermatitis and we began talking casually. Long story short, during the course of our conversation he shared with me how uncomfortable his lower back pain had been and I asked how he had been sleeping. He shared with me that for the last several weeks (all while we were battling his worsening stasis dermatitis) he had been sleeping comfortably each and every night in his lazy boy recliner, but was quick to add, “With my legs elevated, just like you told me to.” I inquired further to assess whether his definition of ‘elevated’ was what I had recommended (elevation above his heart). I learned that in order for him to sleep comfortably with his back pain it meant that he had to compromise and only elevate his legs a few inches off the floor; good for his back but not so for his legs. If we as PAs do not take the time to get lost in such casual conversations with our patients, we might miss opportunities to stumble upon significant insights into our patients’ lives as well as relevant details that may lend to their current diagnosis and treatment.

I appreciate all of the advances in technology and respect that some people may only want to take the most direct and uncomplicated route. As for me, I will continue to wander off course from time to time, connecting more with my patients, and appreciating all that I stumble upon along the way. J

Attend this year’s inaugural SDPA Summer Dermatology Conference.

Thursday, June 10th at 4:50pm

Travis Hayden Editor in chief

Vol. 4, No. 2 SPRING 2010

table of contents

15

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.

Current Treatment Options for Metastatic Melanoma

By Argyro (Angie) Tsiaras, MPA-C

CME

10 Derm PA News & Notes – part one

• Dermatology Market Watch • May is Melanoma/Skin Cancer Detection and Prevention Month

15 Clinical Dermatology

• CME Article – Current Treatment Options for Metastatic Melanoma • Drugs in Dermatology – Aluminum Chloride for Hemostasis • Journal Club: Dermatology PA Perspectives

Departments

04 Editorial Board 05 Editor’s Message 09 SDPA News & Current Affairs 13 Student Scoop 20 From The Patient’s Perspective 23 Dermatoscopy 24 Clinical Snapshots 36 Notes from your Office Manager 40 Outside & Inside the 9 to 5 43 The Difference We Make 44 “Derm Quotes” 46 Professional Opportunities and Development

29 Surgical Dermatology

• Surgical Wisdom – Ten Steps to a Seamless Excision

30 Cosmetic Dermatology • Cosmetic Pearls - Twitter

33 Professional Development

• The History of the SDPA • Dermatology Billing & Coding – Accutane and 99214

42 Derm PA News & Notes – part two • From the Desk of…

• Supervising Physician Corner

Go Green – Read Online As part of the “Going Green” initiative, the JDPA is now available as an electronic only option to interested SDPA members. To start receiving your copy of the JDPA in digital format please visit the SDPA website and update your membership profile.

Journal of Dermatology for Physician Assistants

Vol. 4, No. 2 SPRING 2010

Journal of Dermatology for Physician Assistants

Calendar

FROM THE SPDA News & Current Affairs

of events

2010 june SDPA 1st Summer Dermatology Conference June 10-13, 2010 Chicago, IL AUGUST AAD Summer Academy Meeting August 4 - 8, 2010 Chicago, IL NOVEMBER SDPA 8th Annual Fall Conference November 10-13, 2010 Gaylord Texan Resort Grapevine, TX

2011

FEBRUARY 69th AAD Annual Academy Meeting February 4 - 8, 2011 New Orleans, LA Calendar of Events Submissions Send information to: Editor@jdpa.org

Passing the Torch

W

atching the Olympic games with my husband has become a tradition in our household. Every two years during the games we put our social lives aside to make sure we spend each night together cheering on the USA to victory.

It is such a fun time together that it becomes bittersweet when the closing ceremonies take place and the torch is passed to the next host city. Now, the time is growing near for a newly elected SDPA Board of Directors to take over and I must pass the torch to our new President, Abby Jacobson.

This has been an exciting and busy year for the SDPA and I am proud to know that you, as members, have allowed me to be the leader of this great team. One of my favorite accomplishments this year is the development of our second stand-alone CME meeting for our members. I have made providing educational opportunities for dermatology physician assistants a priority, and I am proud to have been involved since our first CME meeting took place in New Orleans in 2002. During the development of that first CME program, we wondered if anyone would attend and hoped that we would get at least 100 registrants. After many successful years, we are now at a point where we sell out our Fall Conference, and we are able to offer our first Summer CME conference this year in Chicago.

The Board of Directors, committee chairs, and committee members of the SDPA have made my presidential year easy because every individual in each group is dedicated to the growth and development of this organization. I must send out a big thank you to all of those involved, and I sincerely appreciate all the time and hard work that was given this year. I have the utmost confidence that I am passing the torch to a new, highly dedicated Board of Directors who will continue to move the SDPA in a positive direction. J

Kristine Kucera, DHS, MPAS, PA-C President Society of Dermatology Physician Assistants

Vol. 4, No. 2 SPRING 2010

9

Dermatology PA news & notes

Dermatology Market Watch DermLite DL3

AIM at Melanoma is Hosting Free Educational Symposiums AIM at Melanoma is hosting free educational symposiums with renowned melanoma centers around the country for patients and the people who support them. Leading melanoma experts are discussing emerging therapies, the importance of clinical trials, and innovations in research.

AIM has received positive responses from individuals who have attended The Angeles Clinic, University of Pittsburgh Medical Center, and Moffitt Cancer Center symposiums this year.

Our next symposium is scheduled on April 24, 2010 and will be co-hosted by the California Pacific Medical Center in San Francisco, CA. On July 10, 2010, Huntsman Cancer Institute will co-host a symposium in Salt Lake City, UT. To register and/or see all symposium locations, please visit our website at www.AIMatMelanoma.org and click on Patient & Caregiver Symposiums. For additional information, please contact Samantha Guild at sguild@ AIMatMelanoma.org.

The DermLite DL3 is precision-engineered and crafted from solid, highly recyclable aluminum. It is the first handheld DermLite to integrate a 25mm four-element lens, which offers greatly reduced optical distortion and a sharper image across the field of view. Twenty-one high-powered LEDs produce approximately 30% more illumination in cross-polarized mode, and seven nonpolarized LEDs for immersion fluid dermoscopy create a brighter image. For optimum ease of use, one button does it all: A quick tap instantly toggles between polarization modes, and a longer push turns the unit on or off. The DL3 is camera compatible and is equipped with a fully retractable faceplate spacer that allows you to focus your image with an available focal range in excess of ±4mm. The innovative spacer comes with a glass faceplate with 10mm scale, and due to its fully enclosed design, it is easy to clean and keeps the critical optical components completely sealed so that contaminants as well as undesirable ambient lighting no longer affect your image.

Addressing Psoriasis™ Addressing Psoriasis™ was developed to inspire people with plaque psoriasis to actively manage their condition, be more confident and not allow the condition to inhibit their everyday style. Now in its second year, Addressing Psoriasis™ continues to raise public awareness and encourages patients to visit a dermatologist as the first step in managing the condition. Addressing Psoriasis™ is sponsored by Amgen and Pfizer with participation from the American Academy of Dermatology, the National Psoriasis Foundation, Psoriasis Cure Now, the Dermatology Nurses’ Association and the Society of Dermatology Physician Assistants.

This year, Addressing Psoriasis™ kicks off with an exciting new contest inviting people with moderate to severe plaque psoriasis to share their personal stories about the challenges of living with the condition, including the impact on their personal style, and how they think Tim Gunn, television host, fashion consultant and chief creative officer of Liz Claiborne, Inc., may help them present their best selves to the world. Individuals 18 or older with moderate to severe plaque psoriasis are eligible to enter for a chance to win a personal style consultation with Gunn and the opportunity to help raise public awareness of the condition. Five winners will be chosen, each of whom will receive a trip to New York City to receive a one-on-one consultation from Gunn. Dermatologist Susan C. Taylor, M.D., and Gunn are working together again in 2010 to encourage people with psoriasis to visit a dermatologist and take the first step in managing their condition.

To learn how to enter the contest, view complete official rules and find useful resources about psoriasis, visit www. addresspsoriasis.com.

10 Journal of Dermatology for Physician Assistants

SOLODYN INNOVATION

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 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.

SOLODYN Tablets Important Safety Information • The most commonly reported side effects were headache, fatigue, dizziness, and pruritus.

• Minocycline, like other tetracyclines, can cause fetal harm when administered to a pregnant woman.

• 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.

• Central nervous system side effects, including light-headedness, dizziness, or vertigo, have been reported with minocycline therapy.

• In rare cases, photosensitivity has been reported.

• Should not be used during pregnancy nor 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.

• This drug is contraindicated in persons who have shown hypersensitivity to any of the tetracyclines.

See reverse side for brief summary of Full Prescribing Information.

SOLODYN and Benefits built in are trademarks of Medicis Pharmaceutical Corporation. © 2009 Medicis, The Dermatology Company SOL 09-028 10/30/10

Vol. 4, No. 2 SPRING 2010 11

BRIEF SUMMARY (see package insert for Full Prescribing Information) SOLODYN® (MINOCYCLINE HCl, USP) EXTENDED RELEASE TABLETS Rx Only KEEP OUT OF REACH OF CHILDREN INDICATIONS 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 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.

CONTRAINDICATIONS This drug is contraindicated in persons who have shown hypersensitivity to any of the tetracyclines.

WARNINGS Teratogenic effects 1) MINOCYCLINE, LIKE OTHER TETRACYCLINECLASS ANTIBIOTICS, 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 nor by individuals of either gender who are attempting to conceive a child (see PRECAUTIONS: Impairment of Fertility & Pregnancy).

2) 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. 3) 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, 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 PRECAUTIONS: Pregnancy section).

measures with their physician. Treatment should be discontinued at the first evidence of skin erythema.

2. Patients who experience central nervous Central nervous system effects system symptoms (see WARNINGS) should 1. Central nervous system side effects including be cautioned about driving vehicles or using light-headedness, dizziness or vertigo have been hazardous machinery while on minocycline reported with minocycline therapy. Patients who therapy. Patients should also be cautioned experience these symptoms should be cautioned about seeking medical help for headaches or about driving vehicles or using hazardous blurred vision. machinery while on minocycline therapy. These symptoms may disappear during therapy and 3. Concurrent use of tetracycline may render usually rapidly disappear when the drug is oral contraceptives less effective (See Drug discontinued.

Interactions).

2. Pseudotumor cerebri (benign intracranial 4. Autoimmune syndromes, including drughypertension) in adults and adolescents has induced lupus-like syndrome, autoimmune been associated with the use of tetracyclines. hepatitis, vasculitis and serum sickness Minocycline has been reported to cause or have been observed with tetracycline-class precipitate pseudotumor cerebri, the hallmark antibiotics, including minocycline. Symptoms of which is papilledema. Clinical manifestations may be manifested by arthralgia, fever, rash include headache and blurred vision. Bulging and malaise. Patients who experience such fontanels have been associated with the use symptoms should be cautioned to stop the of tetracyclines in infants. Although signs and drug immediately and seek medical help. symptoms of pseudotumor cerebri resolve after 5. Patients should be counseled about discontinuation of treatment, the possibility for discoloration of skin, scars, teeth or gums that permanent sequelae such as visual loss that can arise from minocycline therapy. may be permanent or severe exists. Patients 6.

Take SOLODYN® exactly as directed. Skipping should be questioned for visual disturbances doses or not completing the full course of prior to initiation of treatment with tetracyclines therapy may decrease the effectiveness of and should be routinely checked for papilledema the current treatment course and increase the while on treatment. likelihood that bacteria will develop resistance Concomitant use of isotretinoin and minocycline and will not be treatable by other antibacterial should be avoided because isotretinoin, a drugs in the future. systemic retinoid, is also known to cause 7.

SOLODYN® should not be used by pregnant pseudotumor cerebri. women or women attempting to conceive a Photosensitivity child (See Pregnancy, Carcinogenesis and Photosensitivity manifested by an exaggerated Mutagenesis sections). sunburn reaction has been observed in some 8. It is recommended that SOLODYN® not be individuals taking tetracyclines. This has been used by men who are attempting to father a reported rarely with minocycline. Patients should child (See Impairment of Fertility section). minimize or avoid exposure to natural or artificial Laboratory Tests sunlight (tanning beds or UVA/B treatment) Periodic laboratory evaluations of organ systems, while using minocycline. If patients need to be including hematopoietic, renal and hepatic outdoors while using minocycline, they should wear loose-fitting clothes that protect skin from studies should be performed. Appropriate tests for autoimmune syndromes should be performed sun exposure and discuss other sun protection as indicated. measures with their physician.

100 and 300 mg/kg/day) increased numbers of morphologically abnormal sperm cells.

Morphological abnormalities observed in sperm samples included absent heads, misshapen heads, and abnormal flagella.

Limited human studies suggest that minocycline may have a deleterious effect on spermatogenesis.

SOLODYN® should not be used by individuals of either gender who are attempting to conceive a child.

Pregnancy—Teratogenic Effects: Pregnancy category D (See WARNINGS) All pregnancies have a background risk of birth defects, loss, or other adverse outcome regardless of drug exposure. There are no adequate and well-controlled studies on the use of minocycline in pregnant women. Minocycline, like other tetracycline-class antibiotics, crosses the 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 same level of systemic exposure to minocycline as that observed in patients who use SOLODYN®).

SOLODYN® should not be used during pregnancy. If the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus and stop treatment immediately.

Drug Interactions 1. Because tetracyclines have been shown to depress plasma prothrombin activity, patients who are on anticoagulant therapy may require downward adjustment of their anticoagulant dosage.

2. Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, it is advisable to avoid giving tetracycline-class drugs in conjunction with penicillin.

3. The concurrent use of tetracycline and methoxyflurane has been reported to result in fatal renal toxicity.

4. Absorption of tetracyclines is impaired by antacids containing aluminum, calcium or magnesium and iron-containing preparations.

5. In a multi-center study to evaluate the effect of SOLODYN® on low dose oral contraceptives, hormone levels over one menstrual cycle with and without SOLODYN® 1 mg/kg once-daily were measured.

Based on the results of this trial, minocyclinerelated changes in estradiol, progestinic hormone, FSH and LH plasma levels, of breakthrough bleeding, or of contraceptive failure, can not be ruled out. To avoid contraceptive failure, female patients are advised to use a second form of contraceptive during treatment with minocycline.

Nursing Mothers Tetracycline-class antibiotics are excreted in human milk. Because of the potential for serious adverse effects on bone and tooth development in nursing infants from the tetracycline-class antibiotics, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother (see WARNINGS).

usual total doses are indicated, and if therapy is prolonged, serum level determinations of the drug may be advisable.

PRECAUTIONS General Safety of SOLODYN® beyond 12 weeks of use has not been established.

As with other antibiotic preparations, use of SOLODYN® may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection occurs, the antibiotic should be discontinued and appropriate therapy instituted.

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.

Autoimmune Syndromes Tetracyclines have been associated with the development of autoimmune syndromes. The long-term use of minocycline in the treatment of acne has been associated with drug-induced lupus-like syndrome, autoimmune hepatitis and vasculitis. Sporadic cases of serum sickness Gastro-intestinal effects have presented shortly after minocycline 1. Pseudomembranous colitis has been use. Symptoms may be manifested by fever, reported with nearly all antibacterial rash, arthralgia, and malaise. In symptomatic agents and may range from mild to lifepatients, liver function tests, ANA, CBC, and threatening. Therefore, it is important to other appropriate tests should be performed to consider this diagnosis in patients who evaluate the patients. Use of all tetracycline-class Drug/Laboratory Test Interactions present with diarrhea subsequent to the drugs should be discontinued immediately.

False elevations of urinary catecholamine administration of antibacterial agents. levels may occur due to interference with the Serious Skin/Hypersensitivity Reaction Treatment with antibacterial agents alters fluorescence test.

Post-marketing cases of anaphylaxis and the normal flora of the colon and may permit serious skin reactions such as Stevens Johnson Carcinogenesis, Mutagenesis & overgrowth of clostridia. Studies indicate that syndrome and erythema multiforme have been Impairment of Fertility a toxin produced by Clostridium difficile is a reported with minocycline use in treatment Carcinogenesis—Long-term animal studies primary cause of “antibiotic-associated colitis”. of acne. have not been performed to evaluate the After the diagnosis of pseudomembranous carcinogenic potential of minocycline. A Tissue Hyperpigmentation colitis has been established, therapeutic structurally related compound, oxytetracycline, Tetracycline class antibiotics are known to measures should be initiated. Mild cases of was found to produce adrenal and pituitary Tetracycline therapy cause hyperpigmentation. pseudomembranous colitis usually respond to may induce hyperpigmentation in many organs, tumors in rats. discontinuation of the drug alone. In moderate Mutagenesis—Minocycline was not mutagenic including nails, bone, skin, eyes, thyroid, to severe cases, consideration should be given in vitro in a bacterial reverse mutation assay visceral tissue, oral cavity (teeth, mucosa, to management with fluids and electrolytes, (Ames test) or CHO/HGPRT mammalian cell Skin alveolar bone), sclerae and heart valves. protein supplementation, and treatment with assay in the presence or absence of metabolic and oral pigmentation has been reported to an antibacterial drug clinically effective against activation. Minocycline was not clastogenic in occur independently of time or amount of Clostridium difficile colitis. vitro using human peripheral blood lymphocytes drug administration, whereas other tissue 2. Hepatotoxicity – Post-marketing cases or in vivo in a mouse micronucleus test. pigmentation has been reported to occur upon of serious liver injury, including irreversible prolonged administration. Skin pigmentation Impairment of Fertility—Male and female drug-induced hepatitis and fulminant hepatic includes diffuse pigmentation as well as over reproductive performance in rats was unaffected failure (sometimes fatal) have been reported with sites of scars or injury. by oral doses of minocycline of up to 300 mg/ minocycline use in the treatment of acne. kg/day (which resulted in up to approximately Information for Patients Metabolic effects 40 times the level of systemic exposure to (See Patient Package Insert for additional The anti-anabolic action of the tetracyclines minocycline observed in patients as a result of information to give patients) ® may cause an increase in BUN. While this 1. Photosensitivity manifested by an exaggerated use of SOLODYN ). However, oral administration is not a problem in those with normal sunburn reaction has been observed in some of 100 or 300 mg/kg/day of minocycline to male renal function, in patients with significantly rats (resulting in approximately 15 to 40 times individuals taking tetracyclines, including impaired function, higher serum levels of the level of systemic exposure to minocycline minocycline. Patients should minimize or tetracycline-class antibiotics may lead to patients as a result of use of avoid exposure to natural or artificial sunlight observed in ® azotemia, hyperphosphatemia, and acidosis. (tanning beds or UVA/B treatment) while using SOLODYN ) adversely affected spermatogenesis.

If renal impairment exists, even usual oral or Effects observed at 300 mg/kg/day included minocycline. If patients need to be outdoors parenteral doses may lead to excessive systemic a reduced number of sperm cells per gram while using minocycline, they should wear accumulations of the drug and possible liver loose-fitting clothes that protect skin from sun of epididymis, an apparent reduction in the toxicity. Under such conditions, lower than percentage of sperm that were motile, and (at exposure and discuss other sun protection

12 Journal of Dermatology for Physician Assistants

Pediatric Use SOLODYN® is indicated to treat only inflammatory lesions of non-nodular moderate to severe acne vulgaris in patients 12 years and older. Safety and effectiveness in pediatric patients below the age of 12 has not been established.

Use of tetracycline-class antibiotics below the age of 8 is not recommended due to the potential for tooth discoloration (see WARNINGS).

Geriatric Use Clinical studies of SOLODYN® did not include sufficient numbers of subjects aged 65 and over to determine whether 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.

ADVERSE REACTIONS Because clinical trials are conducted under prescribed conditions, adverse reaction rates observed in the clinical trial may not reflect the rates observed in practice. However, adverse reaction information from clinical trials provides a basis for identifying the adverse events that appear to be related to drug use.

Adverse events reported in clinical trials for SOLODYN® are described below in Table 2.

Table 2 – Selected Treatment-Emergent Adverse Events in at least 1% of Clinical Trial Subjects Adverse Event At least one treatmentemergent event Headache Fatigue Dizziness Pruritus Malaise Mood alteration Somnolence Urticaria Tinnitus Arthralgia Vertigo Dry mouth Myalgia

SOLODYN® PLACEBO N=364 (1 mg/kg) (%) N=674 (%) 379 (56)

197 (54)

152 (23) 62 (9) 59 (9) 31 (5) 26 (4) 17 (3) 13 (2) 10 (2) 10 (2) 9 (1) 8 (1) 7 (1) 7 (1)

83 (23) 24 (7) 17 (5) 16 (4) 9 (3) 9 (3) 3 (1) 1 (0) 5 (1) 2 (0) 3 (1) 5 (1) 4 (1)

Adverse reactions not observed in the clinical trials, but 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.

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: thyroid discoloration, abnormal thyroid function.

Oncology: papillary 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 Carcinogenesis, Mutagenesis, Impairment of Fertility section).

OVERDOSAGE In case of overdosage, discontinue medication, treat symptomatically and institute supportive measures. Minocycline is not removed in significant quantities by hemodialysis or peritoneal dialysis.

HOW SUPPLIED SOLODYN® (MINOCYCLINE HCl, USP) Extended Release Tablets are supplied as aqueous film coated tablets containing minocycline hydrochloride equivalent to 45 mg, 65 mg, 90 mg, 115 mg or 135 mg minocycline.

The 45 mg extended release tablets are gray, unscored, coated, and debossed with “DYN-045” on one side. Each tablet contains minocycline hydrochloride equivalent to 45 mg minocycline, supplied as follows: NDC 99207-460-30 Bottle of 30 NDC 99207-460-10 Bottle of 100 The 65 mg extended release tablets are blue, unscored, coated, and debossed with “DYN-065” on one side. Each tablet contains minocycline hydrochloride equivalent to 65 mg minocycline, supplied as follows: NDC 99207-463-30 Bottle of 30 The 90 mg extended release tablets are yellow, unscored, coated, and debossed with “DYN-090” on one side. Each tablet contains minocycline hydrochloride equivalent to 90 mg minocycline, supplied as follows: NDC 99207-461-30 Bottle of 30 NDC 99207-461-10 Bottle of 100 The 115 mg extended release tablets are green, unscored, coated, and debossed with “DYN-115” on one side. Each tablet contains minocycline hydrochloride equivalent to 115 mg minocycline, supplied as follows: NDC 99207-464-30 Bottle of 30 The 135 mg extended release tablets are pink (orange-brown), unscored, coated, and debossed with “DYN-135” on one side. Each tablet contains minocycline hydrochloride equivalent to 135 mg minocycline, supplied as follows: NDC 99207-462-30 Bottle of 30 NDC 99207-462-10 Bottle of 100 Store at 25ºC (77ºF); excursions are permitted to 15º-30ºC (59º-86ºF) [See USP Controlled Room Temperature].

Protect from light, moisture, and excessive heat.

Dispense in tight, light-resistant container with child-resistant closure.

U.S. Patent 5,908,838* and Patents Pending *90 mg is also covered by U.S. Patents 7,541,347 and 7,544,373 Manufactured for: Medicis, The Dermatology Company Scottsdale, AZ 85256 July 2009 17110103

T

his year marks the 25th anniversary of the AAD’s National Skin Cancer Screening Program. The first Monday of May (this year May 3rd) is Melanoma Monday® and the official launch of Melanoma/Skin Cancer Detection and Prevention Month®. Through the AAD’s National Melanoma/Skin Cancer Screening Program, dermatology providers volunteer to provide free skin cancer screenings in their communities. Since 1985, this public service program has screened more than 2 million people and detected more than 197,000 suspicious lesions, including more than 22,500 suspected melanomas.

By conducting free skin cancer screenings, dermatology providers are bringing attention to the profession of dermatology, helping to educate millions of people about the importance of sun protection and early skin cancer detection, and most important, helping to

Student Scoop The New SDPA Student Website Is Up and Running Lauren R. Zajac, MHS, PA-C SDPA Director at Large

Those of us who work with PA students (precepting and teaching) know that they have a lot of questions about the physician assistant profession as well as the specialty of dermatology. I am well aware of this because I answer the student questions that are submitted to the SDPA on a daily basis. In response to these many questions, the SDPA has created a student website in an attempt to feature all of the information a student might need or want. SDPA student and fellow members can securely connect to the new website from the SDPA homepage or reach it directly from cyberspace. All SDPA members should encourage nonmember PA students to join the SDPA in order to take advantage of this useful resource. The twenty-five dollar annual student membership is well worth it.

directly save lives by finding melanomas in their earliest, most treatable stage.

While May is designated as Melanoma/Skin Cancer Detection and Prevention Month, skin cancer screenings can be performed at any time throughout the year.

As this is an AAD-sponsored program and a member benefit, Academy member dermatologists must order all materials, serve as the Program Director and be present at the screening. Physician assistants can conduct skin cancer screenings under the supervision of a dermatologist.

If you are interested in volunteering, visit the AAD’s shortcut link at www.aad.org/screenings to find a free skin cancer screening location and to learn more about the guidelines for screening coordinators. J Reprinted with permission from the American Academy of Dermatology.

All rights reserved.

Features of the new SDPA student website will include: l A list of dermatology rotations across the country l Dermatology specific resume writing tips and sample resumes l Malpractice insurance policy information l Contract negotiation articles l A student only forum l Case studies l Educational articles from the JDPA l Lists of recommended dermatology textbooks, journals, and websites l Lists of mobile technology sites and programs l Articles and videos of dermatology procedures l Helpful hints on how to survive PA school l Information on how to evaluate medical material on the internet l Excerpts from Emily Massey’s Guide for First Year Derm PAs l And more!

Please email me at lzajac@dermpa.org with any additional thoughts, ideas, and feedback regarding the content of the SDPA student website. I would love to hear from everyone. I hope that students will take advantage of this valuable resource that the SDPA Board of Directors, committee chairs, and volunteers are providing for them.

We look forward to welcoming our new colleagues! J Vol. 4, No. 2 SPRING 2010 13

Dermatology PA news & notes

May is Melanoma/Skin Cancer Detection and Prevention Month®

The Society of Dermatology Physician Assistants Summer

Dermatology Conference CHICAGO

Register Now

at www.dermpa.org

Marriott Downtown, Chicago, Illinois June 10 – 13, 2010

CHICAGO PLANNED TOPICS TO INCLUDE:

(Topics may change without prior notice) s (AIR $ISORDERS s $ERMATOSES OF 0REGNANCY s "ASIC )MMUNOLOGY s .ON )NVASIVE 4REATMENT FOR 0RECANCEROUS AND #ANCEROUS ,ESIONS s 2EVIEW OF THE 3URGICAL !PPROACH TO .ON -ELANOMA 3KIN #ANCER s $ERMATOPATHOLOGY AND #LINICAL #ORRELATION s 4EN 4ONGUE 4ROUBLES s #ONTACT $ERMATITIS s $ERMOSCOPY s $RUG %RUPTIONS

14 Journal of Dermatology for Physician Assistants

s 0ATHOPHYSIOLOGY OF 7OUND #ARE s #ONTACT 3TOMATITIS s (OW TO 'ET THE -OST /UT OF #ODING s #ERTIlCATION 2EVIEW !LL 4HOSE 4HINGS )NSIDE THE 3KIN 9OU -IGHT (AVE &ORGOTTEN %DUCATIONAL SESSIONS WILL BE CONDUCTED BY AN OUTSTANDING FACULTY OF DERMATOLOGY THOUGHT LEADERS 4HIS PROGRAM IS NOT YET APPROVED FOR #-% CREDIT #ONFERENCE ORGANIZERS PLAN FOR HOURS OF #ATEGORY ) #-% #REDIT TO BE AVAILABLE 1UESTIONS Call 800-380-3992.

Clinical Dermatology

Current Treatment Options for Metastatic Melanoma

By Argyro (Angie) Tsiaras, MPA-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 APRIL 2010. 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: 1) Discuss the current management of advanced stage metastatic melanoma.

2) Identify the differences between immunotherapy, cytotoxic chemotherapy, and targeted therapy approaches for advanced stage metastatic melanoma.

3) Recognize the limitations of current available treatment options for patients with advanced stage metastatic melanoma.

4) Understand the need for patients with advanced stage metastatic melanoma to seek clinical trials.

Vol. 4, No. 2 SPRING 2010 15

Current Treatment Options for Metastatic Melanoma SDPA Members Only Content

CLINICAL 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

Current Treatment Options for Metastatic Melanoma SDPA Members Only Content

CLINICAL 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.

Vol. 4, No. 2 SPRING 2010 17

Current Treatment Options for Metastatic Melanoma SDPA Members Only Content

CLINICAL 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.

18 Journal of Dermatology for Physician Assistants

Current Treatment Options for Metastatic Melanoma SDPA Members Only Content

CLINICAL 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.

Argyro (Angie) Tsiaras, MPA-C graduated from the Notre Dame College Physician Assistant Program of Manchester, NH in December 2002. She currently works at the Dana Farber Cancer Institute, Melanoma Division in Boston, MA. She has indicated no relationships to disclose relating to the content of this article.

Vol. 4, No. 2 SPRING 2010 19

From The Patient’s Perspective Melanoma is a Tricky Disease

CLINICAL Dermatology

By Jackie Doss

axilla, I was referred to a general surgeon whose normal Sometime in 2000, when I was forty years old, practice was breast surgery. A needle biopsy confirmed my gynecologist noticed a mole on my upper back that it was melanoma, so she scheduled me for surgery. and suggested I get it checked out because it exhibited several of the characteristics of melanoma. I hadn’t been This, I believe, was mistake number two. sick a day in my life, and I was just “too busy” to fit Rather than getting a second opinion from a another doctor visit into my schedule. Here, of course, melanoma specialist, I simply had the surgery and was mistake number one! A year and a half later, my trusted that between the general oncologist and general husband had a physical. His doctor wanted to biopsy a surgeon, I was being appropriately treated. The 4cm suspicious mole on his back, and it reminded me that mass was removed in February 2004, along with there was one on my back eleven additional lymph that needed attention. So in nodes. Meanwhile, I had ”I have lost many friends to April of 2002, we had our been doing some research moles removed on the same and found that there melanoma and it is a constant day. My husband’s mole was were clinical trial options normal. I wasn’t so lucky. besides the Interferon reminder of a disease that that my oncologist had My mole turned out to doesn’t seem to give up. recommended. I wanted be a melanoma, Clark level III, Breslow depth 0.68mm, to explore all of these So I won’t give up either.” and no ulceration. The PA options, so I investigated the Cancervax clinical trial who removed the mole did a great job of getting clear and referred myself to MD Anderson Cancer Center in Houston on the advice of a margins. Still, I had to have a wide local excision by a plastic surgeon, and was referred to an oncologist friend’s cousin, a radiation oncologist. By the time I got to MD Anderson that April, I had multiple metastases and a dermatologist for follow-up. The dermatologist in the same axilla. scheduled me for the customary three-month checkups.

The oncologist took my history, looked at my pathology The surgical oncologist at MD Anderson told me reports, said that he’d probably never need to see me that if I had come there first, they would have removed again, and that I was one of the lucky ones who “caught all of the lymph nodes in the axilla and followed up it early.” At that time, my biggest concern was the big with radiation treatment because the tumor was large ugly scar on my back. enough to burst and spread to surrounding tissue. I had a complete lymph node dissection in May of 2004, Less than two years later, I felt a pain under my followed by radiation. I then continued my search for a arm. I thought I had pulled a muscle. But it didn’t go away. In January of 2004, I saw the PA at our family clinical trial for adjuvant therapy. I went to Pittsburgh to see if I qualified for the Mel-43 trial. After waiting practice because the pain had increased significantly the customary time for follow-up scans, and “jumping even after taking a course of steroids for a cyst on my through the hoops” to see if I qualified for the trial, hand. I told him that one armpit felt a bit different I had to do one more set of scans in October before from the other one. He said, “You mean this lump?” I starting the trial. Unfortunately, a tumor was found in hadn’t thought of it as a lump! He scheduled me for a the fatty tissue on my left flank, so I did not qualify for mammogram and sonogram, and said that because of the trial. my melanoma history, we needed to rule out metastasis.

After the tests, which confirmed a mass in my left Rather than removing the tumor right away, I decided to do a clinical trial for systemic treatment.

Jackie Doss lives in Dallas, Texas and has been The trial compared DTIC with a breast cancer drug. diagnosed with stage IV melanoma. Jackie My arm of the trial was DTIC. I did two rounds, but reminds us that melanoma is a tricky disease. there was no effect on the tumor. I then did a trial called It behaves differently in different people. For Celingitide, which was a drug that inhibited blood a stage IV melanoma patient, she considers herself quite fortunate, considering that the vessel formation. This trial didn’t seem to be working average survival time without recurrence is either, so I was scheduled for surgery in February of seven months. Her story is one of hope.

2005. Interestingly, the surgeon said that the tumor was 20 Journal of Dermatology for Physician Assistants

From The Patient’s Perspective Take Home points for derm pas:

By Steven K. Shama, MD, MPH l Jackie Doss is one amazing person and sets

an example for all of us. She remains full of hope when many of us would have given up after the first round of treatments. We should not forget to tell Jackie’s story when we have a patient whose treatments seem to be failing.

l Jackie gives me the impression that she was

ultimately in charge of her care. I strongly believe that she was the one who decided that she wanted to try another protocol when the local hospital’s protocols had been exhausted. Let us celebrate her passion to be cured and always support patients who seem to take control by asking if there is something else they can try. After all, it is their life. It is their right to fight!

l I reread Jackie’s first paragraph where she

mentions that her gynecologist wanted her to see a specialist about the mole on her back. While her physician’s recommendation was sufficient, it reminds us that we should make sure that patients follow up with our recommendations, especially when there is a possibility of something significant being found. I truly believe that we need to do that follow-up and we need to do it more often!

&

Dermatoscopy Q A Q: What is it?

Under Dermatoscopy

Answer on page 23 Vol. 4, No. 2 SPRING 2010 21

CLINICAL Dermatology

partially dead. While the tumor seemed to have grown based on the CT scan, the trial drug may have actually affected it.

After that surgery, I didn’t seem to be bouncing back very fast. I was short of breath and very tired when I should have been fully recuperated. I also had severe stomach cramps. It turned out that there were metastases in my small intestine. I had surgery five weeks after the previous surgery and two or three tumors were removed along with 6in of my small intestine.

Then I finally qualified for a clinical trial for adjuvant therapy! I started the Mel-44 trial in July of 2005. I received a vaccine injection at two sites, my right upper leg and my right upper arm. The vaccine was administered subdermally and subcutaneously.

Ouch! The schedule began as once a week, then once a month, then once every three months. Fifteen months after my surgery, I had only one more vaccine left when I started having the familiar symptoms of dark stool and shortness of breath.

A pill camera was used to take pictures in my small intestine, and it didn’t look promising. There was one large tumor near the end of my small intestine. But even more disturbing than the tumor was the fact that there were pigmented areas seen throughout my small intestine. My surgeon didn’t believe he could get it all.

Thankfully, the outcome of the surgery in August 2006 was so much better than expected! The pigmented areas turned out to be benign. They don’t know for sure, but they believe it’s possible that the Mel-44 vaccine helped my body to fight off the cancer cells as they were trying to form.

Since the removal of the last tumor, I was again NED (No Evidence of Disease), and I have remained so for over three years. I am currently receiving no treatment or adjuvant therapy, and I’m very thankful to be alive! So, although the beginning of my story (a <1mm lesion progressing to advanced disease) is atypical, thankfully the updated story is also atypical.

Not too many Stage IV melanoma patients are as blessed as I am to be alive and cancer-free after so many recurrences. While I know that doctors expect my disease to return… I don’t!

At times my life is a roller coaster, but I feel blessed to be here. I have lost many friends to melanoma and it is a constant reminder of a disease that doesn’t seem to give up. So I won’t give up either. I won’t give up fighting. I won’t give up hope. I won’t give in to fear.

I will do whatever I can to get the word out about melanoma prevention so that future generations don’t have to face this fear. J

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22 Journal of Dermatology for Physician Assistants

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Drugs in Dermatology Aluminum Chloride for Hemostasis

By Travis Hayden, MPAS, PA-C

SDPA Members Only Content

Travis Hayden, MPAS, PA-C practices dermatology with John Tu, MD at Dermatology Associates of Rochester, New York. He has indicated no relationships to disclose relating to the content of this article.

&

Dermatoscopy Q A

A: Basal cell carcinoma (trichoblastic carcinoma)

Under Dermatoscopy

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.

Vol. 4, No. 2 SPRING 2010 23

CLINICAL 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.

Clinical snapshots Rhinophyma

By Erik Sorenson, MPAS, PA-C SDPA Scientific and Clinical Affairs Committee Chair

SDPA Members Only Content

CLINICAL 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.

Erik P. Sorenson, MPAS, PA-C has practiced dermatology for nine years and works with Frederic Rosenberg, MD at Advanced Dermatology in Lakewood, California. He has indicated no relationships to disclose relating to the content of this article.

24 Journal of Dermatology for Physician Assistants

Expectations

Reformulated

A tretinoin re-invented for success • Delivered within a unique aqueous gel with a smart combination of ingredients that are known to moisturize and hydrate skin* • Efficacy you can expect only from a tretinoin1 • Low irritation profile1

Important Safety Information: • The most common adverse reactions were mild to moderate irritation of the skin and occurred during the first few weeks of treatment with ATRALIN® Gel. • To prevent aggravating the skin, protect it from sun, tanning lights, extreme wind or cold, and harsh skincare products.

• Use of sunscreen products of at least SPF 15 and protective clothing over treated areas is recommended when exposure cannot be avoided.

• Please see next page for Brief Summary of Prescribing Information. *The contribution to efficacy of individual components has not been evaluated.

www.atralingel.com Reference: 1. Data on file. CORIA Laboratories.

ATRALIN and CORIA are registered trademarks of CORIA Laboratories. ©2008 CORIA Laboratories ATR–10011–0908

Vol. 4, No. 2 SPRING 2010 25

BRIEF SUMMARY

(see package insert for full prescribing information)

For topical use only INDICATIONS AND USAGE Atralin Gel is a retinoid indicated for topical treatment of acne vulgaris.

Important Limitations of Use The safety and efficacy of the use of this product in the treatment of any other disorders have not been evaluated.

CONTRAINDICATIONS None WARNINGS AND PRECAUTIONS Skin Irritation The skin of certain individuals may become dry, red, or exfoliated while using Atralin Gel. If the degree of irritation warrants, patients should be directed to temporarily reduce the amount or frequency of application of the medication, discontinue use temporarily, or discontinue use altogether. Efficacy at reduced frequencies of application has not been established. If a reaction suggesting sensitivity occurs, use of the medication should be discontinued. Mild to moderate skin dryness may also be experienced; if so, use of an appropriate moisturizer during the day may be helpful.

Tretinoin has been reported to cause severe irritation on eczematous or sunburned skin and should be used with caution in patients with these conditions.

Topical over-the-counter acne preparations, concomitant topical medication, medicated cleansers, topical products with alcohol or astringents, when used with Atralin Gel, should be used with caution [see Drug Interactions (7)].

Ultraviolet Light and Environmental Exposure Unprotected exposure to sunlight, including sunlamps, should be minimized during the use of Atralin Gel. Patients who normally experience high levels of sun exposure, and those with inherent sensitivity to sun, should be warned to exercise caution. Use of sunscreen products of at least SPF 15 and protective clothing over treated areas is recommended when exposure cannot be avoided.

Weather extremes, such as wind or cold, also may be irritating to patients under treatment with tretinoin.

Fish Allergies Atralin Gel contains soluble fish proteins and should be used with caution in patients with known sensitivity or allergy to fish. Patients who develop pruritus or urticaria should contact their health care provider.

ADVERSE REACTIONS Clinical Studies Experience Because clinical trials are conducted under prescribed conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.

In two randomized, controlled trials, 674 subjects received treatment for up to 12 weeks with Atralin Gel [see Clinical Studies (14)]. In these studies, 50% of the subjects who were treated with Atralin Gel reported one or more adverse reactions; 30% of the subjects reported treatment-related adverse reactions. In the vehicle group, 29% of the 487 randomized subjects reported at least one adverse reaction;

5% of the subjects reported events that were treatment-related. There were no serious, treatment-related adverse reactions reported by subjects in any of the treatment groups.

Selected adverse reactions that occurred in at least 1% of subjects in the two studies combined, are shown in Table 1 (below). Most skin-related adverse reactions first appear during the first two weeks of treatment with Atralin Gel, and the incidence rate for skin-related reactions peaks around the second and third week of treatment.

In some subjects the skin-related adverse reactions persist throughout the treatment period.

Table 1. Number of Subjects with Selected Adverse Reactions (Occurring in At Least 1% of Subjects) Event

Atralin Gel (n = 674)

Vehicle Gel (n = 487)

Dry Skin

109 (16%)

8 (2%)

78 (12%)

7 (1%)

53 (8%)

8 (2%)

Erythema

47 (7%)

1 (<1%)

Pruritus

11 (2%)

3 (1%)

Pain of Skin

7 (1%)

0 (0%)

Sunburn

7 (1%)

3 (1%)

Peeling/Scaling/ Flaking Skin Skin Burning Sensation

DRUG INTERACTIONS When treating with Atralin Gel, caution should be exercised with the use of concomitant topical medication, medicated or abrasive soaps and cleansers, products that have a strong drying effect, and products with high concentrations of alcohol, astringents, spices, or lime. Particular caution should be exercised with the concomitant use of topical over-the-counter acne preparations containing benzoyl peroxide, sulfur, resorcinol, or salicylic acid. Allow the effects of such preparations to subside before use of Atralin Gel is begun.

USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C. There are no wellcontrolled trials in pregnant women treated with Atralin Gel. Atralin Gel should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Atralin Gel at doses of 0.1, 0.3 and 1 g/kg/day was tested for maternal and developmental toxicity in pregnant Sprague-Dawley rats by dermal application. The dose of 1 g/kg/day was approximately 4 times the clinical dose assuming 100% absorption and based on body surface area comparison. Possible tretinoin-associated teratogenic effects (craniofacial abnormalities [hydrocephaly], asymmetrical thyroids, variations in ossification, and increased supernumerary ribs) were noted in the fetuses of Atralin Gel treated animals. These findings were not observed in control animals. Other maternal and reproductive parameters in the Atralin Gel treated animals were not different from control. For purposes of comparison of the animal exposure to human exposure, the clinical dose is defined as 2 g of Atralin Gel applied daily to a 50-kg person.

Oral tretinoin has been shown to be teratogenic in rats, mice, rabbits, hamsters and nonhuman primates. Tretinoin was teratogenic in Wistar rats when given orally in doses greater than 1 mg/kg/day (approximately 8 times the clinical dose based on body surface area comparison).

In the cynomolgus monkey, fetal malformations were reported for doses of 10 mg/kg/day, but none were observed at 5 mg/kg/day (approximately 80 times the clinical dose

26 Journal of Dermatology for Physician Assistants

based on body surface area comparison), although increased skeletal variations were observed at all doses. Dose-related increases in embryolethality and abortion also were reported.

Similar results have also been reported in pigtail macaques.

Topical tretinoin in a different formulation has generated equivocal results in animal teratogenicity tests. There is evidence for teratogenicity (shortened or kinked tail) of topical tretinoin in Wistar rats at doses greater than 1 mg/kg/day (approximately 8 times the clinical dose assuming 100% absorption and based on body surface area comparison). Anomalies (humerus: short 13%, bent 6%, os parietal incompletely ossified 14%) have also been reported when 10 mg/kg/day (approximately 160 times the clinical dose assuming 100% absorption and based on body surface area comparison) was topically applied.

Supernumerary ribs have been a consistent finding in rats when dams were treated topically or orally with retinoids.

With widespread use of any drug, a small number of birth defect reports associated temporally with the administration of the drug would be expected by chance alone. Cases of temporally associated congenital malformations have been reported with use of other topical tretinoin products. The significance of these spontaneous reports in terms of risk to the fetus is not known.

Nonteratogenic effects on fetuses: Oral tretinoin has been shown to be fetotoxic in rats when administered in doses 20 times the clinical dose based on a body surface area comparison. Topical tretinoin has been shown to be fetotoxic in rabbits when administered in doses 8 times the clinical dose based on a body surface area comparison.

Nursing Mothers It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Atralin Gel is administered to a nursing woman.

Pediatric Use Safety and effectiveness in children below the age of 10 have not been established.

A total of 381 pediatric subjects (aged 10 to 16 years), treated with Atralin Gel were enrolled into the two clinical studies. Across these two studies, comparable safety and efficacy were observed between pediatric and adult subjects.

Geriatric Use Safety and effectiveness in a geriatric population have not been established. Clinical studies of Atralin Gel did not include any subjects over age 65 to determine whether they respond differently than younger subjects.

Marketed by:

CORIA Laboratories, a division of Valeant Pharmaceuticals North America, Aliso Viejo, CA 92656 Manufactured by: DPT LABORATORIES, LTD. San Antonio, Texas 78215 Patent No.: 5,670,547 Revised: 11/2009 137623-1109

Journal Club: Dermatology PA Perspectives

Primary hyperhidrosis increases the risk of cutaneous infection: A case control study of 387 patients JAAD 2009; Volume 61:242-246 Hobart W. Walling, MD, PhD Reviewed By Larissa Franchuk, PA-C

SDPA Members Only Content

CLINICAL 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.

Larissa Franchuk, PA-C is a graduate of the Eastern Virginia Medical School Physician Assistant Program. She currently works in a private dermatology practice in Norfolk, Virginia. She has no relationships to disclose relating to the content of this article.

Interested in learning how to start a journal club?

Journal Club for Dermatology PAs

If so, please join the JDPA in Chicago at this yearâ&#x20AC;&#x2122;s inaugural SDPA Summer Dermatology Conference and plan on attending the SDPA Constituent Relations Committee meeting on Thursday June 10th, at 4:50pm to learn more.

During this meeting, the JDPA will be holding an informational session that will help dermatology PAs learn how to get the most out of attending a journal club and how to organize a journal club for their hometown or state.

Vol. 4, No. 2 SPRING 2010 27

CAMP DISCOVERY Fun and friendship are on the top of everyone’s agenda. And, everyone shares in the discovery of what it’s like to be included. Camp Discovery is a wonderful experience for the campers who attend and for those who volunteer.

Founded and funded by the American Academy of Dermatology, Camp Discovery is for young people with chronic skin conditions and offers a summer camping experience unlike any they’ve ever had.

Under the expert care of dermatologists, nurses and physician assistants, Camp Discovery offers young people the opportunity to spend a week with other campers who have similar skin conditions. Many of the counselors have chronic skin conditions as well, and can provide support and advice to campers.

This year the Academy will offer four different weeks of summer camp.

• June 27 – July 2, Junior Camp in Crosslake, Minnesota (ages 10 - 14) • July 11 – 16, Teen Camp in Crosslake, Minnesota (ages 14 – 16) • August 8 – 13, Camp Dermadillo, Burton, Texas (ages 9 – 15) • August 14 – 21, Camp Horizon, Millville, Pennsylvania (ages 8 – 13) Below are ways that physician assistants may become involved.

Refer your patients to Camp Discovery Dermatology providers are encouraged to refer their pediatric patients to Camp Discovery. Patient referral forms were sent to all Academy members in January.

Volunteer your time at Camp Discovery Volunteer medical staff, including dermatologists, residents, physician assistants, and nurses, are vital to Camp Discovery’s success.

To receive more information or the proper forms please contact Janine Mueller at (847) 240-1737 or jmueller@aad.org.

Support the Camp Discovery Endowment American Academy of Dermatology members and the public can support Camp Discovery by making donations to the Camp Discovery Endowment Fund.

For information on making a contribution to this valuable Academy program, contact Valerie Thompson at (847) 240-1427 or vthompson@aad.org.

For information about Camp Discovery, visit campdiscovery.org 28 Journal of Dermatology for Physician Assistants

10-356

SURGICAL Dermatology

SURGICAL wisdom Ten Steps to a Seamless Excision

Step 9 - Wound Care Step 10 â&#x20AC;&#x201C; Suture Removal

By Michael Fraykor, PA-C and Michael Todd, MD

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.

Michael Fraykor, PA-C, is a graduate of the Touro College Physician Assistant program in Long Island, NY. He is a member of the SDPA, AAPA, and VAPA. Currently, he is employed at the Skin Cancer Center of Northern Virginia where he assists with Mohs surgeries, screens patients, and performs excisions. He has no outside relationships with industry to disclose.

For most physician assistants working in the field of dermatology, excisions are an everyday occurrence. Excisions can occasionally be challenging and intimidating due to size, location, and a patientâ&#x20AC;&#x2122;s expectations. Since I work strictly for a Mohs surgeon, performing excisions and suturing have become second nature to me. I have put together the 10 key points that I have learned that help ensure good excisions as well as good cosmetic results. Hopefully, this 10 part series will provide you with the tools needed for a seamless excision.

Vol. 4, No. 2 SPRING 2010 29

COSMETIC deRMATOLOGY

Cosmetic pearls The Use of Twitter in Your Office 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.

1

2

30GV EBKRUL]RQWDO LQGG Journal of Dermatology for Physician Assistants

3

30

ACNE REGIMEN

REDEFINED

EPIDUO GEL: A VISIBLE DIFFERENCE

*

®

1

Epiduo® (adapalene and benzoyl peroxide) Gel 0.1%/2.5%—A unique fixed-dose combination developed for the first-line treatment of inflammatory and comedonal lesions

www.epiduo.com/hcp *In a phase 3 clinical trial of 1670 patients, median reduction in inflammatory lesions was 70% and median reduction in comedonal lesions was 62% at week 12.

Important Safety Information Epiduo® Gel is a retinoid and antimicrobial combination product indicated for the topical treatment of acne vulgaris in patients 12 years and older. The most common adverse events associated with use of Epiduo® Gel are erythema, scaling, dryness, stinging and burning.

In addition, in clinical trials, adverse events reported in greater than 1% of patients treated with the Gel included contact dermatitis and skin irritation. Excessive exposure to sunlight and sunlamps should be avoided during treatment, and use of sunscreen products and protective clothing is recommended. Concomitant use of irritating topical products (like products containing resorcinol, salicylic acid or sulfur) should be avoided. Epiduo® Gel has not been tested in pregnant or nursing women, or with the elderly. Pregnancy Category C.

Please see brief summary of Prescribing Information on next page.

Vol. 4, No. 2 SPRING 2010 31

EPIDUO™

Rx only

(adapalene and benzoyl peroxide) Gel 0.1% / 2.5% For Topical Use Only Not For Ophthalmic, Oral, or Intravaginal Use. BRIEF SUMMARY INDICATIONS AND USAGE EPIDUO Gel is a combination of adapalene, a retinoid, and benzoyl peroxide, and is indicated for the topical treatment of acne vulgaris in patients 12 years of age and older.

CONTRAINDICATIONS None.

WARNINGS AND PRECAUTIONS Ultraviolet Light and Environmental Exposure: Avoid exposure to sunlight and sunlamps. Wear sunscreen when sun exposure cannot be avoided.

Erythema, scaling, dryness, and stinging/burning may occur with use of EPIDUO Gel. ADVERSE REACTIONS Observed local adverse reactions in patients treated with EPIDUO Gel were erythema, scaling, dryness, stinging, and burning. Other most commonly reported adverse events (≥1%) in patients treated with EPIDUO Gel were dry skin, contact dermatitis, application site burning, application site irritation, skin irritation.

DRUG INTERACTIONS Exercise caution in using preparations containing sulfur, resorcinol, or salicylic acid, medicated or abrasive soaps and cleansers and products with high concentrations of alcohol or astringents in combination with EPIDUO Gel. Concomitant use of topical products with a strong drying effect can increase irritation. Use with caution.

Pregnancy Pregnancy Category C. There are no well-controlled trials in pregnant women treated with EPIDUO Gel. Animal reproduction studies have not been conducted with the combination gel or benzoyl peroxide. Furthermore, such studies are not always predictive of human response; therefore, EPIDUO Gel should be used during pregnancy only if the potential benefit justifies the risk to the fetus.

No teratogenic effects were observed in rats treated with oral doses of 0.15 to 5.0 mg adapalene/kg/day, up to 25 times (mg/m2/day) the maximum recommended human dose (MRHD) of 2 grams of EPIDUO Gel. However, teratogenic changes were observed in rats and rabbits when treated with oral doses of ≥ 25 mg adapalene/kg/day representing 123 and 246 times MRHD, respectively. Findings included cleft palate, microphthalmia, encephalocele and skeletal abnormalities in rats; and umbilical hernia, exophthalmos and kidney and skeletal abnormalities in rabbits.

Dermal teratology studies conducted in rats and rabbits at doses of 0.6-6.0 mg adapalene/kg/day [25-59 times (mg/m2) the MRHD] exhibited no fetotoxicity and only minimal increases in supernumerary ribs in both species and delayed ossification in rabbits.

Nursing Mothers It is not known whether adapalene or benzoyl peroxide is excreted in human milk following use of EPIDUO Gel. Because many drugs are excreted in human milk, caution should be exercised when EPIDUO Gel is administered to a nursing woman.

Pediatric Use Safety and effectiveness of EPIDUO Gel in pediatric patients under the age of 12 have not been established.

Geriatric Use Clinical studies of EPIDUO Gel did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.

Carcinogenesis, Mutagenesis, Impairment of Fertility No carcinogenicity, photocarcinogenicity, genotoxicity, or fertility studies were conducted with EPIDUO Gel. Carcinogenicity studies with adapalene have been conducted in mice at topical doses of 0.4, 1.3, and 4.0 mg/kg/day (1.2, 3.9, and 12 mg/m2/day), and in rats

at oral doses of 0.15, 0.5, and 1.5 mg/kg/day (0.9, 3.0, and 9.0 mg/m2/day).

In terms of body surface area, the highest dose levels are 9.8 (mice) and 7.4 times (rats) the MRHD of 2 grams of EPIDUO Gel. In the rat study, an increased incidence of benign and malignant pheochromcytomas in the adrenal medulla of male rats was observed.

No significant increase in tumor formation was observed in rodents topically treated with 15-25% benzoyl peroxide carbopol gel (6-10 times the concentration of benzoyl peroxide in EPIDUO Gel) for two years. Rats received maximum daily applications of 138 (males) and 205 (females) mg benzoyl peroxide/kg. In terms of body surface area, these levels are 27-40 times the MRHD. Similar results were obtained in mice topically treated with 25% benzoyl peroxide carbopol gel for 56 weeks followed by intermittent treatment with 15% benzoyl peroxide carbopol gel for rest of the 2 years study period, and in mice topically treated with 5% benzoyl peroxide carbopol gel for two years.

The role of benzoyl peroxide as a tumor promoter has been well established in several animal species. However, the significance of this finding in humans is unknown.

In a photocarcinogenicity study conducted with 5% benzoyl peroxide carbopol gel, no increase in UV-induced tumor formation was observed in hairless mice topically treated for 40 weeks.

No photocarcinogenicity studies were conducted with adapalene. However, animal studies have shown an increased tumorigenic risk with the use of pharmacologically similar drugs (e.g., retinoids) when exposed to UV irradiation in the laboratory or sunlight. Although the significance of these findings to humans is not clear, patients should be advised to avoid or minimize exposure to either sunlight or artificial irradiation sources.

Adapalene did not exhibit mutagenic or genotoxic effects in vitro (Ames test, Chinese hamster ovary cell assay, mouse lymphoma TK assay) or in vivo (mouse micronucleus test).

Bacterial mutagenicity assays (Ames test) with benzoyl peroxide has provided mixed results, mutagenic potential was observed in a few but not in a majority of investigations. Benzoyl peroxide has been shown to produce single-strand DNA breaks in human bronchial epithelial and mouse epidermal cells, it has caused DNA-protein cross-links in the human cells, and has also induced a dose-dependent increase in sister chromatid exchanges in Chinese hamster ovary cells. In rat oral studies, 20 mg adapalene/kg/day (120 mg/m2/day; 98 times the MRHD based on mg/m2/day comparison) did not affect the reproductive performance and fertility of F0 males and females, or growth, development and reproductive function of F1 offspring.

No fertility studies were conducted with benzoyl peroxide.

PATIENT COUNSELING INFORMATION – Advise patients to cleanse the area to be treated with a mild or soapless cleanser; pat dry. Apply EPIDUO Gel as a thin layer, avoiding the eyes, lips and mucous membranes.

– Advise patients not to use more than the recommended amount and not to apply more than once daily as this will not produce faster results, but may increase irritation.

– EPIDUO Gel may cause irritation such as erythema, scaling, dryness, stinging or burning.

– Advise patients to minimize exposure to sunlight, including sunlamps.

Recommend the use of sunscreen products and protective apparel, (e.g., hat) when exposure cannot be avoided.

– EPIDUO Gel may bleach hair and colored fabric.

Marketed by: GALDERMA LABORATORIES, L.P. Fort Worth, Texas 76177 USA Manufactured by: Galderma Production Canada Inc. Baie d’Urfé, QC, H9X 3S4 Canada Made in Canada.

GALDERMA is a registered trademark.

Revised: December 2008 P51356-0

Reference: 1. Gollnick HPM, Draelos Z, Glenn MJ, et al; Adapalene–BPO Study Group. Adapalene–benzoyl peroxide, a unique fixed-dose combination topical gel for the treatment of acne vulgaris: a transatlantic, randomized, double-blind, controlled study in 1670 patients. Br J Dermatol. 2009;161(5):1180-1189.

Galderma is a registered trademark. ©2010 Galderma Laboratories, L.P. Galderma Laboratories, L.P. 14501 N. Freeway Fort Worth, TX 76177 EPI-317 Printed in USA 01/10

www.epiduo.com/hcp

32 Journal of Dermatology for Physician Assistants

Professional development

The History of the SDPA

By Patricia Ferrer, 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.

Patricia Ferrer, MPAS, PA-C graduated from the University of Texas Medical Branch in 1998 and obtained her Masters Degree from the University of Nebraska in 2003 (SDPA scholarship). She is an Associate member of the SDPA and Fellow member of the AAPA. She has been working in dermatology for nine years and is currently on sabbatical. She has no outside relationships with industry to disclose.

Patricia would like to thank all who contributed to this article and those who were instrumental in the development of the SDPA who may not have been mentioned. Sadly, Jim Sotack, Bruce Kalin, and Randy Ullendorf are now deceased but their contributions became important building blocks for the SDPA. Sources for this article include: SDPA newsletters from January 1999 â&#x20AC;&#x201C; October 2003; email correspondences with Kristine Kucera, Michele DiBaise, and Mary Monroe. Phone conversations with Greg Buttolph and Gordon Day.

Vol. 4, No. 2 SPRING 2010 33

SDPA Members Only Content

professional development

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.

34 Journal of Dermatology for Physician Assistants

SDPA Members Only Content

professional development

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.

Vol. 4, No. 2 SPRING 2010 35

SDPA Members Only Content

professional development

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.

Notes from your Office Manager How long should you keep patient records?

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.

36 Journal of Dermatology for Physician Assistants

When comedonal acne is your primary concern…

PRESCRIBE DIFFERIN® GEL, 0.3%

Primarily comedonal acne: EXAMPLE A

EXAMPLE B

POWERFUL EFFICACY

HIGH PATIENT SATISFACTION

From baseline to week 12, lesion reduction (total, noninflammatory, and inflammatory) was similar to tazarotene gel, 0.1%1*

86% of patients on adapalene gel, 0.3% were satisfied or very satisfied vs 69% on tazarotene gel, 0.1%1* Local tolerability scores comparable to tretinoin gel microsphere, 0.04%2†

*A phase 3b, 12-week, noninferiority, multicenter, investigator-blinded, controlled clinical study of patients 12 to 35 years of age with acne vulgaris (N=172). At the end of 12 weeks, neither product was found to be inferior. 160 patients participated in the satisfaction survey.

A single-center, randomized, investigator/evaluator-blinded, bilateral (split-face) comparison of healthy subjects ≥18 years of age (N=30). Subjects received Differin® Gel, 0.3% on one half of the face and tretinoin gel microsphere, 0.04% on the other half for 22 days.

†

Important Safety Information Of the patients who experienced cutaneous irritation (erythema, scaling, dryness, and/or stinging/burning) during the clinical trial, the majority of cases were mild to moderate in severity, occurred early in treatment, and decreased thereafter. Adverse events that occurred in greater than 1% of the subjects included dry skin (14.0%), skin discomfort (5.8%), pruritus (1.9%), desquamation (1.6%), and sunburn (1.2%). Pregnancy Category C. Concomitant use of potentially irritating products or overexposure to sunlight or sunlamps, extreme wind or cold, may increase the potential for irritation. Use of sunscreen and protective clothing over treated areas are recommended when exposure cannot be avoided.

Please see brief summary of Prescribing Information on adjacent page.

www.differin.com

Vol. 4, No. 2 SPRING 2010 37

DIFFERIN® (adapalene) Gel, 0.3% BRIEF SUMMARY

Rx only

For topical use only. Not for ophthalmic, oral or intravaginal use.

INDICATIONS AND USAGE: DIFFERIN® Gel, 0.3% is indicated for the topical treatment of acne vulgaris in patients 12 years of age and older.

CONTRAINDICATIONS: DIFFERIN® Gel, 0.3% should not be administered to individuals who are hypersensitive to adapalene or any of the components in the gel vehicle.

PRECAUTIONS: General: Certain cutaneous signs and symptoms of treatment such as erythema, scaling, dryness, and stinging/burning may be experienced with use of DIFFERIN® Gel, 0.3%. These are most likely to occur during the first four weeks of treatment, are mostly mild to moderate in intensity, and usually lessen with continued use of the medication. Depending upon the severity of these side effects, patients should be instructed to either use a moisturizer, reduce the frequency of application of DIFFERIN® Gel, 0.3% or discontinue use.

If a reaction suggesting sensitivity or chemical irritation occurs, use of the medication should be discontinued.

Exposure to sunlight, including sunlamps, should be minimized during use of adapalene. Patients who normally experience high levels of sun exposure, and those with inherent sensitivity to sun, should be warned to exercise caution. Use of sunscreen products and protective clothing over treated areas is recommended when exposure cannot be avoided. Weather extremes, such as wind or cold, also may be irritating to patients under treatment with adapalene.

Avoid contact with the eyes, lips, angles of the nose, and mucous membranes. The product should not be applied to cuts, abrasions, eczematous or sunburned skin. As with other retinoids, use of “waxing” as a depilatory method should be avoided on skin treated with adapalene.

Information for Patients: Patients using DIFFERIN® Gel, 0.3%, should receive the following information and instructions: 1. This medication is to be used only as directed by the physician.

2. It is for external use only.

3. Avoid contact with the eyes, lips, angles of the nose, and mucous membranes.

4. Cleanse affected area with a mild or soapless cleanser before applying this medication.

5. Moisturizers may be used if necessary; however, products containing alpha hydroxy or glycolic acids should be avoided.

6. Exposure of the eye to this medication may result in reactions such as swelling, conjunctivitis, and eye irritation.

7. This medication should not be applied to cuts, abrasions, eczematous, or sunburned skin.

8. Wax epilation should not be performed on treated skin due to the potential for skin erosions.

9. During the early weeks of therapy, an apparent exacerbation of acne may occur. This may be due to the action of the medication on previously unseen lesions and should not be considered a reason to discontinue therapy.

Drug Interactions: As DIFFERIN® Gel, 0.3% has the potential to induce local irritation in some patients, concomitant use of other potentially irritating topical products (medicated or abrasive soaps and cleansers, soaps and cosmetics that have a strong drying effect, and products with high concentrations of alcohol, astringents, spices, or lime) should be approached with caution. Particular caution should be exercised in using preparations containing sulfur, resorcinol, or salicylic acid in combination with DIFFERIN® Gel, 0.3%. If these preparations have been used, it is advisable not to start therapy with DIFFERIN® Gel, 0.3%, until the effects of such preparations have subsided.

Carcinogenesis, Mutagenesis, Impairment of Fertility: Carcinogenicity studies with adapalene have been conducted in mice at topical doses of 0.4, 1.3, and 4.0 mg/kg/day, and in rats at oral doses of 0.15, 0.5, and 1.5 mg/kg/day. These doses are up to 3 times (mice) and 2 times (rats) in terms of mg/m²/day the potential exposure at the maximum recommended human dose (MRHD), assumed to be 2.5 grams DIFFERIN® Gel, 0.3%. In the oral study, increased incidence of benign and malignant pheochromocytomas in the adrenal medullas of male rats was observed.

No photocarcinogenicity studies were conducted. Animal studies have shown an increased risk of skin neoplasms with the use of pharmacologically similar drugs (e.g., retinoids) when exposed to UV irradiation in the laboratory or to sunlight. Although the significance of these studies to human use is not clear, patients should be advised to avoid or minimize exposure to either sunlight or artificial UV irradiation sources.

Adapalene did not exhibit mutagenic or genotoxic effects in vitro (Ames test, Chinese hamster ovary cell assay, mouse lymphoma TK assay) and in vivo (mouse micronucleus test).

Reproductive function and fertility studies were conducted in rats administered oral doses of adapalene in amounts up to 20 mg/kg/day (up to 26 times the MRHD based on mg/m² comparisons). No effects of adapalene were found on the reproductive performance or fertility of the F0 males or females. There were also no detectable effects on the growth, development and subsequent reproductive function of the F1 offspring.

Pregnancy: Teratogenic effects. Pregnancy Category C. Retinoids may cause fetal harm, when administered to pregnant women. Adapalene has been shown to be teratogenic in rats and rabbits when administered orally (see Animal Data below). There are no adequate and well-controlled studies in pregnant women. DIFFERIN® Gel, 0.3% should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. The safety and efficacy of DIFFERIN® Gel, 0.3% in pregnancy has not been established.

1. Human Data In clinical trials involving DIFFERIN® Gel, 0.3% in the treatment of acne vulgaris, women of child-bearing potential initiated treatment only after having had a negative pregnancy test and used effective birth control measures during therapy. However, 6 women treated with DIFFERIN® Gel, 0.3% became pregnant. One patient elected to terminate the pregnancy, two patients delivered healthy babies by normal delivery, two patients delivered prematurely and the babies remained in intensive care until reaching a healthy state and one patient was lost to follow-up.

2. Animal Data • No teratogenic effects were seen in rats at oral doses of 0.15 to 5.0 mg/kg/day adapalene representing up to 6 times the maximum recommended human dose (MRHD) based on mg/m² comparisons. Adapalene has been shown to be teratogenic in rats and rabbits when administered orally at doses 25 mg/kg representing 32 and 65 times, respectively, the MRHD based on mg/m² comparisons. Findings included cleft palate, microphthalmia, encephalocele and skeletal abnormalities in the rat and umbilical hernia, exophthalmos and kidney and skeletal abnormalities in the rabbit.

• Cutaneous teratology studies in rats and rabbits at doses of 0.6, 2.0, and 6.0 mg/kg/day exhibited no fetotoxicity and only minimal increases in supernumerary ribs in both species and delayed ossification in rabbits.

Systemic exposure (AUC0-24h) to adapalene 0.3% gel at topical doses of 6.0 mg/kg/day in rats and rabbits represented 5.7 and 28.7 times, respectively, the exposure in acne patients treated with adapalene 0.3% gel applied to the face, chest and back (2 grams applied to 1000 cm2 of acne involved skin).

Nursing Mothers: It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when DIFFERIN® Gel, 0.3% is administered to a nursing woman.

Pediatric Use: Safety and effectiveness in pediatric patients below the age of 12 have not been established.

Geriatric Use: Clinical studies of DIFFERIN® Gel, 0.3% did not include subjects 65 years of age and older to determine whether they respond differently than younger subjects. Safety and effectiveness in geriatric patients age 65 and above have not been established.

38 Journal of Dermatology for Physician Assistants

ADVERSE REACTIONS: In the multi-center, controlled clinical trial, signs and symptoms of local cutaneous irritation were monitored in 258 acne patients who used DIFFERIN® Gel, 0.3% once daily for 12 weeks. Of the patients who experienced cutaneous irritation (erythema, scaling, dryness, and/or burning/stinging), the majority of cases were mild to moderate in severity, occurred early in treatment and decreased thereafter. The incidence of local cutaneous irritation with DIFFERIN® Gel, 0.3% from the controlled clinical study is provided in the following table: Table 2: Physician assessed local cutaneous irritation with DIFFERIN® Gel Incidence of Local Cutaneous Irritation with DIFFERIN® Gel, 0.3% from Controlled Clinical Study (N=253*) Maximum Severity Scores Higher Than Baseline Erythema Scaling Dryness Burning/Stinging

Mild 66 (26.1%) 110 (43.5%) 113 (44.7%) 72 (28.5%)

Moderate 33 (13.0%) 47 (18.6%) 43 (17.0%) 36 (14.2%)

Severe 1 (0.4%) 3 (1.2%) 2 (0.8%) 9 (3.6%)

* Total number of subjects with local cutaneous data for at least one post-Baseline evaluation.

Table 3: Patient reported local cutaneous adverse events with DIFFERIN® Gel DIFFERIN® (adapalene) Gel, 0.3% Related* Adverse Events Dry Skin Skin Discomfort Desquamation

Vehicle Gel

N=258

N=134

57 (22.1%) 36 (14%) 15 (5.8%) 4 (1.6%)

6 (4.5%) 2 (1.5%) 0 (0.0%) 0 (0.0%)

* Selected adverse events defined by investigator as Possibly, Probably or Definitely Related Related adverse events from the controlled clinical trial that occurred in greater than 1% of patients who used DIFFERIN® Gel, 0.3% once daily included: dry skin (14.0%), skin discomfort (5.8%), pruritus (1.9%), desquamation (1.6%), and sunburn (1.2%). The following selected adverse events occurred in less than 1% of patients: acne flare, contact dermatitis, eyelid edema, conjunctivitis, erythema, pruritus, skin discoloration, rash, and eczema.

In a one-year, open-label safety study of 551 patients with acne who received DIFFERIN® Gel, 0.3%, the pattern of adverse events was similar to the 12-week controlled study.

OVERDOSAGE: DIFFERIN® Gel, 0.3% is intended for topical use only. If the medication is applied excessively, no more rapid or better results will be obtained and marked redness, scaling, or skin discomfort may occur. Chronic ingestion of the drug may lead to the same side effects as those associated with excessive oral intake of vitamin A. Marketed by: GALDERMA LABORATORIES, L.P. Fort Worth, Texas 76177 USA Manufactured by: DPT Laboratories, Ltd. San Antonio, Texas 78215 USA GALDERMA is a registered trademark.

Revised: June 2007 325089-0607

Reference: 1. Thiboutot D, Pariser DM, Egan N, et al; Adapalene Study Group. Adapalene gel 0.3% for the treatment of acne vulgaris: a multicenter, randomized, double-blind, controlled, phase III trial. J Am Acad Dermatol. 2006;54:242-250.

Marketed by: GALDERMA LABORATORIES, L.P. References: 1. Thiboutot D, Arsonnaud S, Soto P. Efficacy and tolerability of adapalene 0.3% gel Fort Worth, Texas 76177 USA compared to tazarotene 0.1% gel in the treatment of acne vulgaris. J Drugs Dermatol. 2008;7 Manufactured by: (6)(suppl):S3-S10.

2. Data on file. Galderma Laboratories, L.P. A 3-week, single-center, randomized, DPT Laboratories, Ltd. investigator/evaluator-blinded, San Antonio, Texas 78215 USA bilateral (split-face) comparison, clinical study of adults 18 years of age GALDERMA is ahealthy registered and older with skintrademark.

(N=30).

Revised: June 2007 325089-0607 Differin andisGalderma aretrademark. registered trademarks.

Galderma a registered ©2007 Galderma Laboratories, L.P. ©2010 Galderma Laboratories, L.P. Galderma Laboratories, L.P. Galderma Laboratories, L.P. 14501 N. Freeway 14501 N. Freeway Fort Worth, TX 76177 Fort Worth, TX 76177 DIFF-088 Printed03/10 www.differin.com DIF-888 in USA 11/07

Dermatology Billing & Coding Accutane and 99214

By Inga Ellzey, MPA, RHIA, CDC

SDPA Members Only Content

professional development

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.

Ms. Ellzey, President/CEO of the Inga Ellzey Practice Group, Inc., in Casselberry, FL, is an expert on dermatology coding, documentation and reimbursement.

She has more than 35 years of experience in the field of dermatology and is the CEO and founder of two nationwide dermatology billing services.

You can reach her at the following number: (800) 318-3271, or email her at: inga@iepg.com.

Vol. 4, No. 2 SPRING 2010 39

Outside & Inside the 9 to 5...

We recently had the pleasure of interviewing Kasey Drapeau-D’Amato, MPAS, PA-C. Upon graduating PA school seven years ago, Kasey began working in dermatology at her current practice and was the first PA employed there. Over the past two years, she has been working outside her 9 to 5 behind the scenes to help improve the quality of the Distance Learning Initiative (DLI) and monitors the SDPA discussion forums daily to offer assistance to members. Kasey is currently serving as the SDPA Distance CME Committee Chairperson, whose responsibilities include oversight of the DLI. For this installment of the Outside & Inside the 9 to 5, Kasey shared with us her experience with and vision for the DLI .

professional development

Describe your current position as the SDPA Distance CME Committee Chairperson…

As the Chairperson for this new committee, I am responsible for developing, organizing, and facilitating quality educational sessions that do not take place at inperson conferences and meetings.

In addition to providing oversight of the DLI, I hope to encourage all SDPA members to complete the DLI to enhance their base of dermatology knowledge. I will work closely with the SDPA Board of Directors to establish certain benefits for those members who have achieved Diplomate status.

of each module of the DLI, I check the SDPA discussion forums multiple times per day to see if there are any members who are having difficulty with the program, and I work with the four other forum moderators to swiftly answer any questions. I also work with the SDPA Board of Directors to develop strategies to bring awareness of the DLI to the AAD and the dermatology community.

What is the greatest challenge of working in your SDPA position with the DLI? It can be

disappointing when a member gives up on a case after only a few minutes.

Kasey DrapeauD’Amato, MPAS, PA-C The DLI is designed to be a challenge and should not be considered as easy Why did you get involved with CME credits. The purpose of the DLI is to prove to this SDPA position? I have been working with the dermatology community that experienced a team of committed SDPA members for the last dermatology PAs have an understanding of couple years to complete the production of the complex dermatological conditions.

DLI. We have all spent many hours troubleshooting, developing test questions, beta testing, and The concern I hear most from SDPA members moderating the SDPA discussion forums. My goal is regarding the DLI is… They are frustrated to have a tool that establishes the knowledge and because it is too time consuming and they feel that commitment of experienced dermatology PAs. there is not enough support.

It is important to me that the DLI actually means something in the real world of dermatology.

What steps have been taken by the SDPA to

When working with the DLI, what does your typical week/month look like? Although Bethany Grubb, PA-C had to invest the most amount of time developing the DLI a couple years ago, it is still very time consuming today. Now that most of the technical issues have been worked out of the program, I am here for support. I read the feedback from members upon their completion

40 Journal of Dermatology for Physician Assistants

address these concerns about the DLI? The

DLI has been completely overhauled to eliminate program glitches. Each case has been evaluated by our technical support at the University of Texas Southwestern and everything is running smoothly.

There is feedback for the most difficult cases and discussions of many DLI cases, both available on the SDPA discussion forums.

Looking into the future, describe your ideal vision for the DLIâ&#x20AC;Ś The DLI is a seventy-hour

forums! We have five very dedicated moderators who are on the SDPA discussion forums almost twenty-four hours a day and are there to help if you are having trouble with the DLI. We have all been in your position and are willing to give support in any way that we can.

program for experienced dermatology PAs that awards Diplomate status at the completion of the course. This Diplomate status will set apart the most motivated and driven dermatology PAs from all the others. It will signify a true understanding of advanced dermatology. Dermatology PAs with Diplomate status will soon be recognized by the dermatology community as being experienced and truly dedicated to the field of dermatology.

Members of the AAD will no longer see Diplomate PAs as potential threats, but as true assets to their practices. This may result in certain benefits at the AAD Annual Meetings and within the dermatology community. Many other health care specialties will be modeling their advanced programs after our DLI program. The DLI is a very valuable tool for dermatology PAs and something we should all be very proud of completing. JJ

What feedback have you had from the AAD and the AAPA about the DLI? The AAD has recognized the DLI and has complimented the SDPA on such a thorough program. The AAPA has mentioned the DLI as one of the few specialized advanced training programs available to PAs.

What is your greatest source of inspiration?

My patients inspire me. They trust me with their heath and it is my duty to provide them with the best care possible. As a dermatology PA, I want every patient to leave my office impressed by my breadth of knowledge.

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Vol. 4, No. 2 SPRING 2010 41

professional development

My favorite bit of advice for SDPA members regarding the DLI isâ&#x20AC;Ś Use the SDPA discussion

Dermatology PA news & notes

From the Desk of...

Casey R. Croes, MPAS, PA-C SDPA Director at Large

Professionalism in the Workplace How do you define professionalism? Is it by dressing in business attire? Is it by addressing your patients by name while looking them in the eye?

Is it by offering the best care that is available each and every day? The Merriam-Webster dictionary defines professionalism as “the conduct, aims, or qualities that characterize or mark a profession or a professional person.” Society expects physicians to exhibit the highest degree of professionalism and I believe that as physician assistants we should hold ourselves to that same high standard as well.

Immediately after I learned how to put one foot in front of the other, my father taught me to give a firm handshake while looking a person in the eye.

Other than having a great sense of humor and being able to laugh at myself, this form of greeting people was at the top of his list of priorities. During college when I was considering my career path, I decided to join the Marine Corps for the challenge of a lifetime.

While in service, I learned a great deal about being professional and giving common courtesy to all.

I have learned that respect is earned. A patient who chooses to place his/her trust in your care, is giving you respect. I believe that you owe him/her the same respect by being prompt and apologizing when you are not. Why should your time be more important than your patient’s time? It is not and that apology goes far for a patient who has left work early, picked a child up from school, and rushed to make it to your office. By showing respect to your patient, you have set the tone for the rest of the visit and the patient will likely trust you with his/her care.

Casey R Croes, MPAS, PA-C is a Director at Large and Diplomate of the SDPA. She is a graduate of Chatham College and practices with The Dermatology Group in northern New Jersey.

42 Journal of Dermatology for Physician Assistants

I have also found that first impressions are truly lasting. As younger physician assistants enter into our profession, patients may have a difficult time taking instruction and advice from a provider who not only looks as young as, but may also be dressed like their teenager. As a health care provider, you should be dressed professionally. If your office permits scrubs and lab coats to be worn, they should be clean, pressed, and fit properly. If you can choose your own work attire, the same should hold true.

When I was in graduate school, I was shocked to hear one of our clinical coordinators say, “Oh, don’t worry, your lab coat will cover everything!” That is simply not true. If you want someone to respect you, show that you respect yourself and others by dressing professionally.

I believe that the best way to show appreciation for what you have been taught is to ‘pay it forward.’

When you volunteer to allow prospective students to shadow you or to precept students, you have an opportunity to model professionalism. This is your chance to show future colleagues how to treat patients with respect, how to dress professionally, and how to conduct themselves as professional health care providers. I cannot imagine a better way to ‘pay it forward.’ Another way to show appreciation is to promote our profession to others. You can do so by continuing to join such professional organizations as the AAPA, the SDPA, and your state PA organization. These organizations represent PAs in lobbying for beneficial legislation and improving our profession as a whole.

Now that you have my thoughts on professionalism, how do our mutual definitions measure up? Is there any room for improvement?

What can you do to ‘pay it forward’ and leave your mark on our profession? If you are interested in allowing prospective students to shadow you or even to serve as a PA student preceptor, please email Lauren Zajac, MHS, PA-C at lzajac@dermpa.org with your practice information. J

The Difference We Make Hope

When I was thinking of writing an article for dermatology As a dermatologist, I will always try to give hope since I practitioners about hope, I shared that idea with one of my believe that all people need and want hope. The person with dermatology colleagues who challenged me with these the thin melanoma could be focusing on a 5% chance of not comments; “Why do we need to read an article about hope? surviving five years and the person with a stage IV melanoma Oncologists should be the ones to write an article about could be focusing on a 94% chance of not surviving five hope and not to a dermatology audience. We rarely deal with years. Each patient can choose to look at it the other way. The life and death situations.” He certainly took the wind from my patient with a thin melanoma can adopt a hopeful attitude sails. I then thought of my typical day because of a 95% probability of living and how often I try to give hope to five years, and the patient “Even a patient with a stage IV beyond all of my patients, not just those who with the stage IV melanoma can find have a significant risk of dying. melanoma with a 94% chance hope in the 6% probability of living beyond five years. In each percentage I first looked up the definition of of dying before five years there lies hope for the individual. To hope - a belief in a positive outcome us there may appear to be a world related to events or circumstances can focus on his/her of difference between the two in one’s life. With this definition I 6% chance of survival.” percentage probabilities, but it is not realized that I give hope all the time. for us to judge.

I truly believe that everyone needs hope and everyone needs to have a I believe in looking at the glass hopeful, hope-filled life. It feels good to give hope. This hope as half full rather than looking at the glass as half empty, not can be expressed even in the most innocent situations and only in life in general, but especially with regard to patients’ certainly not only to the dying patient. conditions. It is not for me to judge the way someone looks at his/her life or how he/she interprets statistics. What they may As an example, I had just seen a fair skinned patient for consider as despair, I might consider hope. a regular skin exam with no previous history of skin cancer.

I told her that I saw no unusual spots on her skin and gave To the person with a stage IV melanoma with a her advice regarding sun protection. I invited her back in one seemingly dismal outlook I might say in warm and kind tones, year and then said, ”I am sure you will do well. Enjoy your day.”

“I know that you will be among the 6%.” The patient may Hope! “I am sure you will do well.” It was simple enough to say challenge me and ask how do I know this. My response would and was more likely than not a true statement. So why not be something like, ”It is my good feeling, my wish, my hope.” express it?

My words are honest and caring. Hopefully my words will be embraced.

Occasionally we may have to deal with the extreme opposite of a normal exam. I recently diagnosed a patient What about dermatologic situations that lie between the with a thin (0.3mm) melanoma. The likelihood of this normal skin exam and the malignant melanoma diagnosis? melanoma hurting this patient is quite small, probably less How often do you tell patients that they may have a basal than 5% in five years. Some may consider this to be a negative cell carcinoma that is not life threatening? This first cancer way of looking at statistics. Looking at it another way, the diagnosis may make them feel vulnerable to disease for the patient has a 95% chance of surviving five years, a positive, first time in their lives. Do they not need words of hope even more hopeful way of looking at statistics. Even a patient with for a basal cell carcinoma diagnosis? What about the teenager a stage IV melanoma with a 94% chance of dying before five or young adult who contracts HPV or herpes simplex virus? years can focus on his/her 6% chance of survival. What we as This typically is a lifelong infection. Do you not mention clinicians have to accept is that each patient determines how that there are approaches to lessen the expression of this he/she wishes to look at the information we provide and what disease and the likelihood of transmission? Not only are is significant to him/her. these educational opportunities expected of our profession but they also can be chances for us to express compassion, Dr. Steve Shama has been practicing general dermatology for 30 years understanding, and give hope. in Boston, Massachusetts. Dr. Shama has been a professional speaker And what about non-dermatologic conditions that your for 20 of those years and enjoys speaking on many topics, some of patients mention while you obtain a medical history? They which include: “Dealing With Difficult People and Looking Forward To may have been diagnosed with a disabling disease, cancer, It!” and “Rediscovering The Joys of Medicine and of Life.” He gives these or a chronic infection. I am sure that even though you are not talks at medical meetings and for the general public throughout the caring for their malady you will express hope. “I wish you well. country. He also travels to private offices to present his workshops and I am sure you will be fine.” talks. You can reach Dr. Shama at www.steveshama.com.

Vol. 4, No. 2 SPRING 2010 43

DERmatology pa news & notes

By Steven K. Shama, MD, MPH

DERmatology pa news & notes

In 1981 a dermatologist in San Francisco, Dr. Marcus Conant, identified the first cases of Kaposi’s sarcoma, lending to the eventual diagnosis of HIV/AIDS. Specific blood tests for HIV were not yet available at the time. Few patients survived but many clinicians gave patients hope that they would be the one to survive. I remember when I told one patient that he had AIDS, and that I truly believed he was going to be one of the ones that did well, he said, “From your mouth to God’s ears.” Patients know that you cannot predict how they will do.

And when it was “obvious” that the end was near, as it was for many of these brave patients, I let them know that I was there for them and that they would not be abandoned. I left them with hope.

There is a wonderful expression in medicine that goes back many years, “To cure sometimes, to relieve often, to comfort always.” I believe comfort is one wonderful way of giving hope. So when should we give hope? Always. We dispense it through soft, gentle, and embracing words, a gentle touch, a warm smile, being a good listener, and simply being with the patient.

“

It doesn’t take very much to give hope. We can always give hope and we should also keep ourselves open to receiving it. Hope is one of the most power forms of medicine that we can dispense every day with many beneficial effects and at no cost. May I suggest a standard prescription to leave with each patient:

Dispense: HOPE Sig: Take liberal amounts p.r.n.

Disp: Quantity sufficient for a lifetime No Substitution

J

Steven K. Shama, MD, MPH

”

Derm Quotes

My take home message is just don’t give up. There is a purpose for it… we have a voice and we are just a piece of the puzzle for the whole SDPA society.

Renee Block, MMS, PA-C, ISDPA President Speaking about the benefits of partnering with the SDPA to form a State Chapter.

Dermcast.tv – January 12th, 2010

?

It’s a matter of educating the physicians about who we are and what we do.

Search the Dermcast.tv ‘People’ section (clue #2 – quoted from an April 2009 interview) and tell us the full name of the PA who said this quote.

DERM QUOTES CONTEST - SDPA members with the correct answer (full name of the quoted PA) will be entered into a drawing to win one SDPA Conference registration fee, compliments of the JDPA. The drawing will take place at this year’s inaugural SDPA Summer Dermatology Conference in Chicago; the winning member does not need to be present to claim prize. Answers must be entered onto a fully completed JDPA Reader Survey along with your SDPA member number by June 9th, 2010.

For every completed survey the JDPA will donate $1 to the Camp Discovery Endowment Fund.

Please visit www.jdpa.org/survey to submit your answer. Limit one entry per member. Winning SDPA member can choose the SDPA Conference of his/her choice to apply the complimentary SDPA Conference registration fee (valid for 1 year from date of drawing). Best of Luck!

44 Journal of Dermatology for Physician Assistants

Supervising Physician CORNER The Foundation of a Good PA/SP Relationship Common Values and Respect

By Jacki Kment, MPAS, PA-C and Margaret Kontras Sutton, MD

According to Dr. Sutton:

Taking time to reflect on the qualities that make my The PAs in our practice have proven themselves relationship with my supervising physician (SP) strong has to be extremely valuable members of our team on given me renewed cause to be grateful for what I have. I multiple levels. By augmenting our two dermatologists have been a PA for sixteen years and have been working in with PAs, we have been able to effectively serve more dermatology with my current SP, Dr. Sutton, for thirteen patients and cut down our wait time for appointments. years. I have been privileged to not only be the first PA in The addition of PAs has also increased the amount of the practice, but also the first dermatology PA in Lincoln, information/knowledge that we share at our regular Nebraska and the fourth dermatology PA in the entire state. office meetings. Having extra providers has allowed us to perform additional administrative tasks such Dr. Sutton allows autonomy of practice, which I as composing patient education consider to be one of her greatest material and developing strengths in working with PAs. We protocols. share a mutual trust and respect for one another. She motivates me to The PA/SP relationship strive for excellence, whether in caris based on trust and constant ing for our patients, taking thorough communication. In most cases and accurate chart notes, promoting the PA has been trained by the team building amongst staff memSP, therefore the physician should bers, or striving for overall personal have a good understanding of wellness. Dr. Sutton encourages me the PAâ&#x20AC;&#x2122;s level of competency. to pursue continued medical educaTraining should not be limited tion, participate in journal clubs, only to those experiences obtained and learn new skills, all in an effort within the practice setting, since Jacki Kment, MPAS, PA-C (left) to provide a wider variety of services there are many situations that are and Margaret Kontras Sutton, MD to our patients. The secret to a great not commonly presented in most PA/SP relationship for us has not only been about respecting clinics. At our practice we expect PAs to spend time one another, but also valuing what the other individual has outside of the clinic reading, attending conferences, to offer and showing gratitude toward one another. and becoming familiar with things that may not be presenting in our clinic. By working side by side with From the beginning, I knew that Dr. Sutton valued our PAs, we physicians learn about our PAâ&#x20AC;&#x2122;s demeanor, family life. This became even more apparent to me after practice habits, personality, and style in dealing with I married and began having children. She allowed me to patients and staff. make schedule changes in order to spend more time with my children and be a mom.

I think that the PA/SP relationship is based on mutual respect. Just as in a marriage, the relationship New PAs often ask how to determine what type of SP cannot be sustained without respect going both ways. they would work best with; my advice is to work with a I try to include Jacki and the other PAs in many of the SP who you share common values with and respect. From operational decisions in the clinic. I deeply value her experience, I have learned that relying on my intuition in opinion and try to be a responsive listener when she making such decisions has served me well. I am so grateful has concerns. J to have found a SP with whom I am well matched in terms of personality, morals, beliefs, values, and practice habits.

Jacki Kment, MPAS, PA-C (left) graduated from PA school at the University of Osteopathic Medicine and Health Sciences in Des Moines, Iowa in 1994 and later received her Master of Physician Assistant Studies degree specializing in Dermatology from the University of Nebraska Medical Center. She began her career working as a family practice physician assistant for the Omaha Indian Tribe of Nebraska. In 1997 she joined Sutton Ryan Dermatology in Lincoln, Nebraska.

Margaret Kontras Sutton, MD (right) graduated from the University of Nebraska College of Medicine in 1979. After a year of family practice residency at Lincoln Medical Educational Foundation, she completed her dermatology residency at Creighton University/University of Nebraska Dermatology Program in 1984 and became Board Certified in dermatology in 1985. Dr. Sutton has enjoyed practicing dermatology in Lincoln, Nebraska for over twenty-five years.

Vol. 4, No. 2 SPRING 2010 45

DERmatology pa news & notes

According to Jacki:

Professional Opportunities and Development

Advertiser INDE X

CME 2010 FREE of charge for PAs

OrthoDermatologics – Retin-A Micro... Pages 2, 3 Ranbaxy – Kenalog Spray...................Pages 7, 8 Medicis – Solodyn.......................... Pages 11, 12 Coria – Atralin................................Pages 25, 26 Galderma – Epiduo........................Pages 31, 32 Galderma – Differin 0.3.................Pages 37, 38 Galderma – Clobex Spray...............Pages 47, 48 For more information on advertising opportunities in the JDPA, please log on to www.jdpa.org

Portland, OR: Saturday, April 10 Atlanta, GA: Saturday, June 5

The International Hyperhidrosis Society

in partnership with Eastern Virginia Medical School, is offering two outstanding opportunities for all healthcare providers to get their hyperhidrosis diagnosis, treatment, and practice management skills into top form.

Advanced Approach to Hyperhidrosis Diagnosis,Treatment and Practice Integration offers attendees dynamic, live-patient training from world leaders in hyperhidrosis management. This educational activity has been approved for 6 AMA PRA Category 1 CreditsTM. The itinerary is a morning lecture and discussion that is focused on hyperhidrosis basics, including topical therapies, iontophoresis, injection treatments of axillary and non axillary hyperhidrosis, and incorporating office staff into patient treatment and management.

The afternoon session is devoted to live-patient instruction. Local physicians, alongside members of the expert panel, will provide hyperhidrosis treatment with Botox or iontophoresis, as necessary, to their patient volunteers. The demonstrations will be done in small group settings so all participants will experience optimal learning. Join Us!

Go to our website to register www.SweatHelp.org

Get in gear.

You’re a creative, innovative professional who’s already mastered some of your field’s most challenging terrain. Now you’re ready to shift into a whole new gear. So make tracks for CHW Medical Foundation in Northern California where you'll discover a working environment, career opportunities and recreational amenities that are more than worth the ride.

Excellent Dermatology PA Opportunity with Mercy Medical Group In Sacramento, CA!

Mercy Medical Group (www.mymercymedgroup.org), a service of CHW Medical Foundation, is a large multi-specialty practice with over 200 physicians and 11 clinic locations. We strive to offer our patients a full scope of outstanding health care services. We're currently looking to add a Physician Assistant to our busy Dermatology Department. This opportunity is full time with no call or inpatient responsibilities. The selected candidate will see patients in a general medical and surgical dermatology practice. Dermatology experience is required.

We offer an excellent compensation and benefits package, including a very desirable retirement plan. CHWMF is affiliated with Catholic Healthcare West, one of the leading healthcare systems in the country.

You'll also benefit from residing in Sacramento which offers affordable housing, outstanding schools, lots of cultural and recreational options and a great location that's just a short drive from Lake Tahoe and the San Francisco Bay Area.

Contact Arlene Wong, Sr. Physician Recruiter arlene.wong@chw.edu P: (916) 733-5774. F: (916) 859-1612. www.mymercymedicalgroup.org

46 Journal of Dermatology for Physician Assistants

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Vol. 4, No. 2 SPRING 2010 47

For moderate to severe plaque psoriasis

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www.psoriasispro.com 48 Journal of Dermatology for Physician Assistants