- Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
- Attend dermatology lectures as part of primary care’s continuing medical education courses.
- Review a good basic dermatology atlas from time to time.
- Learn to correctly describe lesions to a dermatologist by phone.
- Don’t assume that groin rashes are all fungal.
- Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
- Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
- Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
- Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
- Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
- Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
- Be mindful of the rapid onset of purpuric lesions on the skin.
- Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
- Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
- Encourage patients to follow up with a dermatologist on an outpatient basis.
Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.
“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.
Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).
“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”
The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.
The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.
Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”
Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.
“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.