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July/August Focus | SUMMER SUN AND SKIN
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SUMMER SKIN HEALTH |
It's About More Than Sunscreen...
It's that time of year again when our patients are outside enjoying the beautiful weather. As a Dermatology PA, I remind my patients to enjoy the outdoors while also protecting their skin. Frequent sunburns and suntans increase their risk of skin cancer, and I remind them to use sun protection strategies and to always be mindful of their sunlight exposure. 

Sunscreen 101 
Many of my patients will apply sunscreen every morning, but they will forget to reapply throughout the day. I remind them that sunscreen is chemically unstable and once applied to the skin, does not last more than a couple hours. I remind them to reapply sunscreen every 2 hours if they are going to be in direct sunlight, and to apply generously. If they prefer to use a spray, I advise them to spray the area very close to the skin, then rub in the product to ensure even distribution. Patients with short hair should apply sunscreen to their scalp and ears, or wear a wide brimmed hat.
 
Which Sunscreen is Best? 
I get this question frequently. I tell my patients that the brand of sunscreen is not as important as the active ingredients. Most sunscreens sold at the local drug store contain recommended ingredients and are reliable. There are two main types of ingredients: physical sunscreen and chemical sunscreen. 
 
The two main mineral ingredients in sunscreens that provide physical protection from sun radiation are Zinc Oxide and Titanium Dioxide. These ingredients provide a whitish coating on the surface of the skin that reflects the rays and prevents them from penetrating the skin. These ingredients are great for babies, children, and adults with sensitive skin. Because these products provide a physical blocker from the sun, they also prevent browning of the skin and darkening of "sun spots".  I also recommend these ingredients for patients with Melasma as they can prevent further darkening of the skin. Sunscreens with only these ingredients (containing no chemical sunscreens) are great for the face and chest, as they tend to be much less irritating to the skin. 
 
Chemical sunscreens and stabilizers include Homosalate, Meradimate, Octinoxate, Octocrylene, Avobenzone, and Oxybenzone. These products chemically alter the skin's reaction to sun radiation and prevent burning of the skin. They are also stabilizers that help the sunscreen last longer (up to 5 hours). They can prevent a sunburn, but they do not work as well as physical sun blockers at preventing the browning of the skin. These chemicals can also be very irritating and can cause rashes in some patients with sensitive skin. 
 
Treating Acne in the Summer 
Acne medications can make young patients more sun sensitive, so it's imperative that you treat cautiously and counsel patients on their medications. Oral doxycycline, and to a lesser extent minocycline, can make patients very sensitive to the sun, and can cause blistering sunburns if fair-skinned patients are not careful outdoors. Since the sun sensitivity of doxycycline is dose dependent, consider decreasing the dose in the summer if a patient is not compliant with sun protection or is fair-skinned.  I will usually decrease the dose to 40-75mg per day as a once daily dose in the summer, then increase them to 100-200mg as once or twice daily dosing in the winter. If a patient is going to a sunny vacation spot for a week or two, I have them discontinue their oral antibiotic 3-5 days ahead of time, and resume it when they return. Topical acne medications can also cause sun sensitivity where it is applied. Topical retinoids (tretinoin, adapalene, tazarotene) slough off the skin at an accelerated rate and promote new skin formation, but the newer skin does not have the protective properties from the sun. It's important to remind patients that they can continue to use retinoids in the summer, but to increase photoprotection and to reapply regularly. If a patient is going to a sunny vacation spot and does not feel that they can protect their skin, I will also have them discontinue the topical retinoid 3-5 days ahead of time, and resume it when they return.
 
Rhus Dermatitis - Plant-Based Rashes
Poison Ivy/Oak/Sumac and other plant-based dermatitis are common in the summer when patients are spending time outside. Itching typically starts a 1-5 days after exposure to the plant, followed by a rash that is erythematous, vesicular, bullous, and/or edematous. It is usually well defined, but may have skip-areas of clear skin. Remember that Rhus Dermatitis can significantly worsen before it improves, and a patient may worsen or get new areas of involvement up to a couple weeks after the initial exposure. Even if a patient is only mildly itchy upon presentation, they may still need oral prednisone if the condition worsens. I recommend topical clobetasol or fluocinonide cream twice a day for 2 weeks to the skin. If treating with oral prednisone, do not make the mistake of prescribing too short of a course. Rhus Dermatitis can linger for weeks, so I usually start prednisone at 40-60mg per day and taper over 12-15 days. The plant sap can remain on household objects such as keys, clothing, and car seats, so a patient may continue to be exposed if they have not washed all items. The urushiol in the sap (the offending agent) can live on clothing or other objects for months, so it is common for re-exposure to occur. 
 
Options for Topical Treatments of Dermatitis
Although more prevalent in the winter, some patients will get flares of eczema or psoriasis in the summer. Treating these flares present challenges with patient compliance, as most patients do not like to apply a heavy cream or ointment in the summer months, especially to a large surface area of skin. Thankfully, there are several options for treating dermatoses that are easier to apply in the summer heat. Several new topical corticosteroids are available in a foam that spread easily and do not occlude the skin. There are also spray options available for treating areas that are harder to reach, such as the scalp and back. Unfortunately many of the foam and spray topicals are only covered with commercial insurance. If the patient does not have commercial insurance that covers the name-brand foams or sprays, you can prescribe a lotion or solution to cover the same surface area without the sticky or occlusive feel of a cream. 

Amanda Schallman MS, PA-C practices clinical dermatology at Illinois Dermatology Institute in the north suburbs of Chicago. She received her PA degree from Rosalind Franklin University of Medicine and Science and undergraduate degree from the University of Notre Dame. She specializes in skin cancer screening, prevention, and treatment. 
SKIN CANCER BRIEFING |
Current and Upcoming Treatments and More
Skin cancer is the most common type of cancer. In the world, there are 5.4 million non-melanoma skin cancers (basal and squamous cell carcinomas) diagnosed yearly. Additionally, this year over 76,000 individuals will be diagnosed with melanoma.1 Given these staggering numbers, it is important to provide patients with treatment options for their skin cancer. Fortunately, there are many ongoing research projects targeting melanoma and non-melanoma skin cancers.

Standard treatment for non-melanoma skin cancers includes surgical excision or Mohs Micrographic Surgery. A patient with basal cell carcinoma (BCC) is considered to be a candidate for Mohs surgery if there is a high-risk primary tumor or recurrent BCC. High-risk BCCs are those that are >6 mm in high-risk areas such as the face, hands and feet; >10 mm at the scalp and neck; >20 mm on the trunk or limbs; or tumors with aggressive histologic growth patterns. High-risk squamous cell carcinomas (SCCs) are also candidates for Mohs surgery. Features of high-risk SCCs include: recurrent SCC, tumor sizes >20 mm, >4 mm depth of invasion, histologic subtypes of undifferentiated, poorly differentiated, or acantholytic, perineural or perivascular invasion, involvement of high-risk areas of the face, tumors in immunosuppressed patients, and radiation induced lesions. Additionally, Mohs can be utilized for NMSCs in anatomic sites that require tissue conservation for optimal reconstruction (i.e. anterior shins). 2
 
For low-risk superficial or nodular basal cell carcinomas and squamous cell carcinomas in situ (Bowen’s disease), non-surgical options can be considered. Treatment options include: photodynamic therapy, lasers, topical therapies, and smoothened inhibitors. Photodynamic therapy (PDT) is a treatment that involves a photosensitizer, amino-levulanic acid, and exposure to blue light. PDT is FDA-approved for superficial or nodular BCC, with cure rates around 70-90%. However, it is not yet approved for Bowen’s disease.3,4 Several studies supporting success in treating superficial and nodular BCCs have been noted with pulsed dye lasers and super-pulsed carbon dioxide lasers.5 Imiquimod and 5-Fluorouracil (5-FU) are the only topical therapies FDA-approved for superficial basal cell carcinomas. Imiquimod is applied five times a week for up to six weeks or longer, and 5-FU is applied twice a day for three to six weeks.3 Both are being tested for the treatment of superficial squamous cell carcinomas, as successful treatments have been reported.4 Ingenol mebutate, derived from the sap of the plant, Euphorbia peplus, is also being studied as a topical treatment for NMSC.6 Vismodegib (Erivedge) and sonidegib (Odomzo) are smoothened inhibitors targeting the hedgehog pathway used to treat BCCs.6 Other modalities utilized for low-risk, small, well-defined NMSCs include cryotherapy with liquid nitrogen and electrodessication and curettage. Unlike Mohs and excisional surgery, all of these treatment modalities described above cannot guarantee complete clearance, as tissue does not get sent to pathology.7,8
 
The main treatment of melanoma includes surgical excision and a sentinel lymph node biopsy for tumors >1mm thick.9 In patients with metastatic melanoma, new or experimental therapies may be offered such as: immunotherapy (interleukin-2, interferon alfa 2b), MEK inhibitors (trametinib), CTLA-4 antagonist (ipilimumab), and PD-1 blocking antibodies (nivolumab, pembrolizumab).10 Vaccines and targeted therapies are newer treatment options being developed. Current research is going into monovalent vaccines where melanoma cell antibodies are created and injected back into the cell. The main issue with this treatment is that surface antigens in melanoma are constantly in flux. In patients with the BRAF mutation, targeted therapy for BRAF inhibitors has potential. By blocking the BRAF pathway, the treatment may stimulate mutations in the RAS pathway.5
 
Despite the fact that most skin cancers can be preventable with strict photoprotection, it continues to be a widespread issue around the world. Within the last thirty years, more people have been diagnosed with skin cancer than all other cancers combined.11 More nonsurgical treatment options are being investigated for the treatment of non-melanoma skin cancers as are more effective treatments for melanoma.
References
1 Skin Cancer Facts. American Cancer Society. http://www.cancer.org/cancer/cancercauses/sunanduvexposure/skin-cancer-facts Accessed July 9, 2016.
2Miller SJ, Alam M, Andersen J, et al. Basal cell and squamous cell skin cancers. J Natl Compr Canc Netw 2010; 8:836.
3,Basal Cell Carcinoma (BCC) Treatment Options. Skin Cancer Foundation. http://www.skincancer.org/skin-cancer-information/squamous-cell-carcinoma/scc-treatment-options Accessed July 9, 2016.
4Squamous Cell Carcinoma (SCC) Treatment Options. Skin Cancer Foundation. http://www.skincancer.org/skin-cancer-information/basal-cell-carcinoma/bcc-treatment-options Accessed July 9, 2016.
5Samalonis L, A look at the latest skin cancer research. The Dermatologist. 2015: 19-20.
6Fallen RS, Gooderham M (2012). "Ingenol mebutate: An introduction".Skin Therapy Lett 17 (2): 1–3. PMID 22358305
7Basal Cell Carcinoma. DermNet NZ. http://www.dermnetnz.org/lesions/ basal-cell-carcinoma.html Accessed July 10, 2016.
8Squamous Cell Carcinoma. DermNet NZ. http://www.dermnetnz.org/lesions/ squamous-cell-carcinoma.html Accessed July 10, 2016.
9Melanoma Treatments. Skin Cancer Foundation. http://www.skincancer.org/skin-cancer-information/melanoma/melanoma-treatments Accessed July 10, 2016.
10Melanoma. DermNet NZ. http://www.dermnetnz.org/lesions/melanoma.html Accessed July 10, 2016.
11Stern,RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol. 2010; 146(3):279-282.




Christine Go, PA-C is a Dermatology Physician Assistant at Leone Dermatology Center in Arlington Heights, Illinois. She also serves as the current Vice President of the Illinois Society of Dermatology Physician Assistants. 
President's Perspective |
Modernizing the PA Profession
Time is amazing isn’t it? Things are completely different than just twenty or thirty years ago. I believe this is especially true for the PA profession. Don’t get me wrong…..we are still a profession that was founded on collaboration, and born from a need of primary care providers. But the way PAs deliver care over the years has changed - because healthcare in this country has changed. Whether you agree with the changes or not isn’t the question - the question is, how are we, as a profession, going change and adapt so we can do our part? I believe one of the answers is to modernize the profession. Just as the PAs made changes 20-30 years ago, we need to band together with a common voice. Change is hard and it does not happen overnight. 

This “modernization” will take time and sacrifice from all involved and we need to think not only about the present, but about the future. It’s time for PA organizations to work together toward a common goal. From education, to accreditation, certification, and practice, each facet is important. I am particularly proud of the changes AAPA has made over the last few years. They have become a forward thinking organization who is driving change for PAs across the country. From transitioning to modern language of collaboration instead of “supervision”, to considering full practice authority for PAs - AAPA has begun to break down barriers that once held us back. But they can’t do it alone. It will take each one of us to drive change. I encourage each one of the members of the IAPA to look toward the future of the PA profession. What do you want it to look like? How do we want to make an impact? Ask yourself, what can I do to make a difference? A little sacrifice here, a little extra effort there, can lead to big payoffs in the future. 


Jennifer Orozco, MMS, PA-C, DFAAPAIAPA President 2016-17. She is the Director of Advanced Practice Providers at Rush University, Chicago.
Springfield Scene | 
Legislative Update | New Law Passed / Work on Practice Act Continues
Dan Shomon | IAPA Springfield Lobbyist
NEW ILLINOIS LAW HELPING PA PROFESSION SIGNED BY GOVERNOR; 2017 WILL INCLUDE REWRITE OF PRACTICE ACT

The 2016 Spring legislative session in Springfield featured a major legislative accomplishment for the Illinois PAs and our group already looking forward to bigger accomplishments in 2017. 

Governor Rauner has signed the Illinois Academy of Physicians Assistants' rules and regulations cleanup bill into law . The Governor signed the bill a month before expected because there was no opposition and it was agreed language between the Illinois PAs, state regulators, the State Medical Society and the Illinois Society of Advanced Practice Nurses.

With the constantly changing nature of health care, PAs are often faced with questions at their place of employment – mostly hospitals, medical clinics or other community healthcare facilities– about the exact rules and regulations regarding their actions on the job. SB2900 iis a technical cleanup bill that clarifies many state health rules and regulations to ensure that Illinois PA duties and responsibilities are clearly defined and that the rules and regulations are consistent with the Illinois PA Practice Act.

The bill was sponsored by Senator Iris Martinez, D-Chicago, chairman of the Senate Licensed Activities Committee, the panel that handles PA legislation and Rep. Michael Zalewski, D-Riverside. chairman of the House Health Care Licenses Committee.  The bill had 17 cosponsors of both parties. For a link to the actual final language of the 124-page bill, click HERE.

Meanwhile, IAPA President Jenn Orozco, IAPA President-elect Mindy Sanders, AAPA legislative expert Adam Peer and IAPA Springfield lobbyist Dan Shomon met with the Illinois State Medical Society in July to begin working on a rewrite of the PA Practice Act. The practice act expires on December 31, 2017 so IAPA will work with the Medical Society and other groups to pass an improved practice act during the Spring session of 2017. 
The STUDENT Section | Why Students Should Get Involved...
Kris Bridgeman PA-S2 - Rush University | IAPA/AAPA Student Representative
Congratulations and welcome to all first-year students on your acceptance into PA school! I am sure that you are in the throws of anatomy lab, drowning in stress and student loans, all the while reeking of formaldehyde. Well, boy do I have some good news for you! The Illinois Academy of PAs (Physician Assistants) is here to support you! IAPA can be a great resource for you through your journey as a student, and well beyond, into your future endeavors as a practicing PA. Though IAPA unfortunately can’t help you with your formaldehyde issues, the IAPA is a vital source to keep you informed on all things PA. Our state organization serves to educate students and practicing PAs on key government legislation affecting our profession, organize continuing medical education (CME) for practicing PAs, and act as a collective voice for current and future Illinois PAs. 

As a student, there are a number of ways to get involved. First, you should follow us on Facebook! IAPA posts news, stories, or events regarding Illinois PAs to keep you up to date. Another option is to run for your program’s IAPA student representative position. Serving in this role will place you on the front lines of decision making while you represent and serve as a valued resource for your class on current issues. If you aren't ready for that level of involvement, what about submitting an article for publication in the IAPA bi-monthly Executive Briefing called the, “IAPA Insider”? IAPA membership is a professional standard, so whatever your interest level, get involved, you will help further the PA profession both now and for years to come!

If you have any questions or concerns, or are interested in writing a column for "The Student Section" of the "Insider", contact your program’s representative or myself using the following links: Kris Bridgeman (Rush University) | Samantha Thompson (Northwestern University) | David Kunz (Midwestern University) | Sarah Alfson (Rosalind Franklin University) | Jacob Ribbing (Southern Illinois University).
Copyright © 2016 Illinois Academy of PAs, All rights reserved.


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