Employing an aesthetician in a dermatology practice: facts and controversies.

Employment of aestheticians in dermatology offices is becoming an everyday occurrence, as the dermatology patients' demand for cosmetic services taxes the availability of limited resources. Proponents of the practice state that aestheticians can help meet patients' expectations, while allowing dermatologists to focus their practice on the medical needs of patients. Opponents believe employment of fee-for-service aesthetic technicians compromises our ethical duties to our patients and diminishes the stature of dermatology as a profession.

Ethics of utilizing nurse practitioners and physician's assistants in the dermatology setting.

Our current supply of dermatologists in training is insufficient to meet the growing demand for dermatology services. In an era of declining reimbursements and the ever increasing clamor for increased access to care, many practices are turning to nurse practitioners and physician assistants as a cost effective means of fulfilling patient demand. Despite the recommendations of the American Academy of Dermatology, there is no explicit consensus among dermatologists on the educational requirements or appropriate utilization of NPs and PAs in dermatology settings. Colleges of nursing and physician assistant programs recognize the provider demand in dermatology and have begun to implement training programs to address the need for specialty training. Academic settings offer a unique opportunity for NPs and PAs to receive a medically oriented grounding in basic science, dermatopathology, and research.

The ethical controversies of office-based dispensing in academic health centers.

Office dispensing of cosmecuticals has become a widespread practice in private dermatology offices and even has begun to appear in academic dermatology settings. Proponents of the practice state that in-office dispensing is beneficial for the patient and the physician and can be ethically accomplished with the patient remaining the primary concern of the care provider. This requires the maintenance of professionalism and the sale of efficacious, reasonably priced products that are not misrepresented. Opponents believe that in-office dispensing undermines the physician- patient relationship and may produce an inherent conflict of interest. In academia, additional concerns include how students and residents perceive this activity. Does selling products negatively affect professionalism in an academic environment? In an academic teaching environment there is a paramount need to model ethical behavior to medical students and residents. We will discuss the opposition and rationalization for the practice of in-office dispensing in academic teaching settings.

Ethics of clinical trials in dermatology.

The ethics of clinical trials have been the subject of numerous previous publications and mandates that are used by institutional review boards on an everyday basis. The protection of human rights and the sanctity of informed consent are critical components of clinical research monitored by human subjects investigation committees throughout our profession. In this contribution, the everyday conflicts of interest that can compromise clinical research in dermatology are presented in a case format. Of utmost importance, the primary interest of the investigating dermatologist should always be the patient at hand and those who could benefit from the research. Navigating the turbulence created by finances, academia, and corporate America is critical. By presenting several case scenarios within the relatively rare disease arena of cutaneous T-cell lymphoma, these conflicts can be appreciated. Consequently, understanding these influences in one disease setting permits generalizations to be applied to any dermatologic clinical research.

Vitamin D and the skin.

Vitamin D is a fat-soluble nutrient that humans obtain through the diet and by synthesis in the skin upon exposure to ultraviolet B. Vitamin D is then converted by the liver to 25-hydroxyvitamin D, its major circulating form. This form is the best indicator of vitamin D nutritional status and is easily measured. Under the influence of parathyroid hormone, the kidney then converts 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D, the biologically active, hormonal form of the nutrient that is important in the metabolism of calcium and phosphorus and is critical in building and maintaining healthy bones. Many cell types outside of the skeletal system, including various cells in the skin, also express the vitamin D receptor. In addition, many cell types convert circulating 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D for local use. This metabolite has been shown to exert potent effects on cellular differentiation, cellular proliferation, and immune regulation. It is theorized that by these mechanisms vitamin D and its analogues are effective treatment options for psoriasis and other skin diseases. Insufficient vitamin D nutritional status has been associated with a host of other diseases, most notably cancer. There is evidence that supplementation with vitamin D reduces the overall incidence of cancer, although current evidence is insufficient to prove a causative effect. Sunscreen use blocks the ability of the skin to photosynthesize vitamin D, although the effect this has on the vitamin D status of the general population is unclear.