Guidelines for Appropriate and Valuable Referrals to a Dermatologist – Part I

Recently I was asked to develop guidelines for appropriate use of dermatological referrals for naturopathic physicians. While many conditions can be properly assessed and treated by a primary care physician or naturopath, dermatology referrals often provide financial savings and quicker resolution of the condition. This is better for the patient and better for our medical system, which is under great pressure due to many healthcare reforms. Because skin diseases are often diagnosed clinically without the support of objective tests, misdiagnoses by non-specialists often occur. Thus, dermatologic referral should be mandatory when the clinical diagnosis is uncertain or when there is an unexpected or unexplained change in the course of the disease.

Below is a guideline for appropriate use of dermatologic referrals, including common conditions seen by primary care providers.

Acne

Acne is an inflammatory condition affecting the face, back, shoulders and chest which can cause scarring and skin tenderness. Referral to a dermatologist is recommended in the following situations:

  1. Lack of satisfactory response to treatment after a reasonable amount of time (usually eight weeks).
  2. Significant inflammation, cysts or nodules are present
  3. Scarring is actively occurring
  4. Acne is associated with signs of androgen excess such as hirsutism and androgen alopecia
  5. Diagnosis is uncertain.

Skin Growths

Skin Growths or proliferations may represent benign lesions that are common normal findings on the skin in the general population not requiring investigation or removal. These might include: Epithelialnevi, lipomas, skin tags, dermatofibromas, hemangiomas, melanocytic nevi, vascular tumors and mal-formations and seborrheic keratoses.   However, referral to a dermatologist for further assessment would be recommended when:

  1. There are a large number of nevi
  2. Personal or family history of melanoma
  3. Suspicion of malignancy
  4. Diagnosis is in question
  5. Possibility that the lesion may represent a marker of an underlying disease or syndrome.
  6. Primary care physician is unsure of the biologic potential of a congenital or acquired melanocyticnevus
  7. A presumed benign lesion begins to change with:
  8. Bleeding or ulceration
  9. Growth and enlargement
  10. Becomes symptomatic with pain, pruritus, and signs of infection
  11. Change in coloration and border irregularities
  12. Irritation by clothing or repetitive activities because of its anatomic location

Cysts

Cysts in the skin are common saclike growths that form often due to genetic predispositions. These can be asymptomatic, hence, not requiring treatment, or a source of discomfort. However, what might clinically be thought to be a benign cyst might in fact represent other benign and malignant lesions. In the case of enlarging cysts, recurrent, symptomatic, trauma-prone, clinically infected or inflammatory cysts, treatment is usually necessary. For recurrent cysts, or those that symptomatic, intralesional corticosteroids or excision may be recommended. A primary care physician may choose to refer to a dermatologist for :

  1. Definitive treatment
  2. When the diagnosis is in doubt
  3. When the cyst occurs in a cosmetically sensitive area such as on the face
  4. When the primary care physician does not have the surgical office facilities or appropriate surgical experience to treat cysts
  5. When there is suspicion of an associated underlying malformation or syndrome.

Hair Loss

Hair loss can be caused by a variety of etiologies including genetics, medications, infections, auto-immune diseases as well as numerous other medical conditions.   Adequate diagnosis for hair loss may require a careful history, examination of the scalp, microscopic and laboratory tests and occasionally a scalp biopsy.

Referral to a dermatologist is indicated when:

  1. Primary care physician may not have sufficient experience to manage or treat congenital or acquired hair loss or diseases such as alopecia areata or hair loss associated with infection or systemic disease.
  2. Hair loss is associated with scarring
  3. The alopecia is unresponsive to therapy or recommendations within 2 months.

Infections

Infections in the skin are common and sometimes require early diagnosis and therapeutic intervention. These conditions may be acute or chronic in nature. They may be induced by fungal, bacterial, viral, parasitic organisms and require necessary laboratory facilities to help differentiate them from non-infectious inflammatory dermatoses.

Fungal diseases may be difficult to diagnose. A primary care physician may be able to use potassium hydroxide (KOH) examinations and/or fungal cultures to diagnose some cases of dermatophyte infections, tinea capitis, tinea corporis, tinea cruris, tinea pedis, tinea manum, onychomycosis, candida and tinea versicolor. It is clinically appropriate that KOH or fungal culture be done to confirm the diagnosis before initiating treatment, since these tests may yield false negative results after antifungal agents have been initiated.

Referral to a dermatologist is suggested when:

  1. Diagnosis is in question.
  2. Primary care physician does not have the laboratory facilities to check KOH or fungal culture.
  3. Lack of satisfactory response to treatment after a reasonable amount of time (usually one week).
  4. Symptoms are unusually severe.
  5. In cases where systemic antifungal medication is being considered (eg. tinea capitis) or lasers (onychomycosis) and when the primary care physician is unfamiliar with the use of these therapeutic modalities.

Herpes simplex infection is difficult to diagnose clinically, especially in HIV-positive patients.   In non-HIV positive cases, a primary care physician may be able to diagnose some cases of oral, labial or genital herpes simplex virus infections and begin treatment with topical measures and when necessary, oral antiviral agents. Performance of Tzanck smear and/or viral culture, or immunofluorescent tests will increase the diagnostic accuracy and is important to consider before therapy is undertaken.

Referral to a dermatologist is indicated when:

  1. Diagnosis is in doubt.
  2. Lack of adequate response to treatment after a reasonable amount of time (usually 5-7 days) for any episode.
  3. Frequent, severe, painful or scarring outbreak or associated constitutional symptoms.

Herpes Zoster, especially in the elderly may be difficult to diagnose and effectively treat.   In some cases, a primary care physician may be able to diagnose and treat herpes zoster.   Usually a clinical diagnosis is sufficient without a viral culture or immunofluorescent test. Early intervention with systemic antiviral treatment is important to lessen the long-term sequelae of post-zoster neuralgia in certain patients – especially the elderly.

A referral to a dermatologist is recommended when:

  1. Diagnosis is in question.
  2. Lack of satisfactory response to treatment after a reasonable amount of time (usually 5-7 days) or complications.
  3. Location on the face or other high risk of complications.
  4. Unusual or severe pain.

Read part II

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