In the context of rising patient demand, physician workforce limitations, and the increasing complexity of dermatologic care, the distinction between dermatologists and physician assistants (PAs) in dermatology has never been more consequential. As someone who has worked alongside both groups in a variety of clinical and academic settings, I have seen firsthand how crucial it is to delineate roles clearly and responsibly. The integration of PAs into dermatology practices has become not only common but often essential to meet patient volume and maintain operational efficiency. However, this expansion also raises critical questions regarding scope, training, and quality of care.

This article seeks to address these issues in depth. Our goal is not to draw arbitrary lines or promote hierarchy for its own sake, but rather to illuminate the factual, structural, and clinical distinctions that exist between these roles. For professionals involved in dermatologic care, particularly those making staffing, supervisory, or training decisions, a nuanced understanding of these differences is indispensable.

Dermatologists undergo some of the most competitive and academically rigorous training in all of medicine. After completing a four-year undergraduate degree, prospective dermatologists attend medical school, which typically spans four years and culminates in the MD or DO designation. During this time, students are exposed to a broad curriculum covering basic sciences, clinical medicine, and supervised clinical rotations. Dermatology rotations, while brief during medical school, often spark early interest and guide residency applications.

After medical school, dermatologists enter a residency program, which generally involves a one-year preliminary internship (often in internal medicine or surgery) followed by three years of dedicated dermatology residency. These years include intensive exposure to general, surgical, cosmetic, and pediatric dermatology, as well as dermatopathology. Residents are expected to manage complex medical dermatologic conditions, learn surgical procedures, and develop diagnostic acumen that encompasses thousands of skin conditions, some of which are rare or systemic in nature.

Fellowship training is optional but increasingly common. Dermatologists may pursue fellowships in dermatopathology, Mohs micrographic surgery, or pediatric dermatology. Upon completion of residency and any fellowship training, board certification through the American Board of Dermatology (ABD) or American Osteopathic Board of Dermatology (AOBD) serves as a credential of comprehensive competence. This rigorous educational pipeline ensures that dermatologists are thoroughly trained not just in the procedural aspects of dermatology but also in its clinical and pathological foundations.

Physician assistants, by contrast, follow a different educational model. Most PA programs require a bachelor’s degree and prior healthcare experience for admission. These programs typically last about two to three years and culminate in a master’s degree. The curriculum is divided between classroom instruction in basic and clinical sciences and clinical rotations in various fields such as internal medicine, family medicine, pediatrics, and surgery. Some programs include dermatology rotations, but most do not offer this as a core or extended rotation.

After graduation, PAs must pass the Physician Assistant National Certifying Exam (PANCE) and obtain licensure. Those entering dermatology almost always do so without formal dermatology training, which means their education in the field begins on the job. Some dermatology practices offer structured in-house training programs, while others rely on preceptor-driven mentorship. Postgraduate dermatology PA fellowships exist, such as those endorsed by the Society of Dermatology Physician Assistants (SDPA), but these remain relatively few and are not required for practice.

PAs can pursue additional education through the SDPA Diplomate Fellowship, a self-paced academic program designed to standardize dermatology-specific training. However, completion of this fellowship is not a licensing or regulatory requirement. This lack of standardization leads to significant variability in the training and competency of PAs in dermatology, depending heavily on practice environment and supervising physician engagement.

When we compare the educational pathways, the differences in depth and duration are stark. Dermatologists typically undergo over a decade of post-secondary education and clinical training, including thousands of hours specifically in dermatology. They are trained to manage the full spectrum of dermatologic conditions, including systemic diseases with dermatologic manifestations, malignancies requiring surgical precision, and complex diagnostic dilemmas involving skin biopsies and histopathology.

PAs entering dermatology, even with postgraduate training or certification, generally do not receive formal exposure to the breadth of dermatologic pathology encountered in a residency or fellowship. Their clinical acumen is often shaped by the scope of cases seen in their specific practice setting. While many PAs become highly competent in specific domains such as general dermatology or cosmetic procedures, their training is neither as broad nor as standardized as that of board-certified dermatologists.

In the realm of medical dermatology, dermatologists are trained to serve as primary diagnosticians and therapeutic decision-makers. Their training equips them to evaluate a wide spectrum of skin disorders, ranging from common conditions like acne and eczema to complex autoimmune diseases such as pemphigus vulgaris or dermatomyositis. They are proficient in the use of systemic therapies, including immunosuppressants and biologics, and they are well-versed in managing complex pharmacologic interactions. Dermatologists also take responsibility for risk mitigation strategies such as laboratory monitoring and coordinated care with other medical specialties.

PAs in dermatology can evaluate and manage many of the same conditions under supervision or collaboration, depending on state laws. Their practice in medical dermatology often centers around high-volume, lower-complexity conditions, although experienced PAs may handle more challenging cases. However, in many practices, especially those with high patient volumes, PAs are often limited to conditions that follow protocolized management or where risk stratification is lower. Prescription authority is determined at the state level and may require physician oversight, particularly for high-risk medications like isotretinoin or systemic immunosuppressants.

Procedural dermatology encompasses a wide array of techniques, from basic cryotherapy and curettage to complex surgical excisions and cosmetic interventions. Dermatologists are thoroughly trained in surgical technique, tissue handling, and margin assessment. Those who complete Mohs surgery fellowships specialize in microscopically controlled cancer excisions that demand not only technical skill but deep understanding of dermatopathology.

PAs may perform a range of procedures depending on their experience, state regulations, and practice protocols. Many perform biopsies, cryotherapy, and simple excisions. In aesthetic practices, PAs are frequently involved in administering injectables and operating laser devices. However, the extent of procedures they are permitted to perform is usually determined by the supervising physician, and they typically do not handle advanced surgical procedures.

Dermatologists frequently manage complex cases that require coordination with rheumatology, oncology, or infectious disease. Conditions such as cutaneous T-cell lymphoma, severe hidradenitis suppurativa requiring biologic therapy, or drug-induced dermatoses demand a depth of systemic knowledge and diagnostic accuracy that falls within the purview of board-certified dermatologists. PAs may assist in the ongoing management of such patients but usually do so with physician guidance and typically do not initiate or modify advanced systemic therapies on their own.

One of the most often misunderstood elements of PA practice is the legal structure that governs supervision and collaboration. While dermatologists are licensed to practice without restrictions in all 50 states, PAs work under varying levels of oversight depending on state regulations. Some jurisdictions require direct supervision, while others permit collaborative agreements that provide greater flexibility in how PAs engage with physicians. Although some states are moving toward models that reduce the formal supervisory burden, collaboration with a physician remains an essential and beneficial component of effective dermatologic care.

Even in states that have adopted more flexible regulatory frameworks, the actual delegation of clinical responsibilities is shaped by internal practice protocols, the complexity of cases, and specific payor requirements. Supervision in this context is not simply a legal obligation. It serves as a vital clinical safeguard, particularly in situations where diagnostic uncertainty or therapeutic risks are high. Having a collaborating physician involved in care decisions helps maintain quality standards and ensures that patients receive safe, evidence-based treatment.

Supervisory structures can also differ widely based on practice setting. Academic medical centers often follow strict protocols that include detailed documentation reviews and regular co-signatures. In contrast, private dermatology practices, especially those with a high patient volume, may structure oversight in ways that reflect the operational realities of their workflows. However, in any setting, having a clear and collaborative relationship between PAs and supervising physicians is crucial. It allows for better case discussions, more thorough oversight, and shared responsibility for outcomes.

Administrative and billing requirements further shape the landscape. Chart review frequency, documentation standards, and payor-specific supervision rules can influence how services are billed and reimbursed. Some insurers mandate documented physician involvement for reimbursement, especially for certain procedures or new patient visits. Navigating these rules correctly has a direct impact on the financial and legal standing of a practice.

In every model, strong collaboration with a physician is not only beneficial from a regulatory standpoint but is also professionally enriching. Working closely with an experienced dermatologist allows PAs to expand their clinical knowledge, refine procedural skills, and contribute more meaningfully to the care team. Practices that invest in structured, high-quality collaborative relationships see the benefits in both patient outcomes and operational performance.

Billing mechanisms for services rendered by PAs depend heavily on whether the practice follows incident-to billing or direct billing protocols. Incident-to-billing allows the practice to bill under the supervising physician’s National Provider Identifier (NPI), typically at 100% of the Medicare Physician Fee Schedule rate. To qualify for incident-to billing, the physician must be involved in the patient’s care plan, and the service must be rendered in a setting that meets specific supervision criteria.

If these criteria are not met, or if the visit is a new patient consultation or involves a new problem, the PA must bill under their own NPI, generally reimbursed at 85% of the physician rate. Private payors may follow similar or different rules, leading to considerable administrative complexity. Practices must carefully document the level of physician involvement to ensure compliance and prevent fraud allegations.

The differential in reimbursement rates between physician and PA services, coupled with differences in compensation, creates economic incentives that influence staffing decisions. From a business standpoint, employing PAs may improve access and profitability, especially in high-volume general dermatology settings. However, over-reliance on lower-cost providers without adequate training or supervision can lead to suboptimal outcomes, legal exposure, and reputational risk.

Many practices use a hybrid model where dermatologists focus on high-complexity and procedural cases, while PAs manage follow-ups, chronic disease maintenance, and cosmetic services. This allows for a stratified workflow that maximizes revenue and efficiency. However, such models demand robust protocols, clear delegation of duties, and a culture of continuous learning to avoid clinical errors and preserve quality.

When evaluating the quality of care delivered by PAs versus dermatologists, it is important to acknowledge the limitations of available data. Several studies have attempted to assess diagnostic accuracy, prescribing patterns, and patient outcomes across provider types. Some retrospective studies suggest that PAs can safely and effectively manage common dermatologic conditions under appropriate supervision, especially when operating within standardized treatment pathways.

However, discrepancies in diagnostic concordance have been observed, particularly in complex or atypical presentations. For example, studies analyzing biopsy outcomes have shown that dermatologists are more likely to perform biopsies in high-risk lesions that ultimately result in a malignancy diagnosis, indicating a higher pre-biopsy diagnostic accuracy. Similarly, dermatologists are generally more conservative in initiating systemic therapies, likely reflecting a greater awareness of the side-effect profiles and monitoring requirements associated with such treatments.

In contrast, PAs have been shown to biopsy a higher volume of lesions with lower diagnostic yield, potentially due to less confidence in visual diagnosis or a lower threshold for procedural management. While this does not necessarily reflect poor care, it underscores differences in clinical training and decision-making approaches. These nuances are crucial when considering the allocation of responsibilities in a busy dermatologic practice.

From a medico-legal standpoint, dermatologists carry primary liability for care delivered in most practices, especially when services are billed under their name. That said, PAs are not immune to malpractice exposure. Cases involving delayed diagnosis of melanoma, inappropriate use of isotretinoin, or cosmetic complications have led to litigation against both PAs and their supervising physicians.

Data from malpractice insurers indicate that while claims against PAs are less frequent than those against dermatologists, this is largely a function of their more limited scope. When claims do occur, they often involve failure to recognize malignant lesions or complications from cosmetic procedures. For dermatologists, malpractice risk more frequently arises from procedural complications or failure to diagnose aggressive skin cancers in a timely manner.

Robust supervision, peer review, and continuing education are critical tools in risk mitigation. Practices that implement standardized protocols, foster collaborative case discussions, and invest in ongoing training tend to demonstrate lower medico-legal risk profiles and better patient outcomes across the board.

Patient perception plays a pivotal role in the success of a practice, especially in fields like dermatology where cosmetic and aesthetic outcomes significantly influence satisfaction. Many patients report high levels of satisfaction with care delivered by PAs, particularly when rapport, accessibility, and communication are strong. However, studies have also shown that patients often do not fully understand the difference in training between PAs and dermatologists. This lack of awareness can lead to mismatched expectations or concerns about care quality when complications arise.

Among physician peers, there is variability in how PA integration is perceived. In academic settings, PAs are often valued for their ability to enhance clinical throughput and assist in procedural care. In private practice, opinions range from enthusiastic endorsement to cautious skepticism, often depending on the individual PA’s training, competence, and oversight structure. Regardless of setting, transparency in provider credentials and scope of practice is essential for maintaining patient trust and inter-professional respect.

The evolving landscape of dermatologic care increasingly necessitates team-based models where responsibilities are delegated based on training, experience, and risk stratification. In many high-volume practices, PAs serve as front-line providers for routine follow-ups, acne management, wart treatment, and maintenance of chronic dermatoses. This allows dermatologists to focus on surgical cases, complex diagnostics, and higher-acuity patients.

Successful collaborative models depend on clear communication, mutual respect, and well-defined escalation protocols. Practices that foster routine case review meetings, shared documentation systems, and open-door policies for second opinions tend to function more cohesively and deliver higher quality care. Conversely, models that operate on loosely defined supervisory relationships risk care fragmentation, inconsistent outcomes, and burnout among both PAs and physicians.

While dermatologists frequently serve as principal investigators in clinical trials, contribute to peer-reviewed publications, and hold teaching appointments, the academic role of PAs in dermatology remains limited but growing. Some PAs participate in case reports, co-author research, or lecture at PA training programs. However, institutional limitations, lack of protected time, and fewer academic pathways tend to constrain their involvement compared to physicians.

As PA postgraduate training programs in dermatology expand, there is potential for more structured academic integration. This includes roles in didactic instruction, skills labs, and student mentorship within both PA and dermatology residency programs. Such engagement benefits not only the individual provider but also elevates the level of interdisciplinary education and clinical collaboration across the field.

Leadership roles within dermatology have traditionally been dominated by physicians, particularly within the American Academy of Dermatology (AAD). However, professional organizations such as the Society of Dermatology Physician Assistants (SDPA) have established a national platform for PAs to advocate for expanded training, credentialing, and legislative influence. These organizations play an important role in shaping best practices, lobbying for Optimal Team Practice legislation, and promoting continuing medical education.

Dermatologists who serve on institutional boards or within state medical societies also play a critical role in defining scope boundaries, credentialing standards, and collaborative practice agreements. A healthy partnership between these advocacy bodies is essential to ensure that expansion of PA roles is guided by patient safety, data-driven outcomes, and ethical alignment.

Dermatologists enjoy a broad range of career opportunities spanning private practice, hospital-based care, academic medicine, industry, and global health. The ability to subspecialize further within dermatology opens doors to highly focused careers in dermatopathology, surgical oncology, or pediatric care. Many dermatologists also pursue administrative leadership roles, policy work, and innovation in areas such as teledermatology and AI-driven diagnostics.

Academic dermatologists frequently engage in curriculum design, resident mentorship, and national conference leadership. Those in industry may consult for pharmaceutical companies, design clinical trials, or advise on regulatory strategy. The versatility of the dermatology skill set, coupled with the high demand for services, positions dermatologists for long-term career flexibility and influence.

PAs in dermatology also have expanding opportunities, although their career pathways tend to be more clinically focused. Many remain in general dermatology for the majority of their careers, while others shift toward aesthetics, procedural care, or clinical leadership within group practices. Some practices promote experienced PAs into supervisory roles over newer hires, training coordination, or operational management.

With increasing access to postgraduate programs, specialty certifications, and national networking platforms, PAs are gradually establishing clearer developmental milestones. However, upward mobility into academic, research, or entrepreneurial roles remains more limited compared to physicians. Nonetheless, in high-performing practices where mentorship is strong and clinical excellence is rewarded, PAs can build long, impactful careers in dermatology.

From an ethical standpoint, the clarity of provider roles is critical to safeguarding patient welfare. PAs and dermatologists alike must be forthright in explaining their qualifications, limitations, and decision-making frameworks to patients. Ambiguity in titles such as “dermatology provider” or “skin specialist” can mislead patients and erode trust, particularly if adverse outcomes occur or specialist-level decisions are made by providers without equivalent training.

Ethical practice also requires knowing when to refer. PAs must feel empowered to escalate cases to dermatologists without fear of judgment or economic penalty. Dermatologists, in turn, must be willing to support their PA colleagues with timely consultation and clinical guidance. This mutual respect forms the backbone of ethical, patient-centered care.

The legislative environment is evolving rapidly. With workforce shortages, increasing rural demand, and policy pushes toward team-based care, many states are relaxing PA supervisory requirements. While this may improve access, it must be matched with accountability structures, training mandates, and transparent outcome tracking. Professional bodies have a responsibility to advocate for policy that balances access with safety, and both dermatologists and PAs must engage in these efforts.

At the federal level, reimbursement policies, malpractice statutes, and credentialing protocols continue to shape the practical boundaries of each profession. Staying informed and involved in these discussions is not only a civic responsibility but a professional necessity for those shaping the future of dermatologic care.

Finally, the differences between dermatologists and physician assistants in dermatology are substantial, multifaceted, and consequential. From the depth of training and clinical scope to legal frameworks, regulatory structures, and professional trajectories, each role offers unique contributions to patient care. Understanding these differences is not about defending turf, but about ensuring that each professional works within the full extent of their training in a system designed for safety, efficiency, and excellence.

As the demand for dermatologic services continues to grow, the collaboration between dermatologists and PAs will be vital. Success in this evolving model depends on honest communication, mutual respect, ongoing education, and structural safeguards that prioritize patients above all. For those of us responsible for shaping the future of our field, clarity and commitment in defining these roles is the foundation upon which enduring progress will be built.

At Collaborating Docs, we understand firsthand the importance of well-structured, compliant physician collaborations, especially in dermatology where scope of practice, supervision requirements, and clinical complexity can vary significantly by state and specialty. For physician assistants working in dermatology, securing the right collaborating physician is not just a regulatory checkbox. It is a foundational aspect of safe, confident, and high-quality care.

We work with dermatology-focused PAs every day who are navigating this complex landscape. Whether you are launching your own practice, expanding your clinical role, or simply ensuring your current setup meets evolving state laws, Collaborating Docs connects you with experienced collaborating physicians who are not only compliant but committed. We don’t believe in surface-level supervision. We prioritize meaningful partnerships that offer the kind of support you need to practice at the top of your ability.

Founded by Dr. Annie DePasquale, Collaborating Docs has facilitated over 5,000 successful matches nationwide with a network of more than 2,000 vetted collaborating physicians. Our proven system delivers guaranteed matches in 14 days or less, with most completed within a week. Dermatology is a nuanced and highly regulated field, and we are proud to be the trusted partner for PAs and NPs who want to get it right from day one.

If you are a PA in dermatology looking for a reliable, fast, and fully compliant collaboration, we are here to help. Let us take the complexity out of the process so you can focus on what really matters: your patients.

Get started with Collaborating Docs today and secure the collaboration you need, the right way. Visit our website to learn more or begin your match.