This issue of the Journal of Dermatology Nurses’ Association (JDNA) marks the launch of a new feature entitled, “Diagnostic Dilemmas in Dermatology.” For the past several months, the fledgling column has been nurtured along by Lakshi Aldredge; Dermatology Nurses’ Association (DNA) Past President; Dr. Timothy Quinn, an academic Boston-based dermatopathologist; and me. To see the first case study populating the pages of our peer-reviewed journal is most gratifying. We are hoping that this column will resonate with readers and writers alike.
Allow me to share some history on the project.
As long-term DNA members, Lakshi and I lamented the loss of “What’s Your Diagnosis,” a stock column that ran for many years in the Dermatology Nursing Journal and briefly in JDNA. The column was predictably clever, thought-provoking, and visual. Moreover, it became satisfying to the mind as we all made efforts to guess the diagnosis before it was unveiled by the authors. JDNA readership surveys informed us that this platform for a column not only was popular by vote but mourned by masses when it disappeared from our printed and, later, online pages.
The idea for merging clinical case studies with dermatopathology correlatives was certainly not a novel concept nor was beyond the reach of a nursing peer-reviewed journal, the likes of the JDNA. The process we anticipated (and found to be true) revolved around designing a template for the column, figuring out a mechanism for slide review, and integrating dermatology nurse/nurse practitioner perspective with that of the collaborating dermatopathologist. As such, “Diagnostic Dilemmas in Dermatology” moves beyond nailing the diagnosis based on the careful scrutiny of patient history, physical examination, and thoughtful differential diagnosis. It calls upon a different skill set largely driven by timely communication between providers and correlation of information as new data roll in.
We learned that we had a friend and potential collaborator for the column when we were introduced to Dr. Timothy Quinn at DNA’s Annual Convention in Denver, 2012. His session on “Lichenoid Dermatoses” was oversubscribed with an eager pathology-craving nursing audience. The presentation stressed the importance of communicating clinical information, key physical examination features, clinical photographs, and best guesses with the collaborating dermatopathologist. Calling into question the histopathological diagnosis when it does not seem to fit with the clinical examination or patient history was stressed. Performing additional skin biopsies might be warranted, as the lesion or dermatosis in question evolves over time. Dr. Quinn made a point of referencing memorable cases that he shared with nurse practitioner colleagues in the New England area. The take-home message was that quality collaborations set the stage for quality patient care.
The premier case study selected for “Diagnostic Dilemmas in Dermatology” is a real-life story of a patient with a pruritic, inflammatory dermatosis. The proposed differential diagnosis is histiocytosis versus mastocytosis. The challenge presented reaches well beyond the analysis of the skin pathology. This case calls upon a multidisciplinary care approach with NP, supervising dermatologist, hematology/oncology, and pathology, all putting their heads together to guide and interpret multiple layers of data. What was learned in the end was that a commitment to follow this patient over time was essential, as the underlying disease had yet to “declare itself.” In my opinion, this is a big clinical care challenge!
The “Diagnostic Dilemmas in Dermatology” column does not necessarily call for exotic, once-in-a-lifetime type of cases. In fact, Dr. Quinn suggests that writers consider “unusual presentations of common problems.” Skin manifestations associated with “obsolete diseases” might not be so rare, as healthcare is delivered to a diverse, mobile, and global patient population, or an atypical lesion in an uncommon location or an old medication with a new rash; the possibilities are endless.
We invite each of you to consider sharing your clinical cases, puzzling and maybe not so, with each other through the “Diagnostic Dilemmas in Dermatology” column. A patient story, clinical photographs, and skin biopsy will set you on your way! Sharing clinical experiences in the JDNA can broaden nursing care perspectives and improve quality of life and care for the dermatology patients we all serve.