Feature: Adding a Subspecialty with Ease: Spotlight On: Pediatric Dermatology - By Arun P. Venkat, M.D., M.B.A., and Fred E. Ghali, M.D. In this series, we’ll explore key clinical and practical components that you’ll need to know to successfully incorporate subspecialty services into your practice. P ediatric patients are an interesting patient population to work with because they tend to get over a variety of illnesses more easily, often cannot fully understand their disease process, need special techniques during the history and physical exam, and require a strong doctor and parent relationship in order to facilitate healing. These special needs often attract certain physicians and create unique subspecialties, such as pediatric dermatology. Pediatric Dermatology at a Glance Pediatric dermatology is one of the official subspecialties recognized by the American Board of Derma-tology (ABD) and the Accreditation Council of Graduate Medical Education (ACGME). Pediatric dermatologists typically care for patients from birth to 18 or 19 years of age. A variety of conditions are commonly treated, including but not limited to alopecia, atopic dermatitis, bacterial and fungal infections, birthmarks of multiple types, molluscum and warts, genodermatoses, vitiligo, and much more. A recent survey of dermatology chairpersons throughout the country showed a significant shortage of pediatric dermatologists with 24 departments recruiting for more than 1 year and only 6 pediatric dermatologists in training.1 Given the current workforce statistics, pediatric dermatology offers those with an inclination toward the field an ample opportunity for career development. Cutis marmorata telangiectatica congenita. Photo courtesy of Dr. Ghali. What Kind of Training Is Required? Various academic pathways are available for ascertaining a subspecialty in pediatric dermatology. A large proportion of pediatric dermatologists have completed residency training in pediatrics, subsequently followed by a second residency in dermatology. Additionally, some have completed a general internship year, followed by a dermatology residency, and then completed a 1- to 2-year pediatric dermatology fellowship. Gianotti-Crosti syndrome. Photo courtesy of Dr. Ghali. Presently, you can choose one of three pathways to become board-eligible in pediatric dermatology (www.abd.org). Ring warts. Photo courtesy of Dr. Ghali. The First Pathway. The first involves an intern year in pediatrics, followed by a dermatology residency and a 1-year pediatric dermatology fellowship. The Second Pathway. Another option is to do a general intern year in a preliminary medicine, surgery or transitional program, followed by a dermatology residency and 2 years of a pediatric dermatology fellowship. The Third Pathway. The final option is available to those who have had special interest, experience and expertise in pediatric dermatology for at least 5 years. In regards to the last option, these individuals are eligible to sit for the annual pediatric dermatology-certifying exam between 2004-2009, after which this path will no longer be an option. Molluscum contagiosum. Photo courtesy of Dr. Ghali. Currently, 13 pediatric dermatology fellowship programs are listed on the Society for Pediatric Dermatology’s Web site, www.pedsderm.net. As further options may be available at programs not listed, interested dermatology residents should contact different department chairpersons and investigate opportunities. Furthermore, the ABD has approved a new combined pediatrics/dermatology residency program. This program is 5 years or 60 months in length, with 30 months dedicated to each respective field. The post graduate year 1 (PGY-1) must have at least 10 months of pediatric training and the PGY-2 must have at least 10 months of dermatology training. The remaining 3 years are divided equally between dermatology and pediatrics. These are the multiple training options available to physicians interested in pediatric dermatology. Mastocytoma of the neck. Photo courtesy of Dr. Ghali. A good pediatric dermatology clinic not only needs well-trained physicians, but also needs excellent ancillary service providers. Just as in any other dermatology office, administrative staff are needed for common everyday tasks. Also, a new trend has been the utilization of physician extenders such as pediatric nurse practitioners. Just as in the adult clinics, these physician extenders can improve the clinic in various ways, such as improving patient care accessibility, increasing patient education, and assisting in minor procedures. These benefits can be of particular importance in the academic setting, where pediatric dermatology clinics may have several month appointment waiting periods. Other essential ancillary service providers include medical assistants, licensed vocational nurses and registered nurses. Other areas of training that may be useful in a pediatric dermatology clinic include training in assisting with laser, surgical, and phototherapy procedures. For the most part, the training needed for those providing ancillary services in the pediatric dermatology clinic is not complicated to secure. With a properly trained staff, a newly trained pediatric dermatologist can readily start practicing in a setting of his or her choice. An ulcerated hemangioma. Photo courtesy of Dr. Ghali. Clinic Operations An increasingly large demand for pediatric dermatologists exists in both academic and private practice settings. A large majority typically practice in the academic/university hospital setting. This is in direct contrast to the field of adult dermatology, where only 10% to 20% of the dermatologists practice in the academic/university setting. Presently, only a small proportion of pediatric dermatologists are in private practice, usually situated in large urban areas. Some of the private-practice-based pediatric dermatologists split their clinical time seeing mainly pediatric patients and some adult patients, while others may focus 100% of their clinic time on pediatric patients. Giant bathing trunk nevus. Photo courtesy of Dr. Ghali. Pediatric dermatology clinics tend to be slower paced than the adult counterpart clinics since parents often have a lot of questions and children often require additional attention during visits. Perioral dermatitis. Photo courtesy of Dr. Ghali. The Right Tools Certain clinical tools are helpful in a pediatric dermatology clinic. Useful supplies include cantharadin extract (for warts and molluscum), liquid nitrogen (for warts and molluscum), squaric acid (for warts and alopecia), and topical anesthetics (pre-op for minor procedures). Secondly, access to the use of a pulsed dye laser is useful for treating port-wine stains and other vascular lesions of the skin. The costs associated with this laser, as well as the possible need for general anesthesia, often limit its use to a hospital or outpatient surgical facility. Another important tool is a phototherapy unit, which is often used in the treatment of atopic dermatitis, pityriasis lichenoides, psoriasis and vitiligo. The most useful and safest mode of therapy is the narrowband UVB phototherapy unit, which may cost around $10,000 depending upon the amount of bulbs contained in the unit. Reimbursement Issues Due to a high number of referrals from the general pediatricians, the patient encounter codes may be weighted more toward consultation visits, which can be especially true in the academic/university setting. Common procedural codes in pediatric dermatology include the following: 17000 (common warts) 17100-17111 (flat warts and molluscum) 17106-17108 (destruction of vascular proliferative lesions such as port wine stains, hemangiomas or pyogenic granulomas) 96910 (phototherapy). In terms of procedures that may require insurance company prior authorization, the treatment of vascular proliferative lesions can prove challenging to ensure coverage. Often health insurance will only reimburse if these vascular lesions (e.g. port wine stains) are present on the face or neck. Additionally, some insurance plans may deny authorization for clinic visits for alopecia or vitiligo because some companies view these conditions as “cosmetic”. In general, it is best to gain prior approval for these diagnoses before providing therapy. Otherwise, most coding and billing issues are relatively straightforward in pediatric dermatology. X-linked ichthyosis. Photo courtesy of Dr. Ghali. Choosing this Area of Practice There is a high demand for pediatric dermatologists and it should not be difficult to seek employment in either the academic or private practice setting. This is an exciting time to be a part of this specialty as the field is currently evolving. As previously mentioned, it is now an official subspecialty of dermatology with the American Board of Dermatology. In general, a pediatric dermatology clinic is not very complicated in terms of equipment or staff needs and there is definitely an opportunity to practice in either the academic and private practice setting. Taking care of pediatric patients with skin disorders can be extremely exciting and rewarding. If interested in becoming a pediatric dermatologist, seek out a mentor in the field, and dedicate time during your educational training to find out if a career in pediatric dermatology is right for you. Skin & Aging - ISSN: 1096-0120 - Volume 13 - Issue 12_2005 - December 2005 - Pages: 57 - 59