When Should a Primary Care Doc Refer to a Dermatologist?

The answer to the question depends on the extent of training in dermatology and the individual physician’s comfort level in dealing with skin diseases.  Currently, the definition of “primary care providers” includes family practitioners, internists, pediatricians, and gynecologists, but may be expanded to include nurse practitioners.  The education of U.S. medical students in Dermatology ranges from a few hours of basic anatomy and physiology of skin in the early years to an entire rigorous module including lectures on both common and serious skin diseases such as psoriasis, eczema, acne, skin cancer, and autoimmune blistering diseases.

In the later years of medical school, as the students plan their career to become generalists or specialists, they may take elective clinical rotations in Dermatology at universities with post-graduate residency programs or in private practices with dermatologists who have an interest and experience in teaching.  Such voluntary rotations, called “externships” or “clinical clerkships,” are critical for medical students who want to become dermatologists as well as for those who plan to go into primary care, but they are only taken by a minority of the class.

In the post-graduate years, that is, after the medical student has obtained the doctor degree, and is in the process of completing an internship or residency, they usually have the opportunity to rotate again in the dermatology clinic of their hospital or university.  I have found that here is where nascent doctors get the strongest foundation in the diagnosis and treatment of the most common skin diseases that will hold them in good stead for their ultimate practice in primary care.  Some of the primary care doctors who realize that they missed this opportunity may later take time out of their own practice to work with a dermatologist colleague or take continuing medical education courses that emphasize skin diseases and related procedures.

I have found that most family practitioners and pediatricians are comfortable managing common conditions such as acne, warts, molluscum contagiosum, impetigo, drug-induced and viral rashes, and acute contact dermatitis (for example, poison ivy) unless they are recalcitrant to treatment.  They are less likely to manage chronic skin diseases long-term such as psoriasis and atopic dermatitis.  Some primary care docs including internists and gynecologists have mastered the technical performance of the skin biopsy for diagnosis and the use of cryosurgery (liquid nitrogen freezing) for treatment of warts and actinic keratoses (pre-cancers).  While these procedures are technically easy to learn and perform, and the equipment is generally inexpensive, the selection of the site to biopsy and the interpretation of the pathology report are more demanding.  If an inflamed lesion or a skin cancer is frozen, they will generally not resolve, and may progress.

Dr. Sidbury at Seattle Children’s Hospital suggested that if a primary care provider answers “yes” to one or more of the following questions, then he or she should consider referral to a dermatologist.

  • Is there a long list of possible diagnoses, for example, psoriasis, eczema, drug reaction, or cutaneous lymphoma?
  • Does the diagnosis involve high risk of morbidity or mortality, for example, pemphigus, pemphigoid, lupus, melanoma, or cutaneous lymphoma?
  • Has the patient failed initial therapy or relapsed quickly after stopping therapy, indicating chronic skin disease?
  • Does the treatment require a modality of treatment typically administered in a dermatology office, for example, phototherapy for severe psoriasis, vitiligo, chronic eczema, or cutaneous lymphoma?
  • Does the treatment have a significant risk of adverse effects, for example, chronic prednisone for pemphigus or pemphigoid, plaquenil for lupus, cyclosporine for pyoderma gangrenosum or oral lichen planus, or methotrexate or etanercept for psoriasis and psoriatic arthritis?
  • Does the patient have an uncommon or rare disease such as granuloma annulare, necrobiosis lipoidica, mastocytosis, REM syndrome, or Rosai-Dorfman disease?
  • Does the patient have a genetic skin condition, for example, Hailey-Hailey disease, Darier disease, ichthyosis, or Vohwinkel syndrome?

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