CME Recap: SDPA Summer Dermatology Conference

Continuing medical education is beginning to resume as in-person events. The Society of Dermatology Physician Assistants (SDPA) Summer Dermatology Conference 2021 took place in Chicago, IL, from July 22 to July 25. The American Academy of Dermatology Summer Meeting 2021 followed a few weeks later in Tampa, FL, on August 5 to August 8.

Keep reading for more insights from the SDPA’s conference, and visit the-dermatologist.com for more conference coverage from the AAD Summer Meeting 2021!

The Good, the Bad, and the Ugly of Nails with Dr Glick¹
Nails can be challenging for even seasoned dermatology providers, but a familiarity with “the good, the bad, and the ugly” of nail presentations can help improve diagnosis and treatment. In his session, Brad Glick, DO, MPH, FAOCD, provided attendees with new confidence in treating nails in their daily practice.

The good of nails is that anatomy can provide clues to a diagnosis. Growth, for example, can be either accelerated or reduced, signaling psoriasis or onychomycosis, respectively. In addition, the nail matrix anatomy can help differentiate between diagnoses. “Remember that the undersurface of the nail plate is formed by the distal matrix, the midportion is from the midmatrix, and the proximal portion of the nail matrix form the top of the nail plate. That’s really important [to remember] in evaluating longitudinal melanonychia and other pigmented disorders,” explained Dr Glick. Melanocytes are found in the distal matrix but not in the nail bed, thus pigment in the nail bed is not typically melanocytic in origin.

Site of nail damage is critical to identify. The proximal matrix is affected by Beau’s lines, pitting, longitudinal riding and fissuring, and trachyonychia. However, if there is involvement of the proximal and distal matrices, then onychomadesis, koilonychia, and nail thinning may be diagnoses. The nail bed can be affected by onycholysis, subungual hyperkeratosis, apparent leukonychia, and splinter hemorrhages.

The bad of nails is the presentation of diseases. Dr Glick discussed the various presentations of nail conditions and signs, emphasizing for many of the presentations to think systemic disease if multiple digits show nail abnormalities. Medications can also induce nail changes, said Dr Glick. In particular, chemotherapeutic agents are often at fault.

The nails also offer clues to dermatologic diseases. Psoriasis, for example, often affects multiple nails, particularly finger nails, showing irregular pitting, salmon patch/oil drop signs, and onycholysis with erythematous borders. Parakeratosis pustulosa, however, is psoriasiform lesions but tends to be exclusive to children and limited to one nail. Lichen planus is rare, with nail presentation occurring in up to 10% of patients, and shows onychorrhexis, plate thinning, and dorsal pterygium and affects several nails.

“The ugly of the nail unit are malignancies,” said Dr Glick. Nail unit malignancies can be easy to miss because of some diagnostic conundrums, but he recommended that “any non-healing lesion impacting the functional nail unit should get a biopsy.” Providers should follow the ABCDEFs of melanoma identification.

Strategies for Healing Burnout²
Many medical providers are facing growing feelings of burnout in their practice. Abby Jacobson, MS, PA-C, offered strategies to manage and mitigate burnout.

“Health care provider burnout has been shown in the literature to lead to depression, provider suicide, and increased rates of substance abuse,” said Jacobson. “It’s also been associated with poorer patient outcomes, increased medical error, decreased quality of care, and also is an independent factor in physician malpractice suits.”

Signs of burnout include tiredness that does not respond to adequate rest; feelings of helplessness, trapped, or defeated; increased cynical or negative attitude; decreased productivity, interest, and satisfaction; and changes in appetite or sleep habits. Providers can check their level of professional burnout by using the validated Maslach Burnout Inventory, and if experiencing burnout, providers should not lie to themselves and try to self-trick into loving their job. “You would not tell your patient ‘just lie to yourself long enough, it’s ok not to validate your feelings.’ That’s not healthy,” said Jacobson.

Options to fight against professional burnout start with looking at work-life balance. Providers should look into negotiating less hours or looking at adding additional resources such as more staff to decrease workload. Making personal health a priority should also be a key focus; both physical health and mental health should be considered. Jacobson said another option is to look into changes in career or work environment, or even to try a side gig, which can serve as a creative outlet or an exit strategy.

Career changes can include education (faculty, program director, dean), business (hospital or medical administration, practice owner) medical science liaison, and pharmaceutical industry (medical director, marketing, pharmacovigilance, medical information).

Transgender Medicine: What Derms Should Know³
Tiffany Pierce, PA-C, discussed what dermatology providers should know when it comes to transgender medicine. Her presentation highlighted the foundational knowledge necessary for providing care, examples of procedures or conditions seen in the dermatology practice, and resources to improve education.

“When I started doing my research for the presentation, I realized I could, in 1 year, read about every single paper on transgender medicine published 10 or 15 years ago, because there were maybe 15 or 30 papers,” started Pierce. She highlighted that the literature has skyrocketed within the past few years, noting a major shift toward inclusive and accepting care. Approximately 1.4 million people (0.6%) of the population in the United States identify as transgender, though some studies estimate the number may be as high as 1.6%.

Providers should work to master basic terminology for patient groups, including transgender (person whose gender identity of expression is different from their sex assigned at birth), cisgender (person whose sex assigned at birth is the same as their gender identify or expression), gender expression (person’s outward presentation of their gender (eg, how they dress), gender identity (person’s internal understanding of their own gender), intersex (umbrella term for unique variations in reproductive or sex anatomy, including chromosomes, genitals, and internal organs), and sexual identity (person’s internal understanding of their sexual preference).

Further, providers should be careful not to mistakenly assume a patient’s sexual orientation based on their gender identity. In addition, physicians should not think of gender as binary, because “it is scientifically inaccurate to use ‘female brain’ or ‘male brain,” said Pierce.

“Pronouns are a really, really, really big deal,” said Pierce. She added that including identification options such as transgender, intersex, and other in addition to male and female could potentially lead to higher patient satisfaction. “Dermatology is well-suited to make significant improvements in the lives of transgender patients,” she said. “Just call the people how they want—you may never understand how that can make that person feel."

Transgender considerations in dermatology include changes in hair and sebum production secondary to hormone therapy, and pre- and postoperative interventions for gender-confirming surgeries, and aesthetic techniques for rejuvenation, among others. Dermatologists should also note that transgender patients may show unique presentations of routine skin conditions. On the horizon, practitioners can look for increased awareness, such as publications, organizational support for transgender rights, and updates to the iPLEDGE program to include transgender standards.

Treating the Scalp and Hair in Skin of Color⁴
Heather Woolery-Lloyd, MD, emphasized the need for dermatologists to familiarize themselves with hair practices for patients with skin of color. “You really need to understand hairstyling methods, because they significantly contribute to the hair loss and scalp disorders that we see in our patients,” said Dr Woolery-Lloyd. Unprocessed hair styles include afros, locs, twists, and braiding with either cornrows or multitufted braids. Additional styles include extensions, hot combing, chemical relaxers, and keratin.

“The only hair style that’s not associated with any type of hair loss is the afro,” Dr Woolery-Lloyd explained. “Afros are very popular right now, which is wonderful from a dermatologic standpoint because really they’re the best hair style that offers the healthiest hair.” However, this means that other hair styles have been associated with hair loss.

Extensions are also popular and can be either braiding or gluing hair onto existing hair or cap. A cap is what a patient may refer to as a “sew in,” in which cornrows are applied to the scalp and the extensions are sewn onto the scalp. Locks are a natural hairstyle in which the hair is not combed and forms knots spontaneously, though smaller locks can be created by twisting hair. Cornrows and multitufted braiding are also well-known styles. These take hours to create and last a while, though stylists need to be careful not to place too much tension in the braids.

“Again, in a culturally sensitive way, you can tell your patients to just avoid tight styles because that can contribute to the loss of edges,” said Dr Woolery-Lloyd. “Our patients won’t use the term traction alopecia. They’ll say ‘I’m losing my edges,’ which is the frontal hairline,” she explained further. Prevention is key when it comes to traction hair loss, and looser styles should be encouraged.

Chemical relaxers, while not as popular a tool as in the past, are made with either lye (sodium hydroxide) or no-lye (guanidine hydroxide). Both break down disulphide and create more brittle hair prone to breakage, and these products can also cause chemical burns. Keratin is another product that typically uses some level of formaldehyde, and the FDA is now working to regulate these products and their labels. Lastly, hot combing is another technique to straighten the hair. While it has not been proven, hot combing is thought to be a cause of scarring alopecia in African American women.

Dr Woolery-Lloyd discussed central centrifugal cicatricial (“scar- ring”) alopecia, nothing that it is important to set realistic expectations with patients. It is necessary to explain that the first goal of treatment is to prevent further hair loss because CCCA is a progressive condition. The second goal is the possible growth of new hair, with 10% to 30% regrowth considered a clinical success depending on the stage.

References
1. Glick B. Nails. Presented at: Society of Dermatology Physician Assistants Annual Summer Dermatology Conference 2021; July 22-25, 2021; Chicago, IL.
2. Jacobson A. Healing healthcare burnout. Presented at: Society of Dermatology Physician Assistants Annual Summer Dermatology Conference 2021; July 22-25, 2021; Chicago, IL.
3. Pierce T. Transgender medicine. Presented at: Society of Dermatology Physician Assistants Annual Summer Dermatology Conference 2021; July 22-25, 2021; Chicago, IL.
4. Woolery-Lloyd H. Skin of color. Presented at: Society of Dermatology Physician Assistants Annual Summer Dermatology Conference 2021; July 22-25, 2021; Chicago, IL.