XX FAMILY HEALTH TEAM Medical Directive #PA-16

Title and Number of Directive: Order Table PA-16: Dermatology

This table cannot be relied upon in the absence of: PA Medical Directive #16 – Dermatology

1. OVERALL CONDITIONS

- The PA may evaluate and provide care for patients presenting with the following new or ongoing conditions: o Maculopapular and plaque disorders: . Eczematous disorders:  Contact .  .  .  Sebhorreic dermatitis.  Perioral dermatitis.  Stasis dermatitis.  Dyshidrotic eczema.  Diaper dermatitis. . . . . . o Papulopustular inflammatory lesions: . Acne vulgaris. . Acne rosacea. . Folliculitis. o Localized skin infections: . Furuncles and carbuncles. . Cellulitis. . Abscess. . Impetigo.

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. Secondary skin infection. . Candidal . o Bites (insect, reptile, animal, human). o . . Tinea versicolor. . Tinea capitis. . . . Tinea pedis. o Drug eruptions. o Parasitic infections: . Scabies. . Pediculosis. o Viral disorders: . Condyloma accuminatum. . Exanthems. . Herpes simplex virus. . Molluscum contagiousum. . Verrucae (HPV). . Herpes zoster. . Varicella. o Benign skin conditions: . Blister. . Callouse. . Skin tag. . Lipoma. . Epidermoid cyst. . Actinic keratosis. . Actinic cheilitis. . Seborrheic keratosis. . Milia. . Hemangioma. o Moles/nevi. o Pigmentation disorders:

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. Acanthosis nigricans. . Melasma. . Vitiligo. o Angioedema and urticaria. o Hairs and nails: . Alopecia. . Paronychia. . Onychomycosis. . Ingrown nail. . Nail trauma. - PA will discuss patient status and care with the physician on an ongoing basis as identified in the Practice Outline, and as necessary.

Guidelines: - Compendium of Pharmaceuticals and Specialties, 2012.

Orders Indications and Contraindications.

2. HISTORY AND PHYSICAL EXAMINATION

- The PA may complete a focused history based on presenting condition. o History of present illness. o Pertinent past medical history.

- Focused physical exam may include: o Vital signs. o ENT. o Respiratory system. o Dermatology.

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3. COUNSELING

- Lifestyle modification as appropriate. - Environmental factors if contributory. - Education regarding condition. - Conservative treatment, e.g. emollients, Calamine.

4. LABS AND INVESTIGATIONS

- The PA may order any of the following labs as necessary: o CBC. o Renal function (creatinine, BUN, A:Cr). o Liver function tests (AST, ALT, alk phos, GGTT, bilirubin). o Rheumatoid factor. o ESR o hs-CRP

- Samples for culture and histopathology.

5. IMMUNIZATIONS

- In accordance with PA Medical Directive Guidelines: #1 – Periodic Health Exam. - Canadian Immunization Guide – Seventh Edition 2006.

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6. PROCEDURES

- The PA may apply silver nitrate. Indications: - Antiseptic, wound cauterization.

Contraindications: - Not for use on broken skin, cuts or wounds. - As per CPS guidelines.

- The PA may apply the following Indications: keratolytic agents: - Common or periungal warts. o Cantharidin. - Condylomata acuminatum. o Podophyllin. - Molluscum contagiosum. o Salicylic acid. - Palpebral warts. o Trichloroacetic acid. - Plantar warts.

* Not all medications apply to all conditions, appropriate guidelines shall be utilized.

Contraindications: - Not for use on broken skin, cuts or wounds. - As per CPS guidelines.

- The PA may order or perform Indications: cryotherapy. - Destruction of diseased skin tissue.

Contraindications: - Lesions suspicious for melanoma, SCC, sclerosis or recurrent BCC. - Areas of end-stage compromised circulation. - Lesions in which identification of tissue pathology is required.

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- The PA may order or perform collection Indications: of skin scrapings or nail clippings. - Diagnose fungal infections.

- The PA may perform the following skin Indications: biopsies: - Obtain tissue sample for diagnosis by histopathology. o Shave biopsy. - Perform an excision for curative or cosmetic purposes. o Punch biopsy. o Curettage. Contraindications: o Excisions. - Significant coagulopathy. o Incisions. - Preparations, anesthetics, preservatives or other materials to which the patient is allergic. - Partial-thickness biopsies are discouraged if not contraindicated if melanoma is suspected.

- The PA may perform incision and Indications: drainage of an abscess. - Localized collection of pus that is tender and not spontaneously resolving.

Contraindications: - Facial lesions require consultation with supervising physician.

- The PA may perform laceration and Indications: incision repair using the following: - Lacerations that are open and less than 12 hours old (<24 hours old on face). o Sutures. - Some bite wounds in cosmetically important areas (close follow-up recommended). o Wound closure tapes & strips. - Repair of sites where lesion has been surgically removed. o Tissue adhesive. Contraindications: - Wounds more than 12 hours hold (>24 hours old on face). - Animal and human bite wounds (exceptions: facial wounds, dog bite wounds). - Puncture wounds.

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7. THERAPEUTICS

Burrow’s solution Indications: - . - Stasis dermatitis.

Contraindications: - As per individual medication guidelines in CPS.

Topical corticosteroids Indications: - The PA may recommend the following - Corticosteroid-responsive dermatoses. topical corticosteroids: - Contact dermatitis. o Amcinonide. - Atopic dermatitis. o Betamethasone. - Nummular eczema. o Clobetasol. - Diaper dermatitis. o Clobetasone. - Lichen simplex chronicus. o Desonide. - Seborrheic dermatitis. o Desoximetasone. - Scalp psoriasis. o Diflucortolone. - Seborrheic dermatitis. o Fluocinolone. o Fluocinonide. * Not all medications apply to all conditions, appropriate guidelines shall be utilized. o Halcinonide. o Halobetasole Contraindications: o Mometasone. - As per individual medication guidelines in CPS. o Triamcinolone.

Topical anti-fungals Indications: - The PA may recommend the following - Diaper dermatitis. topical anti-fungals: - Seborrheic dermatitis. o Ciclopirox. - Tinea versicolor o Clotrimazole.

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o Ketoconazole. - Tinea corporis. o Miconazole. - Tinea pedis. o Nystatin. - Candidal intertrigo o Terbinafine. o Tolnaftate. * Not all medications apply to all conditions, appropriate guidelines shall be utilized.

Contraindications: - As per individual medication guidelines in CPS.

Topical skin products Indications: - Selenium sulfide. - Tinea versicolor - Coal tar shampoo. - Seborrheic dermatitis - Psoriasis -

Contraindications: - As per individual medication guidelines in CPS.

Oral anti-fungals Indications: - The PA may recommend the following - Onychomycosis. oral anti-fungals: - Tinea capitis. o Fluconazole. - Tinea versicolor. o Itraconzole. o Ketoconazole. * Not all medications apply to all conditions, appropriate guidelines shall be utilized. o Terbinafine. Contraindications: - As per individual medication guidelines in CPS.

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Topical antibiotics Indications: - The PA may prescribe the following - Mild secondary skin infections. topical antibiotics: - Mild impetigo. o Fusidic acid. - Folliulitis & furuncles. o Mupirocin. - Perioral dermatitis. - Dyshidrotic eczema.

Contraindications: - As per individual medication guidelines in CPS.

Oral antibiotics Indications: - The PA may prescribe the following oral - Moderate-severe secondary skin infections. antibiotics: - Moderate-severe impetigo. o Amoxicillin/clavulanate. - Hot tub folliculitis. o Azithromycin. - Carbuncles. o Cephalexin. - Cellulitis. o Ciprofloxacin. - Animal bites. o Clarithromycin. - Perioral dermatitis. o Clindamycin. - Diabetic ulcers. o Cloxacillin. o Doxycycline. * Not all medications apply to all conditions, appropriate guidelines shall be utilized. o Erythromycin. o Metronidazole. Contraindications: o TMP/SMX. - As per individual medication guidelines in CPS.

Antihistamines Indications: - The PA may prescribe the following - Pruritus associated with skin conditions. antihistamines: - Urticaria. o First generation: . Hydroxyzine. Contraindications:

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. Diphenhydramine. - As per individual medication guidelines in CPS. o Second generation: . Cetirizine. . Desloratadine. . Fexofenadine. . Levocetirizine. . Loratadine.

Acne products Indications: - The PA may prescribe the following - Acne vulgaris*. acne products: - Acne rosacea*. o Topical: - Psoriasis**. . Adapalene. . Azelaic acid. * Not all medications apply to all conditions, appropriate guidelines shall be utilized. . Benzoyl peroxide. **Tazarotene only. . Clindamycin. . Dapsone. Contraindications: . Erythromycin. - As per individual medication guidelines in CPS. . Salicyclic acid. . Sulfacetamide. . Tazarotene. . Tretinoin. o Oral antibiotics: . Doxycycline. . Erythromycin. . Minocycline. . Tetracycline. . Trimethoprim. o Oral contraceptives: . Tri-Cyclen®. . Alesse®. . Diane 35®.

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. Yasmin®. . Yaz®.

Pediculocides Indications: - The PA may prescribe the following - Pediculosis. pediculocides: - Scabies. o Permethrin. o Pyrethrins and piperonyl * Not all medications apply to all conditions, appropriate guidelines shall be utilized. butoxide.

Contraindications: - As per individual medication guidelines in CPS.

Indications: Topical skin products - Actinic keratosis. - The PA may prescribe the following - Condyloma acuminata. topical skin pruducts: - Molluscum contagiosum o Imiquimod. - Superficial basal cell carcinoma (in consultation with supervising physician). o Podofilox * Not all medications apply to all conditions, appropriate guidelines shall be utilized.

Contraindications: - As per individual medication guidelines in CPS.

Antivirals Indications: - The PA may prescribe the following - Herpes simplex virus. antivirals: - Herpes zoster. o Acyclovir. - Varicella zoster. o Famciclovir. o Penciclovir. * Not all medications apply to all conditions, appropriate guidelines shall be utilized. o Valacylcovir.

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Contraindications: - As per individual medication guidelines in CPS.

8. REFERRALS

- The PA may make a OTN Telederm referral as appropriate.

- The PA may make referrals to dermatologist in consultation with supervising physician.

9. ABSENTEE NOTES

The PA may write absentee notes as appropriate.

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