SDPA Summer Conference: Key Sessions

The Society of Dermatology Physician Assistants (SDPA) Annual Summer Dermatology Conference took place June 22–25, 2023, in Boston, MA, offering tracks on acne/rosacea, advanced dermatopathology, surgery, alopecia, and professional development delivered by some of the best in the field. In this article, I have highlighted a few key sessions as a brief snapshot of the full agenda. 

Nails: What You Need to Know 

Podiatrist Tracey Vlahovic, DPM, FFPM, RCPS (Glasg), kicked off her lecture with a discussion reviewing nail anatomy and the proper way to examine nails. Nails should be examined in good light and need to be void of polish, gel, and acrylics. It is important to determine if a patient’s anatomy could be contributing to mechanical disturbance of the nail. 

When evaluating abnormal nails, onychomycosis (OM) is the diagnosis 50% of the time. She stressed the importance of tempering the expectations of patients with severe OM who may not be able to achieve complete resolution of their nail dystrophy. Of note, she recommended the use of UV shoe sanitizers for prevention of repeated exposure to dermatophytes. She does not, however, recommend total nail avulsion for OM. Nail avulsion is not curative for nail fungus and often results in cosmetic sequelae, including a disappearing nail bed. Additional treatments she has found to be unsuccessful for OM include duct tape, Vicks VapoRub, tea tree oil, tolnaftate, and undecylenic acid. 

Although terbinafine resistance is being increasingly reported, Dr Vlahovic does not routinely run terbinafine resistance panels. When a patient presents with treatment-resistant disease, expanding the differential is always warranted, including the consideration of lichen planus and psoriasis. To properly collect a nail specimen, Dr Vlahovic recommended debridement of the distal nail and curetting from the proximal nail bed. 

Blistering Diseases 

Categorizing the type and distribution of blisters is of utmost importance when approaching a patient with a blistering disease, said Megan Holben Noe, MD, MPH, MSCE, a dermatologist with Brigham & Women’s Hospital in Boston. She indicated that practitioners should consider other important historical factors, including the patient’s age, timing, comorbidities, outdoor exposures, new medications, and family history. Ideally, when obtaining biopsy specimens, the hematoxylin-eosin specimen is taken from the lesional skin, whereas the direct immunofluorescence specimen comes from perilesional skin. Additional features of the diagnostic workup may include serum immunofluorescence studies, laboratory tests to identify underlying comorbidities, and microbial tests as needed. 

She also discussed common bullous presentations, such as edematous bullae, which often present in patients with chronic edema and will resolve when edema improves. Severe contact dermatitis, such as with poison ivy, can present as bullae localized to the site of contact and requires treatment with high potency steroids. Bullous impetigo is caused by the exfoliative toxin produced by Staphylococcus aureus that can be cultured from blister fluid and treated with topical antibiotics. 

Although herpes zoster is a presentation with which most of us are familiar, it is important to consider the state of the patient’s immune system. Patients who are immunosuppressed can present with disseminated zoster, which may have internal and central nervous system involvement. 

Generalized bullous fixed drug eruption is a rare variant and important mimicker of Stevens-Johnson syndrome. Patients with this condition tend to present with widespread lesions without mucosal involvement. The approach to a patient with a suspected drug eruption should be counseling to stop any possible causative agents and nonessential medications before confirming the diagnosis and drawing additional labs. Most of these patients will require supportive care, with consideration of treatment with systemic steroids or immunosuppressive agents. 

Interesting Cases in Pediatric Dermatology 

Anna (Cristy) Garza-Mayers, MD, PhD, a pediatric dermatologist at Massachusetts General Hospital, engaged the audience with a discussion on pediatric cases, including one featuring an infant with scalp and facial lesions who was experiencing worsening of their condition with sun exposure. Ultimately, the patient was diagnosed with neonatal lupus erythematosus (LE), a condition passively transferred maternally. Many of these mothers may have asymptomatic connective tissue disease. On the other hand, up to half of the infant patients present with skin lesions and “raccoon eyes,” a pathognomonic finding. Because the condition is associated with congenital heart block, it is essential to refer the patients to pediatric cardiology for evaluation. Patients with neonatal LE must be counseled to practice sun protection. Skin lesions will typically clear by age 1 year, but there is a risk that this condition will recur in up to 25% of subsequent pregnancies. 

In a separate case, Dr Garza-Mayers reviewed annular erythema of infancy, which presents with enlarging erythematous annular patches and plaques, and is a benign diagnosis of exclusion. These patients do not present with systemic findings and the condition tends to resolve without residual scarring or atrophy within a year. Dr Garza-Mayers also explored the common presentation of infantile hemangiomas. Although most hemangiomas are benign, it is important to evaluate these patients for the PHACES acronym, (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies) to determine the need for further workup. Diagnosis of infantile hemangiomas is typically clinical and does not require a biopsy. If patients present with more than 5 hemangioma lesions, evaluation with abdominal ultrasound is recommended to help identify any internal hemangiomas of the organs. Treatment of hemangiomas includes topical timolol, oral propranolol, and laser treatment. 

Dr Garza-Mayers reviewed the differential diagnosis of café au lait lesions. It is typically considered normal to have up to 5 café au lait lesions, therefore, patients who present with more than 6 café au lait lesion need to be evaluated for neurofibromatosis 1 (NF1). The rate of NF1 is one in 3000 births, with 50% occurring due to a spontaneous mutation. Additional findings that may correlate with NF1 include nevus anemicus and juvenile xanthogranulomas. 

Lastly, juvenile localized scleroderma conditions were explored, including morphea en coup de sabre. Patients who present with localized scleroderma need to have a full skin examination, including a genital exam, to check for lichen sclerosus et atrophicus. Localized scleroderma is not on the spectrum of systemic sclerosis.