Lidocaine Shortage, OTC Supplements & More: Your Questions Answered

From dealing with a shortage of lidocaine across the country to answering questions about supplements for skin, hair, and nails, dermatology NP/PAs find themselves continually adapting. Jayme M. Heim, MSN, FNP-BC and Sandri Johnson, MSN, FNP-BC respond to questions from colleagues. Plus, updates on biologic treatment selection from Jennifer Soung, MD, and insights from David E. Cohen, MD, MPH on a new treatment for chronic hand eczema.

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Transcript

Transcript provided as a courtesy. It has not been edited for accuracy.

Welcome to The Dermalorian Podcast from the Dermatology Education Foundation. The Dermalorian Podcast is made possible with support from Johnson & Johnson. In dermatology clinics across the country, thousands of procedures and excisions every day require local anesthetic, but what happens when there is a lidocaine shortage? That was one of many questions posed by attendees at this year's DEF Essential Resource Meeting or DERM. DEF Advisory Council members and DERM faculty members Sandri Johnson and Jayme Heim took time to answer questions from attendees. Here's Sandri Johnson.

Sandri Johnson:

Always excited to be here, being part of the faculty at the DEF is one of the highlights of my life. My name is Sandri Johnson. Like Paul mentioned, I am a nurse practitioner in North Carolina, been in dermatology for 21 years and I love to share tidbits of information and help in education.

Jayme Heim:

Hello, I'm Jayme Heim, and I'm also very glad to be here and I really feel that it's so important to have APP education. I work at West Michigan Dermatology in Michigan, and I've been an MP for almost 20 years.

Paul:

All right, so you guys as faculty members are available to answer questions from the attendees, and we got several of them, especially in the app. So one of them was someone asking if anyone's seeing a lidocaine shortage, and if so, are there alternatives? What can you do? So tell us, are you seeing that or not?

Sandri Johnson:

We sure are, Jayme, you want to talk about your experience first?

Jayme Heim:

In our office, we have a really busy office, so we have three sites in our office. We have Mohs surgery as well as multiple biopsies that are carried out throughout the day. And after COVID, we saw this lidocaine shortage and so we have continued because we can't get enough lidocaine into our office, we actually have, we make that up ourselves. It's a 1% lidocaine with epi and a one to 10 solution of 8.4% sodium bicarb. Along with that, it has to be documented in EMA, and so that is in EMA, it's documented and it goes down to a 0.5% lidocaine.

Sandri Johnson:

We are experiencing similar, our office is not as busy. We don't have Mohs surgeon, so most of the procedures that we have are simpler procedures that don't require that much anesthesia. For the more complex sessions might use alternatives to lidocaine like Marcaine or bupivacaine, which you have to keep in mind. It might have a slower onset of action, but it will have a longer duration of activity so that is beneficial. We occasionally will also use saline as an alternative, but we try to keep our volumes down. We also do a dilution with bicarb and epinephrine.

Paul:

In a similar vein, we had a question about just making shots more comfortable in general. We obviously know some patients are scared, just don't like any pain. What are some of the things that people can try to make the experience more comfortable for patients?

Sandri Johnson:

I'm presuming we're talking about shots that people will administer at home and not the shots that we give in the office?

Paul:

I think both. I think if there's anything you're doing in the office as well, them too.

Sandri Johnson:

Well, the first thing is at least for us is we don't rush through any of that. We want to have a comfortable environment. We are always trying to be very goal-oriented to keep in mind what is it that we're trying to achieve. If it's clear skin with a psoriasis or a atopic dermatitis injection, very goal-oriented. One of the things that I've done since my children were young is I came up with this concept of a mommy's magic Band-Aid. So a prescription of the cream that has lidocaine and prilocaine. Put a little bit of that on the pad of a Band-Aid and put it where you're going to be injecting, and then about an hour later, open the Band-Aid, cleanse the area, give the injection there so you have a reduction in pain for that. We also use cool compresses, vibration as well. Any other mode of destruction. How about you, Jamie?

Jayme Heim:

I think that really, it's not only children, but it's adults too.

Sandri Johnson:

Very much so.

Jayme Heim:

And so it's really nice that those adults too that want to come in for their injection in the office. I find that, A, having somebody else talk to them while you do the injection. Or lots of times they'll look at their phone and that's a great distractor. Emla always works very well, which you were talking about and that works very well. So anything that can be used as the distraction mode. Also, I will use the buzzy on children as well as on adults. And then also sometimes it's even just applying that pressure and so it takes away that pain for that area. And in going ahead and doing your injection, that really helps. That really helps a lot.

For children, I find that especially when you're doing injection site reaction, the parents in the act, to go ahead and show them how to hold. So it's really important to show them how to hold. My little bit older children, I always have something there to give them as a incentive. I have three little things that they can pick from, and then they can go ahead and pick from it. So then they're more likely to, because they really want that little gift afterwards.

Sandri Johnson:

The surprise.

Jayme Heim:

Yes, exactly. And so that really helps them to use the Emla too. And then too, an iPad helps too for those younger children in that. But if the parent, and especially if it's a child, a younger child, just don hold them and put the legs down between one or their legs in that, well, I give the injection or that because lots of times they don't feel comfortable doing that. That works really well. And I'll have my MA who's in the office work with me and they'll do the distraction. Bubbles actually work very good too for children. Children love to watch bubbles because it distracts them enough.

Sandri Johnson:

I think we all do.

Jayme Heim:

Exactly.

Sandri Johnson:

An adult loves a bubble too.

Jayme Heim:

Yep, so there are really a lot of things that you can do to distract adults as well as children.

Paul:

Yeah, it's a great inexpensive tip too. I mean, bubbles are.

Sandri Johnson:

Bubbles.

Paul:

Bubbles are cheap.

Jayme Heim:

Yes, they are cheap.

Paul:

You are listening to The Dermalorian Podcast from the Dermatology Education Foundation. We'll get more insights from Jayme Heim and Sandri Johnson in a moment. But first it's time for this episode's Dermalorian Clinical Clip. Multiple factors can influence the selection of a biologic treatment for psoriasis with or without joint involvement, but the order of FDA approval shouldn't be one of them. That's according to dermatologist Dr. Jennifer Song.

Jennifer Song:

Do I have to use biologics? Do I have to start with a TNF and then go to Stelara and then to the next, who says you have to use drugs in the order in which they were approved? So we have, the reason why more drugs are invented is because they're safer and better efficacy. So in terms of Stelara, I was using for a very long time because this was one of the biologics with more convenient dosing in our adolescent, in our adolescent patients with psoriasis. That's where it had settled in the recent years. But just about a week or two ago, Tremfya or guselkumab is now FDA approved for as young as six years old, which is huge.

Even though Stelara or ustekinumab I've used for safety is so great, parents still read the package insert so you have to guide them through it and talk about real world evidence. And it's so nice to be able to offer one of the IL-23 drugs because the package insert along with IL-17s is just so clean. It's really simplified, made that safety discussion so much easier. In fact, all of our safety information fits on one slide these days when I'm talking to you about IL-17s and IL-23. Guselkumab is now approved as young as six years old. They also have recent data that shows not only does it help for the signs and symptoms of psoriatic arthritis, but it also prevents radiographic progression. So they actually did further studies to really show that a 23 can be powerful to prevent that radiographic progression.

Paul:

Sticking with the theme of safety, let's get back to nurse practitioners Sandri Johnson and Jayme Heim for updates on the use of dietary supplements in dermatology.

We also got a lot of questions about supplements. Specifically, the first part was hair supplements. So do you guys recommend them? What are your thoughts on those for your patients?

Sandri Johnson:

This is definitely a big one. We deal with a lot of hair loss in our clinic, and this is a very emotional diagnosis for some of us as providers and clinicians. It might be personal to us as well, so doing a lot of research on what's out there and what works. And there's so many campaigns by manufacturers that might not have data to back up their claims. But yes, we definitely recommend vitamins for hair loss specifically. I personally like Nutrafol. A shout-out to them, they're here. I find them to be very effective. I've seen it in not only personally, but in a lot of the patients, with a downside of cost on that one. We have to be very mindful about what the treatment of all these diagnoses actually will cost. So Nutrafol is the one for me.

Jayme Heim:

Yeah, I agree. And I think that patients, lots of times they're looking for supplementation because they want something more natural. And there are several different pathophysiologic reasons why there is hair loss. A, part of our job to really find out really why this patient is exhibiting the hair loss it is. Is it patterned hair loss? Is it because they've just gone through a lot of patients we saw that went through COVID and they ended up having telogen effluvium, I mean things like this. So finding out and then educating towards that.

But overall, good supplements sometimes are very expensive, and as you know, we do not have an FDA approved supplement. And so therefore, trying to seek the best guidance is sometimes difficult. So I would say also too, for those patients who maybe just cannot afford something like Nutrafol, and I've done this and I really, what we have is we have a formula on in our local pharmacy with a grocery store, and it has a prenatal vitamin. Overall good prenatal vitamin, it has all of those minerals and everything in it. And that's what I've done too if people just want to take something and they're not ready to do other things, at that point.

Sandri Johnson:

If it helps grow a baby, it might help you grow some hair.

Jayme Heim:

That's exactly right. Exactly.

Paul:

Great point. So then people were asking just more broadly about supplement recommendations. Is there anything that you think can be beneficial? And is there anything you either don't want patients to take or you need to know if they're taking?

Sandri Johnson:

That's a very broad question because there is so much. I mean, I think when it comes to overall health, there's a lot of vitamins that we recommend just for the support of our immune system. For example, vitamin D is your master vitamin to support your immune system. Vitamin C, a very powerful antioxidant, but we're talking about hair and collagen. We need that vitamin C to even produce collagen or assimilate collagen. Zinc is a big one for us in dermatology, for wound healing, et cetera. We deal with a lot of inflammatory disorders as well so omega-3 are our big in our office.

And then probiotics, gut health, we have learned over the last few years how the core of our immune system is within our microbiome in our gut, so gut health is big, and another antioxidant would be maybe CoQ10, coenzyme Q10 for the antioxidants. The last one that is just big now is magnesium, right?

Jayme Heim:

Yes.

Sandri Johnson:

So magnesium is getting all the hype and it's not hype. It's true because magnesium is another master vitamin that will help your muscles. It helps your bones, cardiovascular health, mood, sleep, energy. So that's becoming a large recommendation in my office is magnesium.

Jayme Heim:

I really don't exclude anything if patients would like to try these supplements. I don't have a problem with it as long as it's not detrimental to them their health. And as long as they're not taking over what the FDA suggested amounts are for those. Because two, if you take too much of a supplement too, there is a side effect to that. There is a toxicity for some of them, and so that's why you really have to be mindful of that. But if it's not going to be harmful to them, absolutely, why not?

Sandri Johnson:

Yeah, your fat soluble vitamins, your A, D, E, K are the ones that you have to be mindful of what we recommend. Of course, we're mostly dealing with vitamin D from the ones that I recommend, but too much is, more is not always better.

Paul:

And I think it's important, you started with vitamin D when you first started to answer, and I understand that this whole story is resurfacing again, that people want to get out in the sun because they want their vitamin C, but they can take a supplement and they'll be fine.

Sandri Johnson:

Yeah.

Jayme Heim:

That's right. And lots of times in primary care, when they see patients with psoriasis, they think, "Oh, you know what? You're probably vitamin D deficient. Let's just draw your vitamin D level," and it comes back normal. And so there's not a lot of times that they have to supplement with vitamin D because really we do get enough vitamin D, most of us do. And so that is one thing that needs to be educated on a little bit better.

Paul:

This is The Dermalorian Podcast made possible with support from Johnson & Johnson. Before we conclude this episode, we turn to dermatologist Dr. David Cohen for this episode's Dermalorian Derm Decoder. Dr. Cohen addresses chronic hand eczema and a new treatment option: delgocitinib.

David Cohen:

During the annual DEF meeting, Joe made quite an announcement that topical delgocitinib cream became available for the treatment of chronic hand eczema. Chronic hand eczema is a difficult in vexing inflammatory condition of the hands caused by a multiplicity of causes. It could be allergic contact dermatitis, irritant contact dermatitis, physical natures, endogenous causes, and atopic dermatitis. It is not one cause. It is a multiplicity of causes and we really had limited treatments available. We were really borrowing treatments from eczema and sometimes systemic immunomodulatory or immunosuppressive therapy to get control. Hands are critical to our activities of routine daily living. We use them from the moment we wake up to perform routine activities to performing almost every aspect of our work, right?

So when your hands, although 1% of the total body surface area of your fingertips, you can't do just about anything you need to when they're inflamed. You can't zip your pants up or button your shirt, or certainly perform a punch biopsy or liaise with clients on a regular basis while your hands are inflamed. So finally, we have a pan-JAK inhibitor that had remarkable safety and remarkable efficacy at alleviating the signs and symptoms of hand eczema. I think we're all excited to have that opportunity to use it.

Paul:

Thank you for joining us. The Dermalorian Podcast is produced for the DEF by Physician Resources. If you've missed episodes, catch up now wherever you get your podcasts, and be sure to tell your colleagues. Stay tuned for more clinical insights and practical tips from the DEF.