Transcription:
Pediatric Skin Care with Stephanie Kronberg

Trisha Williams:  Hi guys. Welcome to the Advanced Practice Perspectives. I'm Trisha Williams.

Tobie O'Brien: And I'm Tobie O'Brien. This is a podcast created by advanced practice providers for advanced practice providers. We will be highlighting our amazing APPs here at Children's Mercy and do some education along the way.

Trisha Williams: We are so happy that you're joining us today. It's time to sit back, tune in and let's get started.

Tobie O'Brien: So today, we have a special guest with us, Stephanie Kronberg. Now with warmer weather on its way, although as we are recording this podcast, we had two inches of snow in late April, but as warmer weather is approaching, we wanted to sit down and talk with her about skincare. So Stephanie, welcome to the Advanced Practice Perspectives podcast. Thank you for joining us.

Stephanie Kronberg: Yeah, thank you so much for having me.

Trisha Williams: Yeah, Stephanie, we're super excited to have your take on pediatric skincare, having you be an advanced practice provider in our dermatology clinic. So tell us a little bit about yourself.

Stephanie Kronberg: So I grew up in Minnesota, and kind of lived there as a child, went to college there and got my nursing degree there. And I worked for a few years there as a nurse on kind of like a medical-surgical floor. And we had kids and adults on our floor. And I loved working with the kids the most. So then I decided to go back to school to be a pediatric nurse practitioner. And so my husband and I moved out to Boston, Massachusetts. And I went to school at Boston College and earned my master's degree there.

And so we had so much fun living in Boston. We made some really great friends, ate some amazing seafood and just loved living by the ocean. And it was great. But then I couldn't find a job there. And so then I started applying for jobs kind of throughout the country and especially in the Midwest, since that's where I was from. And then kind of randomly ended up getting a job at Children's Mercy in the Dermatology Department. And that was about seven years ago. So that's when I started, I've been in dermatology since that time.

And then just a little bit about my personal life. I'm married to Jordan, who I met in college, and then we have two little boys. Everett is four and Oliver is two. We live in the Brookside neighborhood of Kansas City. And on weekends, you'll find us going to McLain's Bakery and going for walks and bike rides to the park and just kind of hanging out in the backyard.

Tobie O'Brien: So tell us a little bit more about your role in dermatology. Well, first of all, we are so glad that Boston didn't have anything for you and you had to come here.

Trisha Williams: Even though Boston is one of my favorite cities. Boston's a fantastic city, but we're glad you're here.

Tobie O'Brien: So I get wanting to stay. So tell us about the Dermatology Department and tell us what your role really is in the Dermatology Department.

Stephanie Kronberg: So I work mostly in the outpatient setting. Our main clinic is at the Broadway location. And I work two days a week there. And then we have a Northland location where I work one day a week as well. And so I see a variety of diagnoses. I would say the top two are probably eczema and acne. But then we also see a lot of warts, psoriasis, hydradenitis suppurativa, variety of skin infections. And then a lot of times, kids will be referred for one thing, one diagnosis, but then they'll be sent home with a completely different diagnosis or a list of multiple diagnoses.

Trisha Williams: So how many advanced practice providers are there in the dermatology clinic?

Stephanie Kronberg: So we have quite a few. We have six nurse practitioners in dermatology. Most of us do just outpatient clinic. But then one of our nurse practitioners, Meredith, does both outpatient and inpatient. So she rounds on all of our inpatient consult, usually with our attending physician who's on call. And then we see patients at a variety of locations, Broadway Northland, Kansas East. And then we also do a lot of telehealth. One of our nurse practitioners has been doing telehealth for a few years now. But with COVID now, we are all doing telehealth. So we do a lot of that.  

Tobie O'Brien: Well, tell me how is telehealth working for you guys? Do you like it? I would think if anything, I thought, "Wow, dermatology might be able to do pretty well doing telehealth." What do you think of it?

Stephanie Kronberg: Yeah. A lot of people think that. And in a way, yes, I feel like somethings are really great for telehealth. I think acne is a really good diagnosis to see in telehealth as long as families are sending us good quality photos ahead of time. It can be difficult if patients don't send photos and they have kind of blurry video and we're also only seeing kind of a small portion of their skin instead of all of their skin. So yeah, it's been pretty good. But yeah, I think some things are more appropriate for telehealth than others.

Trisha Williams: Yeah, I can speak from a parent perspective. I have two teenagers and my teenage son was seen in dermatology via telemedicine right at the start of COVID. And we felt like it was a very productive visit. And, on the provider side of it, doing telemedicine in otolaryngology where we work is extremely difficult. So I was very grateful that from a parent perspective, our visit was very productive and I felt good about it. And it was for acne, so...

Stephanie Kronberg: Yeah. Oh, I'm glad you had a good experience with it. But yeah, I think acne is great for telehealth.

Trisha Williams: So you have six advanced practice providers. How many physician colleagues do you have in dermatology as well?

Stephanie Kronberg: We have five physician colleagues.

Trisha Williams: Ah, you guys are a small department. I feel like that's small.

Stephanie Kronberg: Yeah, we are pretty small actually.

Tobie O'Brien: Stephanie, do you guys, the APPs, do any procedures in dermatology?

Stephanie Kronberg: We do some. For our warts patients, we do a lot of cryotherapy with liquid nitrogen. So that's like when you freeze a wart. You may be familiar with that. We also inject warts with a yeast protein. So for some of our kids who have a lot of warts, we can use candida antigen, which it works with the immune system to kind of help the immune system, recognize the wart virus and fight it off. So we inject the warts with a small amount of the yeast protein. So we do a lot of that. We do some skin biopsies too, just more for helping with the diagnosis.

Tobie O'Brien: I see. Okay. Well, you know, I was talking with Stephanie offline about this, but you said that you guys see a lot of molluscum. And I was laughing and telling Stephanie that my-- well, she's eight now, but when she was two, she had bad molluscum. And I think we said, Dr. Canty and I remember saying to her, "Oh my gosh, I think this must be why she wants me to scratch her back all the time." And Dr. Canty said, "No, I think she just wants you to rub her back and scratch her back." So she said, "It's not from the molluscum." So you guys see a fair amount of that as well.

Stephanie Kronberg: Yes. Yes. So we do see a lot of molluscum. Unfortunately there's not a lot of great treatments out there for molluscum. But we're always happy to see kids for molluscum and kind of talk it through with parents and all of the times they just want to know kind of what to expect.

Trisha Williams: It's very common. My son had it as well. He's my fair-skinned ginger red-headed child that gets everything, so...

Stephanie Kronberg: Yeah, it is pretty common.

Tobie O'Brien: Well, I had the pleasure of working with Stephanie in the academy. We took that together. And so I just wanted for a second to highlight her because she was, I believe, one of the only ones in our cohort whose letter to the editor was published. And I thought that was such an accomplishment and I was hoping she could share a little bit about that for our listeners.

Stephanie Kronberg: Yeah, sure. So yeah, I was excited too when I heard that it was published. So in my letter to the editor I mentioned an incident that occurred when a baby with a non-contagious genetic skin condition, it was called ichthyosis and it basically causes really dry skin. So that baby was kicked off an American Airlines flight due to the appearance of his skin. And so that was kind of the basis of it.

But the significance of this story is really that kids with skin conditions, they're unique in that a lot of times their condition is visible to other people. So unlike a heart condition or diabetes where you can't really necessarily see it from the outside, our kids you can see it. And so sometimes they're bullied and sometimes they get kind of self-conscious just about how their skin looks. And then there's variety of strangers in the grocery store, grandparents, well-meaning friends and family, but all sorts of people giving unsolicited advice. And it gets kind of old for these kids and these families.

So I was basically just kind of asking the public to be kind and not stare at people who look a little bit different than them. Because there are a lot of studies that show that skin conditions don't just affect the skin, but they can really have an impact on quality of life and mental well-being.

Trisha Williams: Sure. How impactful that letter must've been. I need to find it and read it. Good on you. That's fantastic. So also, a little birdie told me that you were a speaker during the National Associations of Pediatric Nurse Practitioners Annual Conference. What is that about?

Stephanie Kronberg: Yeah. So I will have to give a big shout out to my nurse practitioner colleague, Rebecca Flynn, because she had presented at nap in the past and invited me to submit an abstract with her. So we co-presented, which made it a lot less intimidating. And it was supposed to be an in-person lecture. This would have been about a year ago. But just like everything else, it turned virtual due to COVID. And so instead of giving the presentation in front of hundreds of people, we did it from our office at our clinic in front of a screen. So it was a lot less intimidating.

Trisha Williams: For sure.

Stephanie Kronberg: Yeah. So we recorded it. It was not live So, yeah, I was a lot less nervous presenting it. But hopefully, someday I'll get the chance to present in person because I feel like there's probably something kind of more exciting and rewarding about actually getting to see the audience.

Trisha Williams: Actually having those nerves and armpit sweat remember the name of. What was your topic about?

Stephanie Kronberg: Yeah. So it was called Atopic Dermatitis: The Old, The New and The Trending. So atopic dermatitis is another name for eczema. An eczema is a really common skin condition that we see in our clinic, probably the most common thing we see. And so our presentation just looked at some of the old ideas for treatment, some of the new ideas and new treatments that are out there and then some of the more trendy topic.

So I won't go too much into eczema, but some of the old things are like topical steroids, moisturizers, frequent bathing, staying away from things with fragrance. And so those things are still really important. Those who've kind of stood the test of time. But then there are also a couple of new medications that have come out over the last couple of years, and some of them have been really impactful to our patients especially those with pretty severe eczema.

But then the trending that's kind of the more interesting part. So eczema is such a common skin condition and it often starts in infancy. And because like I said, it affects a child's appearance and then it causes itching and it can affect sleep. So this can be really bothersome to parents understandably. And so they often do get advice from strangers saying, "Oh, you need to do this and that." Like, "This works for my kid," and "Oh, no. This works for my kid. You need to cut out this food or that food and start probiotics or try breast milk baths," like all sorts of different ideas.

Trisha Williams: Wow.

Stephanie Kronberg: Yeah. There's so many ideas out there. And so, especially if you look on, there's a variety of different Facebook groups for moms of kids with eczema, and there are just so many ideas out there. And so think it's helpful for us to know that ahead of time and just know what people are reading, but also try to kind of meet families in the middle. So don't say, "Oh no, all those ideas are ridiculous. You need to do what I tell you to do." More just like, hey, if they're doing something and they think it's working, like this morning, I had someone say that they ordered some Dead Sea salt, I think probably from Amazon, and they threw it in the bathroom and they think it really helps. So I'm like, "Well, I don't think it's going to hurt. And if you think it's helping, go ahead and continue that. But also will you please do these other things that I know are going to help." So it's kind of like meeting them in the middle and letting them do some of their ideas and then some of our ideas, as long as their ideas aren't harmful.

Trisha Williams: I think that's a really good piece of advice for all providers, right? You know, with technology comes more ways for parents to gather information, get input from others, solicit advice from all sorts of walks of life. And like you said, they're ideas and we can't necessarily say, "Oh, that's ridiculous. Those was a ridiculous." Like we have to meet them in the middle. If they're doing something that as long as it's not harmful and they feel like it helps, meet them in the middle. I think that's a great piece of advice.

Stephanie Kronberg: Yeah. You know, you want to be respectful to them so they can trust you too.

Trisha Williams: You're so wise.

Tobie O'Brien: I love it. Well, I know you can't really endorse any products, but just what are some of your favorite like skincare products for those kids with eczema then?

Stephanie Kronberg: Yeah, as far as moisturizers, we usually recommend either ointments or creams. So we like the nice thick moisturizers. So we always tell people to stay away from lotions. If it comes out of a pump and it's a thin watery lotion, it's probably not going to do a whole lot for you. So stick with the thicker creams or the greasy ointment like Vaseline. Vaseline is super cheap and it works really well. And most people don't react to it. So that's the one that we recommend quite a bit. It's not good for kids with acne. They should avoid it. If you have acne, you should stick with just like an oil-free moisturizer, and then for soap, just fragrance-free and it really doesn't matter what brand it is. It can be bar soap, it could be liquid soap, just make sure it's fragrance-free and same with laundry detergent too.

Tobie O'Brien: I'm always a sucker for that, like dermatology-tested and approved at Target. "Okay. Which one should I get?" I'll stare at it for like 10 minutes. So it's good to know.

Stephanie Kronberg: Yeah, you got to watch out for those.

Tobie O'Brien: All right. So as we head into this summer and all of us, it as well as our kids our own children, as well as children that we come into contact with in the clinic, I think this would be a great opportunity to hear your thoughts on skincare that we can be helping them understand better, taking good care of their skin during the summertime when they are always exposed to the outside sun. So I wondered if you could share a few tips with us on what you tell your patients and things that we may be could implement on a daily basis with our kids.

Stephanie Kronberg: Yeah. Sure. So I'll start by saying sun protection is really important all year round. But it's even more important, like right now as the weather's warming up, just because we are spending a lot-- well, hopefully, soon we'll be spending a lot more time outside as it warms up. And the biggest reasons to use sun protection, we probably all know this, is just because sun exposure can lead to skin cancer and early aging.

So one thing that I think most people know that sunburns are bad for the skin, but some people may not know that a suntan and even freckling are signs of sun damage too. So you want to try to avoid even getting a tan in the summer if possible. And then sun protection, you want to do it on the sunny days obviously, but then cloudy days too, because some of the sun's rays can penetrate clouds and even car windows. So ideally, you just kind of get into the habit of using sun protection every single day.

And then some tips that a lot of people already know some of these, but, as much skin that you can cover with clothing, hats, sunglasses, that's probably the best thing you can do and swim shirts are great. So if you can have your kids doing long sleeve swim shirts, that's ideal and just kind of staying either inside or in the shade from 10:00 to 2:00. Those are the times that the sun is the strongest.

And then a lot of people wonder which sunscreen is best. And so three things to look for when you're looking at sunscreen, number one, you want it to be broad-spectrum, so UVA and UVB protectant. You want it to be SPF of 30 or more, and then you also want it to be water-resistant. And there are two different types of sunscreens. So there are physical blockers and there are chemical blockers and they work in different ways.

Chemical blockers absorb the sun's rays while physical sunscreens work more like a shield. So they sit on the surface of the skin and they deflect the sun's rays. The physical blockers are the ones that we typically recommend for our patients, just because they're better for sensitive skin and the ingredients are safer. Not to say that the chemical ingredients are unsafe, but I just don't think we know enough right now. So we will typically recommend the physical blockers. Those are going to contain either zinc oxide or titanium dioxide, or sometimes those. And these are the ones that are a little bit harder to rub in, but I think it's worth it.

And as far as like what's better a lotion or a spray or a stick? I think the sticks are really good for the face and especially near the eyes, just because then you don't have to worry about getting the lotion or cream in the eyes. But then other than that, we prefer creams and lotions over sprays, just because with the creams and lotions, it's a little bit easier to make sure you're actually covering all your skin. With the sunscreen spray, it can be a little bit tricky. A lot of people miss spots, and then there's the risk of inhaling some of it too. So if you have to use a spray or if that's all your kid will use, then just make sure to have them right into their hands and then rub it in to their skin.

Trisha Williams: I didn't know there was a difference between chemical and physical protection for sunscreen. Now with those two, is there one that has to be applied more frequently? Because like I said, I have a very fair skin ginger, and he is a red-haired, blue-eyed, pasty child. And he's a teenager now, so I have to tell him like he's an every hour and a half kid to put sunscreen on or he burns. So would one last longer than the other?

Stephanie Kronberg: Not necessarily. Either one you're going to want to do it at least every two hours and then more often with swimming or sweating. For anyone with like fair, sensitive skin, I would recommend a physical blocker, so the zinc oxide or titanium dioxide. For teenagers, let's say he really didn't like rubbing it in so much and like it left kind of a white discoloration on his skin and that really bothered him, then he could do a chemical blocker. I think whatever you're going to use is better than nothing for sure.

Trisha Williams: Yeah, good point. Good point. And then in regards to like our otolaryngology patients, I do a lot of ear surgery and see a lot of post-op ear surgery patients that have postauricular scars, is there a particular sunscreen barrier that you recommend for scars? Because I know a lot of our other advanced practice providers take care of surgical patients with scars. Like I always recommend sunscreen, but I just basically say, "Use some sunscreen on that scar back there." So any other types of recommendations?

Stephanie Kronberg: I don't think there are any particular sunscreens or brands that you need to go toward. I would probably do the physical blocker. I would probably recommend that they wear a hat too, if they're open to doing that, just to kind of give an extra barrier.

Trisha Williams: Sure. Good idea.

Tobie O'Brien: Yeah, I love it. I love swim shirts, but I'm like ready to bring some swim pants in, like why don't we market those? " I don't know. I think I could totally do it.

Stephanie Kronberg: No, I think I've seen them out there. I've seen a couple of kids at pools with like an entire swimsuit, so like head to toe, arms, legs, everything. And then I'm always like, "Oh, wow, that's impressive."

Trisha Williams: I'm going to try to get my 15-year-old to wear that.

Tobie O'Brien: Well, I hate rubbing in zinc oxide that much. I think I would totally buy that.

Stephanie Kronberg: It is totally a pain.

Tobie O'Brien: Yeah. Oh, well, we so appreciate you sharing your expertise and we hope it's helpful to our listeners to be able to have these little tidbits of information to share with, you know, their patients or family or however they can use this information. Thank you for sharing all of this.

Stephanie Kronberg: Oh, yeah, you're welcome.

Trisha Williams: Yeah, it was fantastic for me as a parent and for a provider as well. So thank you so much. And you know, we kind of ask all of our guests one final question, and if you've listened to our podcast, you kind of know what that final question is and you're ready for it. But if you could give yourself, your younger self, a piece of advice, like go back to a year after you graduated from your nurse practitioner program, what kind of advice would you give yourself? Because you gave us a lot of good advice today, but what would you give yourself?

Stephanie Kronberg: Yeah, that's a good question. So when I was thinking about this, so it all kind of goes back to like, I have kind of a like a people pleaser, perfectionist personality. So I would want to tell myself that no one expects you to know everything and you don't have to be perfect. Just show up on time every day, work really hard while you're there, and then go home and read about the things later, the things that you saw.

Just because I feel like when you're reading about stuff, it means so much more once you've actually seen a patient with something. So reading about it later, I think has been really helpful. And then just telling myself too that like, you're going to feel like you don't know anything, but then if you can jump forward like six months to a year, you'll be shocked by how much you actually know.

Trisha Williams: Agreed. Good piece of advice. I love it.

Tobie O'Brien: Yeah. Great advice. Oh, Stephanie, thank you so much for your time and for sharing your expertise and wisdom with us. And listeners, thank you for tuning in. Our next episode, we will feature Cassandra Newell from our very own emergency department to talk about all the chaos in the emergency department as well as some summer safety tips from her.

If you have a topic that you would like to hear about or you're interested in being a guest on our podcast, you can email us at tdobrien@cmh.edu or twilliams@cmh.edu. Once again, thanks so much for listening to the Advanced Practice Perspectives podcast.