Dermatology (Management of Common Diseases in Family Practice)

A clinical diagnosis D1 was made and the patient was advised appropriate management. At the same time, a digital image with the help of a Clinical photographs were taken against a blue background to maintain uniformity.

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The images were then reviewed by a dermatologist, and a final diagnosis D2 was made on a monthly basis [ Figure 1 ]. The PCP was a medical graduate with 3 years of training in primary care and public health. The PCP was provided a structured history-taking template. However, no formal training was provided to him regarding dermatological history-taking and diagnosis. The specialist teledermatologist was a faculty at the Department of Dermatology of a premier tertiary care government hospital. The pattern and type of disease prevalent in the community was explored by descriptive statistics.

The operational issues regarding collection, storage and transfer of images were documented on a daily basis in a diary. A total of patients with dermatological diseases were recruited into the study. Of these, 85 Most of the patients 89 cases, Itchy lesions , Lesions were distributed mostly over the extremities Distribution of dermatoses diagnosed by the teledermatologist according to age, sex, type and site of lesion. Among the infective disorders diagnosed by the dermatologist, bacterial infection Among the non-infective dermatoses, eczemas Contact dermatitis, atopic eczema, seborrhoeic dermatitis, nummular eczema, lichen simplex chronicus, hand eczema and fingertip eczema were some of the other disorders noted under eczemas [ Table 3 ].

The most common diagnoses made by a PCP were dermatophyte infection Most common diagnoses made by the dermatologist were eczema PCPs correctly diagnosed only 2 of the 14 cases of psoriasis but 7 out of 8 cases of impetigo and 16 out 18 cases of scabies were diagnosed correctly.

However, 11 cases of eczema had been misclassified as scabies. All five cases of papular urticaria had been misidentified as scabies whereas PMLE had been misdiagnosed as dermatophyte infection in 6 out of 7 instances. The PCP could correctly diagnose pityriasis versicolor in 6 out of 7 cases [ Table 5 ].

Dermatology is still regarded as a subject of marginal importance during graduate medical education. Diagnostic skills for common dermatologic diseases among medical graduates therefore remain elusive. The scarcity of specialized human resources in dermatology coupled with poor access to dermatology services in remote areas leaves no other option but to explore the role of teledermatology as a support tool in primary care dermatology.

Family Physicians with Special Interest in Dermatology

Since dermatology is a specialty with utmost importance of visual inspection, a significant proportion of common conditions can be diagnosed and treated by teledermatology. Based on the criteria proposed by Kanthraj, this study can be classified as Grade-3 teledermatology practice, i.

The PCPs thus need to be trained on these 10 common skin conditions so that they can appropriately manage a large proportion of patients with common dermatologic complaints.

Certain diagnoses like airborne contact dermatitis, PMLE, lichen simplex chronicus, nummular eczema, papular urticaria, hand eczema, fingertip eczema, pitted keratolysis and molluscum contagiosum were made exclusively by the dermatologist. PCPs tended to overdiagnose dermatophyte infection, eczema, scabies and pyoderma. Non-dermatologists occasionally used non-specific terms such as rash, dark circles, dry skin, fungal infection to diagnose some conditions. There are many studies documenting overall agreement between the diagnosis made by the PCP and the face-to-face consultation with the dermatologist.

All of these studies highlighted poor knowledge of dermatology in primary care providers. The diagnostic agreement between primary care providers and remote dermatologists ranged from Since the diagnosis by the specialist dermatologist was based on digital images of patients seen by the PCP, taking proper images for better visualization becomes extremely important. Therefore, a simple manual on camera specification, background of images, site s to be photographed and quality of the images should be prepared.

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Although American Telemedicine Association has set guidelines for standard teledermatology practice, we need to look at them critically and adapt them suitably. The major limitation in this study stems from the fact that the diagnosis made by the dermatologist is based on digital images and patient's history and not actually examining the patient which could have been the ideal situation. Teledermatology can reduce the need for conventional clinical consultations while still maintaining clinical safety.

The role of teledermatology as a useful training tool, supervision of primary care providers, and for clinical governance and quality assurance in clinics in remote rural areas needs to be explored further. There was poor agreement in the diagnosis of psoriasis, fungal infections and recognizing various types of eczematous conditions.

This study thus highlights the importance of training PCP in the field of dermatology to recognize common skin conditions encountered in routine practice. National Center for Biotechnology Information , U. Indian Dermatol Online J. Author information Copyright and License information Disclaimer. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.

This article has been cited by other articles in PMC. Dermatologist, diagnostic agreement, primary care physician. Open in a separate window. Table 1 Distribution of dermatoses diagnosed by the teledermatologist according to age, sex, type and site of lesion. Table 2 Distribution of infective dermatoses diagnosed by the dermatologist. Table 3 Distribution of non-infective dermatoses diagnosed by the teledermatologist.

To examine the scope of this problem, we undertook a retrospective analysis of utilization of dermatology consultations by non-dermatology in-patient services and identified skin conditions associated with these consultation requests. Medical record review described in this study was approved by the Institutional Review Board of the University of Iowa College of Medicine. A retrospective chart review of consecutive dermatologic consultations was performed. The following variables were collected and entered into a Microsoft Access database: We calculated the frequency of dermatologic consultations requested by the various hospital clinical departments.

We also calculated the frequency of the primary diagnoses by the non-dermatology teams and compared it to the final diagnoses of the dermatology consult service. Standard mathematical formulas were applied to summarize the data in the Microsoft Access database. The age and gender distribution of the study population can be found in Table 2. Hospital services requesting dermatologic consultations. The various hospital medical services syn. A similar overall source pattern for in-patient dermatologic consultations at the University of Miami was observed by Falanga et al.

Fewer pediatric dermatologic consultation requests at UIHC could have resulted from the fact that there was no board-certified pediatric dermatologist on the dermatology faculty at UIHC. Annual hospital admission rates of the consulting departments tended to correspond to the rates of dermatologic consultations they requested. Internal medicine and surgery constituted the largest percentage of annual hospital admissions and dermatologic consultations. However, if the percentage of annual hospital admissions per department referred for dermatologic consultation are compared, psychiatry referred the largest percentage of its patients 1.

Pediatrics referred only 0. Reasons for hospital admissions. Table 4 presents a comparison of the reasons for admission of the patients in the present study to that of Falanga et al. Clinical information listed on the consultation request form. Our analysis revealed that 52 percent of the time the primary ward team demonstrated the ability to generate dermatologic differential diagnoses for the skin findings in question.

The ward team was given credit for this ability if they proposed two or more possible diagnoses on the consultation sheet accompanying the patient. Forty-eight percent of the time the consultation had only vague descriptions of the skin lesions in question with no differential diagnosis. Skin disorders responsible for the consultations. The final diagnosis determined by the consulting dermatology staff served as the gold standard in this study. The following common dermatoses, as listed in Table 5 accounted for a large majority of dermatologic consultations: Other diagnosis, which were seen in consultation with a frequency of 6 cases or less include: Accuracy of submitted diagnoses on dermatologic consultation request form.

Overall, the consulting ward teams provided an accurate preliminary diagnosis in This is exceedingly low in comparison to a mean 48 percent diagnostic accuracy of nondermatologists reported in the study by Falanga et al. The percent of correct diagnosis by consulting departments is listed in Table 6.

Internal medicine, psychiatry and pediatrics had the highest percent correct, while neurology and obstetrics and gynecology had the lowest percent correct. One must take into account that different services obtain consults for various reasons and regarding cases of varying complexities, which may skew this data. The percentage of time that the consulting team was able to correctly diagnose the most common diagnosis seen in consultation is listed in Table 5. Laboratory tests performed by the Dermatology Consultation Service.

In many of the dermatologic consultation work-ups, laboratory tests were used to aid in diagnosis. The Dermatology Consultation Service performed tests during the consultations Table 7. Fifty-four skin biopsies were performed. Sixty-one percent of all other lab tests performed resulted in a positive result aiding in determining the diagnosis. Negative results were also beneficial in ruling out possible diagnoses in the differential, however it was not possible to quantify the role of negative tests in this study.

Impact of dermatologic consultation on patient management. Dermatology consultation resulted in a change in or addition to treatment in A change is treatment was defined as the initiation or addition of a new topical or oral medication, the discontinuation of a previous medication and the addition of wound care instructions. The most common change in treatment was the addition of a topical corticosteroid or emollient. Table 8 lists the top ten most common changes in treatment recommend by the consulting dermatologic team.

Our study showed that the mean accuracy of the submitted diagnosis by the ward teams was A change in treatment based on dermatologic consultation occurred in The high rate of misdiagnosis or null diagnosis by ward teams could be expected to result in unacceptably high morbidity and mortality rates for the affected patients. This study also raises the question of whether dermatologic consults may be suboptimally utilized resulting in an increased cost of health care to the patient secondary to prolonged hospital stay and ineffective treatment trials.

This data supports the need for increased training of nondermatologists enabling them to better recognize and treat inflammatory and other common dermatoses. Our findings were somewhat different from those of a previous study [ 3 ]. This discrepancy may be accounted for by the fact that the study by Falanga et al. The need for an in-patient dermatology instructional program to provide ward teams with a better sense of when and how to utilize a dermatologic consultation was identified. Unfortunately, neither of these proposals or goals have been met as demonstrated in the present study and previous studies [ 3 ].

Ward teams in our hospital rarely attempted to perform simple diagnostic laboratory tests on their patients with skin problems. In part, this may be due to regulations limiting access to the materials needed to perform these tests on an inpatient unit or due to a lack of education on how and when to perform these tests properly. However, the majority of final dermatologic diagnoses were made by the Dermatology Consultation Service by visual examination alone. This emphasizes the importance of the ability to recognize common dermatoses by non-dermatologist physicians who care for patients in a hospital setting.

There are few other studies that evaluate the ability of non-dermatologists to diagnose and treat cutaneous disease, as well as the ability to use a dermatologic consultation appropriately in the inpatient setting. However, there have been numerous studies evaluating these issues in the outpatient setting. The outpatient based studies showed that primary care providers were able to identify common dermatoses approximately 40 - 60 percent of the time.

This is very similar to that seen in the inpatient setting. Inadequacies in dermatologic knowledge most likely stem from the fact that medical students typically receive less than 20 hours of formal dermatologic training during four years of medical school.

Despite this, physicians in pediatrics, family medicine, and internal medicine were responsible for seeing One survey [ 7 ] demonstrated the large percentage of dermatologic concerns seen and treated by internists despite their lack of training. Fifty percent of internists reported percent of their patients presented with a cutaneous concern as their chief complaint. There was no correlation between the internist's ability in dermatology and the number of patients encountered for cutaneous concerns and treatment.

There was a correlation between the amount of training the internist received and their ability in dermatology.

Preface | Clinical Dermatology | AccessMedicine | McGraw-Hill Medical

Often it is taken for granted that dermatologic concerns are incidental, and although perhaps uncomfortable and unattractive, of little consequence to the patient's general health. A South African study emphasized the considerable interface between cutaneous and systemic disease and the importance of the dermatologic diagnosis to the overall care of the patient [ 8 ].

Five hundred inpatients on non-dermatologic primary teams demonstrated skin conditions related to the presenting illness in 50 percent of cases. These skin conditions contributed substantially to the diagnosis of the systemic illness in