Pearls From the SDPA 17th Annual Fall Dermatology Conference

Physician assistants from all over the country came to Scottsdale, AZ, for the Society of Dermatology Physician Assistants (SDPA) 17th Annual Fall Dermatology Conference. The conference, held from November 20 through November 24, included presentations on pearls for performing cosmetic procedures, workshops for improving surgical techniques, and updates in various fields, including pediatric dermatology, management of psoriasis, and more. Below are some highlights from presentations at the conference.

Pearls for Injecting Lips
Ilanit Samuels, PA-C, presented “Lips: Do’s and Don’ts,” which covered best practices for all providers who perform lip injections.¹ 

Considerations for correct lip proportions include ethnicity, gender, and patient’s desires, said Ms Samuels. She emphasized the importance of talking to patients about their expectations and desires prior to performing lip injections. In addition, she recommended having photos of different lip options available. 

According to Ms Samuels, it is much easier to augment then to change the shape of the lips. She recommended having patients bring in old photos of what they looked like when they were younger in addition to discussing their expectations. She also stressed the importance of the chin profile and lip projection. The upper lip should project more than the bottom lip, she said, adding that if patients want to go bigger with their lips, she recommends elongating the chin to make sure everything looked proportional.

When performing injections, she inverts the lip for two reasons: to see the mucosae, and to make sure the filler will not migrate. Ms Samuels recommended injecting fillers slowly to avoid complications and reduce bruising. Prior to injection, she uses ice for patient’s comfort and vasoconstriction, which also helps with bruising. Furthermore, Ms Samuels recommended injecting the lips last, changing gloves and needle, and using antiseptic to clean the lips.

There is no right or wrong way to inject fillers, she said. In her practice, Ms Samuels usually starts with the vermillion border, followed by the body because it requires less filler for the lips. She then injects the cupids bow, which is the most painful area to do, and ends with the philtral columns. Providers should watch videos of physicians performing injections to learn and figure out the best method for them.

To reduce potential complications, Ms Samuels recommended asking about lidocaine allergies, performing aseptic prep, and talking to patients about disease and immunosuppressive medications. She also recommended prophylactic valacyclovir for patients with a history of herpes simplex virus. 

For preventing bruises, Ms Samuels provides patients with a list of things to avoid 7 to 10 days before a procedure, including fish oil and alcohol. She discussed pulse dye light therapy as an option for cutting healing time of post-filler bruising from 3 weeks to about 24 to 48 hours. While topical arnica/bromelain extract does not address bruising, Ms Samuels noted that she has used it to help with redness.

Immediate swelling is usually caused by extrusion force, she noted. However, latent swelling, which occurs 2 to 5 months later, is usually caused by an immunologic trigger such as the flu or a vaccine. This usually resolves in about 6 weeks, she added.

She recommended treating swelling with prednisone, hyaluronidase, doxycycline, and colchicine. For vascular compromise, she recommended hyaluronidase, warm compress, and daily follow up with the patient. For patients with vascular compromise, Ms Samuels suggested providers give their cell phone number for patients to call with questions or for emergencies.

Addressing Burnout Head On
During her presentation, “What I Didn’t Learn In Residency,” Jennifer Holman, MD, discussed tips for preventing burnout.²         

Dr Holman recommended thinking about burnout as addressing a depleted bank account and not a dead battery. It requires constant maintenance and awareness of how much is available. There are 3 accounts:

• Physical (exercise, nutrition, and sleep);
• Emotional (relationships); and
• Spiritual (sense of purpose and volunteering).

The symptoms of burnout are exhaustion, depersonalization, and lack of efficacy, which can be doubting or experiencing an existential crisis in work, said Dr Holman. Burnout is caused by working in a high-stress and difficult job and can also be caused by specifics of the job or life outside of work, she explained. For example, having bad work relationships with a supervising physician or staff can cause burnout, as well as call schedules, administrative duties, and electronic medical records (EHR).

Other signs of burnout include saying phrases like I cannot go on much longer or I just need to put my head down and get through the day.

“If you are saying these things, you are heading towards burnout and need to change something,” said Dr Holman. It is an ongoing dilemma that will need ongoing strategies, she added.

One strategy Dr Holman recommended was becoming a master of the EHR system the office uses. Be a power user, she said, and know as much as you can so it becomes a tool and not a burden.

Additionally, know what needs to be documented, use scribes, and learn to use the templates can help save time and make the office more effective. It will make your life and your staff’s lives easier, she said. Dr Holman also recommended batch processing in order to reduce time spent during paperwork throughout the day.

Team huddles are critical, said Dr Holman. These can help address any in-practice issues and help solve potential problems. She recommended thanking the team in advance, especially on days that look rough. In addition, it is important to delegate work carefully and know your team’s strengths.

Out of the office, Dr Holman uses a life calendar that tracks all of her children’s activities as well as her workout routine, breaks, and vacations, even if she does not know where she is travelling. She also actively follows the “3Ds” in her marriage: dialogue daily, date weekly, and depart quarterly (at least a night to have time away from the children). Bucket lists help her stay productive and provide a source of inspiration as something to look forward to. Dr Holman also encouraged providers to take all of their vacation time to unwind away from their practice and the stress of everyday life. Likewise, providers should create rituals for when they leave work to go home, using the analogy of Mr Rogers taking his suit jacket and dress off to change into his characteristic cardigan and sneakers when he walked into the door.

Understanding yourself is crucial and an ongoing process, she added. She recommended the book The Road Back to You by Ian Morgan Cron. “You are never going to be a good provider if you are heading towards burnout,” Dr Holman concluded. 

Recommendation for Patients Before Patch Testing
Patch testing is an incredibly helpful tool for identifying allergens in patients with allergic contact dermatitis. However, patch testing may not be feasible or necessary for every patient. Rajani Katta, MD, shared her recommendations for these patients.³

Dr Katta said she asks patients about their skin care routine and what products they use on their face, hair, and body. It is not enough to just tell patients to stop using certain products, said Dr Katta, adding that she is very specific with what she recommends to each patient. “Early on I was not as specific,” she said. “However, there are so many options available now that is can be very difficult for patients to find one that does not have their allergen.” She has lists of products patients can use on her website and updates this list every year.

One reason it can be difficult for patients to find a product without allergens is because there is no legal definition for the term hypoallergenic. These products can still have allergens, and sometimes they even have more, said Dr Katta. Fragrance-free is also another confusing term, because a product can contain fragrances as long as it is not used as one, she added. Patients will think a product that is labeled all-natural, hypoallergenic, and/or fragrance-free is safe, noted Dr Katta, but these can still contain known allergens. In addition, Dr Katta stated she rarely recommended baby products for her older patients because these are sometimes worse that adult products.

Nickel is still the number one allergen and can be leached out by sweating. After nickel, the top 15 allergens include fragrances and other preservatives. There is a difference between no fragrance labeling and fragrance-free labelling, Dr Katta said, and there are at least 127 fragrance additives.

Importantly, Dr Katta noted, no product is nonallergenic. When she selects “least allergenic” products to recommend to patients, she looks for ones that have fewer than 50 allergens within the ingredient list. It is important to recognize that less allergenic options are not nonallergenic, she said, and to discuss this with patients as every product has some type of allergen. Many patients will do better if they follow these specific recommendations and understand these differences in labels, she said.

            The presentation covered the management of eyelid dermatitis, cheilitis, hand eczema, facial dermatitis, and generalized dermatitis. In addition, she recommended several products that have fewer allergens and may be safe for patients with allergic contact dermatitis. For the full story, visit What to Recommend Before Patch Testing and Dr Katta’s website.

References

1. Samuels I. Lips: Do’s and Don’ts. Presented at: SDPA 17th Annual Fall Dermatology Conference; November 20, 2019; Scottsdale, AZ.

2. Holman J. What I Didn’t Learn in Residency. Presented at: SDPA 17th Annual Fall Dermatology Conference; November 23, 2019; Scottsdale, AZ.

3. Katta R. Before the Patch Test: What to Recommend and Avoid in Suspected Allergic Contact Dermatitis. Presented at: SDPA 17th Annual Fall Dermatology Conference; November 22, 2019; Scottsdale, AZ.