From One Teacher to Another: SDPA Fall Conference Preview

The Society of Dermatology Physician Assistants (SDPA) is gearing up for its 20th Annual Fall Dermatology Conference in Miami, FL, November 17–20, 2022, with an impressive list of faculty slated to lecture on trends, best practices, and other updates in dermatology. SDPA member and professor Sarah B.W. Patton, MSHS, PA-C, recently spoke with renowned dermatologist and expert in allergy patch testing, psoriasis, and eczema, Matthew Zirwas, MD, about the presentations he will deliver on Saturday, November 19. An excerpt from the interview is below.

Sarah Patton: SDPA conferences offer a great opportunity to pick up nuggets of wisdom to share with my patients and students. When I teach atopic dermatitis (AD), I use a quote from one of your presentations. You said AD is “best defined as pruritic and chronic in a patient with a family history of atopy and with presentation sparing the groin.” I think this is a perfectly condensed explanation of AD. Can you describe why you choose to lecture at SDPA conferences?
Matthew Zirwas: The topics that SDPA asks me to lecture about are always relevant and allow me to be clinically practical. What can I tell practitioners that will help them provide better care next week? I can discuss the day-to-day challenges we deal with and offer solutions or diff erent ways to approach cases. Also, as a teacher, who you are teaching is as important as what you are teaching. The mindset of the people who come to SDPA conferences is a desire to grow as providers, which is what I am constantly doing for myself, trying to grow.

Sarah Patton: The conditions you specialize in—contact dermatitis, AD, and all the itches—take a lot of time, meaning the time you need to spend on the education piece with your patients. How have you fi gured out how to balance that with the way in which medicine is currently delivered with many of us crunched for time?
Matthew Zirwas: Five years ago, I would have answered that by saying, “It is hard. For a lot of these patients, I need a 30-minute visit, so I try to schedule double appointments or have the patient come back.” This has changed signifi cantly because of what I have learned from dupilumab. Figuring out all the patient’s triggers for their dermatitis and itch, including lifestyle issues, dietary issues, work issues, and stress, as well as getting patients to address all these issues, was important (and still has a role). But for patients who have AD, their skin is looking for something, anything to react to, essentially taking the position “the world is dangerous, and I am going to react to anything I can find.”

Sarah Patton: It is like the fight-or-flight response of the skin.
Matthew Zirwas: That is the perfect way to put it. Think about it as nervous skin that flies off the handle at anything. Even if we identify the 6 issues with that particular patient—change this with your diet, change the soap you are using, change the moisturizer you are using, do this with your laundry, get a humidifier, get a water softener—they might get better for 3 months and then 3 months later, their body is going to find other stuff to react to and they begin chasing their tail. This is what I saw repeatedly until we got our first therapy that made patients’ skin stop being so nervous. I have changed from going into depth about eliminating triggers to talking with patients about ways of getting their bodies not to overreact to the environment.

I educate patients about medications, such as biologics and Janus kinase (JAK) inhibitors, that work so well that they can continue living their lives and their skin will not overreact anymore. When they start talking about what triggers their eczema, I agree that there are environmental and/or dietary triggers, but many of them are unavoidable, such as their own sweat, air pollution, pollen in the air, clothing touching their skin, and laundry detergent residual in their clothing. And even if we identify and eliminate all avoidable triggers, their body will just find new things to react against.

I also try to get patients to be less reactive against their environment. First, I recommend a probiotic for all my patients with AD because evidence is now conclusive that probiotics help AD, presumably because the intestinal microbiome plays a significant role in immune regulation. Second, L-histidine and oral phytoceramides are oral supplements with very good evidence that they improve the skin’s resistance to the environment by improving the skin barrier. In my experience, these supplements and probiotics help, but they do not have anything like the efficacy of the systemic and new topical drugs we have available. I am most commonly using the probiotics and supplements in conjunction with prescription therapy.

I emphasize to patients that the highly effective topical and systemic treatments we have now are completely different from previous options, whether we are talking about a highly targeted biologic or a broader spectrum topical or oral JAK inhibitor, or other new treatments. Topical tapinarof, which is currently approved for psoriasis and is in trials for AD, has been stunning. If I have relatively free rein in terms of what I can prescribe for people, it is hard for me to imagine someone I cannot help. Now, I truly have treatments that are efficacious and safe in the long term.

Sarah Patton: It is my fourth year teaching physician assistant (PA) students, and I have many who are interested in dermatology. Due to the extensive time it takes to train a PA in dermatology, most dermatologists do not want a new graduate, yet everyone needs to learn. What advice would you give to a graduating PA student who is interested in dermatology but having difficulty breaking into the field?
Matthew Zirwas: My first piece of advice would be to attend as many dermatology meetings as possible, both to learn and network. If they cannot get into dermatology and they really want to, the 2 things I have seen work are to sign a 5-year contract so the dermatologist knows that the PA is not going to leave and to add a prorated buyout where the PA would be required to pay the practice if they do leave before their contract expires. I have also seen the option of having a PA work as a medical assistant (MA) for 6 months. In this role, they would be used more as an MA initially to learn how the dermatologist practices and transition into a PA role over time.

Sarah Patton: Is it like an apprenticeship?
Matthew Zirwas: Yes. Although they are only getting paid, for example, $20/hour, they are really getting paid $50/hour because of the value of the training. At the end of 6 months, the practice can hire this person as a PA or, at the very least, the PA can then market themselves as having 6 months of training in dermatology.

Sarah Patton: Although I totally understand why physicians want PAs already trained, I always see it from a different side in that every dermatologist I have met practices differently. Ideally, the way I see being a PA is taking the best from the providers who train you and making it your own.
Matthew Zirwas: I could not agree more. When I hired a group of PAs, I trained them for our practice for about 6 months, then they went to work with their supervising physicians. I got calls from the supervising physicians saying, “They saw somebody with X and did Y. That is not what I do. I thought you said they were trained?” Well, I had taught them to do X when they saw Y. It was not that they had not been trained, it was just that what I had taught them was different from what their new supervisor did. This showed me the importance of the PA and the supervising physician knowing each other’s practice habits. Even if someone is already trained and experienced, in the ideal situation they should still shadow a new supervising physician for a month or longer.

At SDPA’s conference in Miami, FL, Dr Zirwas will present on “New & Emerging Treatments for Atopic Dermatitis” and serve on a panel titled “Kodachromes.” Visit https://tinyurl.com/yc39rk2y for additional information and to register for the conference.