Nurse Practitioners in Dermatology

As it stands, nurse practitioners are the last providers to enter dermatology. We are often outpaced by our physician associate (PA) colleagues when it comes to being hired as they are more likely to have a dermatology rotation during graduate school. Additionally, their education is based on the medical model making it more familiar to dermatologists and future employers. Not only do new NPs have a steep learning curve when it comes to the practice of dermatology, the pace of clinic, the terminology, and the 3,000+ diagnosis, but we also have the steep learning curve of becoming a provider and being respected as one. PAs have their own challenges, some of which we share, but they have been present much longer in dermatology, as seen by their current dominance. Professional societies have noted the growth in dermatology NPs and PAs, with the American Academy of Dermatology's 2017 survey highlighting that dermatologists employing at least one PA or NP increased from 25% in 2005 to 46%  in 2014. Workforce projections in 2015 estimated a 30% growth for dermatology PAs over ten years, while the number of dermatology NPs remains harder to pinpoint (Bobonich et al., 2023).

The Primary Care Argument

We are taught that the role of the NP was created to help fill the gap in the number of primary care providers. However, times have changed. The demand for specialty care amongst the public is growing and will continue to grow with the increase in the number of older adults. I don’t know about the current state of other specialties and NPs being hired based on their broad experience, I only know about dermatology. As it stands right now, our broad experience as nurses and primary care training in NP school and other primary care settings is not competitive enough to enter dermatology. Even NPs who are offered a job without dermatology experience and given on-the-job training still voice the stress of practice and the need for additional support 6-12 months after starting. It’s disheartening to spend more than a decade in healthcare, owe $100,000+ in student loans, and then have to spend additional money to participate in a post-graduate program, further prolonging your entry into your preferred specialty.

Primary care is important. I will be the first to admit that. This is especially true in dermatology where internal medicine serves as the underlying foundation to medical dermatology, where the skin is the window to the internal homeostasis of the body and major organ systems. I am not making an argument to get rid of primary care, I am making an argument to make room for dermatology in nursing curriculum, and I'm not the only one. Primary care NPs have reported that 65-85% of the cases they treat on a daily basis are cutaneous conditions. Their primary goal is to confidently initiate the appropriate treatment to help reduce signs and symptoms while their patients wait for a dermatology evaluation. This basic understanding of the most common dermatoses is the focal point of my argument as this level of instruction will help primary NPs meet the needs of their patients and help aspiring dermatology NPs meet the entry-level qualifications for hire.

Nursing School & The Clinical Setting

The skin, hair, and nails get very little attention in nursing school. Instead, the focus is on the integumentary system with emphasis on pressure ulcer prevention and incontinence care, both in nursing school and at the bedside. This is despite the fact that the skin is the largest organ of the body, a window into the internal manifestation of many acute and chronic diseases (often an early indicator), and directly impacts our daily living and how we’re perceived in the world. In the acute setting, skincare is often not even an assigned task in the EMR that has to be completed in a 12-hour shift, making it seen as a low priority. It’s given low priority when compared to other organ systems, even though skin and soft tissue infections cost the healthcare system billions of dollars and cause families undue stress. I'm arguing for basic skin, hair and nail education where preventative practices are associated with low cost and less time, in comparison to complications associated with skin breakdown and disease which are associated with high costs, increased patient care time, and increased risks for morbidity, mortality, and psychodermatoses. The curriculum should include the latest edition/version of:

-Dermatology Scopes and Standards

-Dermatology NP Competencies

-The American Academy of Basic Dermatology Curriculum

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Change in Curriculum & Practice

I know it takes years to adjust the curriculum because so many factors have to be considered, particularly when it comes to the current cohort of students. All I’m asking is that the next time you revamp, restructure, or create nursing curriculum, clinical orientation, and textbook requirements, that you consider the language used to teach students about skin, hair, and nails; that dermatology not be ignored as part of the clinical rotation requirements, and that the EMR is designed to support efficient documentation that can inform an adequate diagnosis, evaluation, and nursing care. Nurses are taught to take ownership of the skin when it comes to repositioning, incontinence care, and pressure prevention. But are not given the adequate training to assess, document, and evaluate changes in condition. Little to no attention is given to the scalp, hence the need for the Hair For You advisory board. The nails are all but ignored, in fact, hospitals rarely if at all stock nail clippers. Nurses in the intensive care unit (ICU) have a slight advantage when it comes to caring for the skin, but there’s something to be said when that knowledge isn’t translated vertically or horizontally to our colleagues in other areas of nursing care.

Dermatology Nurses Association

To start, I would refer you to the Dermatology Nurses’ Association (DNA), the first and largest organization dedicated to the education of nurses and nurse practitioners in dermatology. There’s no need to reinvent the wheel, they have a rich catalog of resources and experienced, passionate providers who would love to improve dermatology care, increase access to nurse-led care, and improve patient wait times. They can use their experience as dermatology nurse practitioners to inform how academic education and clinical training should be structured to adequately prepare aspiring NPs to practice dermatology. In fact, they've already published the Dermatology Scopes & Standards (available for purchase) and the Dermatology NP Competencies (available for free). They would love to increase awareness about a specialty that is rewarding, enriching, and impactful to the community. The education and training must start in nursing school so that when NPs apply for their first job in dermatology, they will have acquired at least two years of experience to meet the criteria, be able to hit the ground running, and help decrease patient wait times. More importantly, we need a community of dermatology nurses and nurse practitioners to teach, conduct research, publish the latest findings, disseminate evidence-based practice strategies, advocate for legislation, and translate how Artificial Intelligence can be adopted in clinical practice. This will only happen with increased awareness, education, and mentorship.

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Schools of nursing, we’re ready for you. Every week I hear from another aspiring nurse practitioner who wants to practice dermatology, so I know they’re ready for you too.

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Kimberly Madison, DNP, AGPCNP-BC

I am a nurse practitioner with a passion for writing, entrepreneurship, education, and mentorship. I created this blog to share my journey as source of motivation and as a blueprint as you embark on your journey. Most importantly, I’m looking forward to increasing access to dermatology education and clinical training for aspiring and practicing nurse practitioners. I invite you to view the mission and vision statement on the homepage to see how we can best partner to make our dreams align.

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