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

Impetigo and pyoderma may indicate serious medical/surgical problems. With adequate clinical and laboratory experience, a primary care physician may be able to diagnose and treat impetigo and other bacterial pyodermas with topical and oral antibiotics.

 

A referral to a dermatologist would be indicated if:

  1. The diagnosis was uncertain.
  2. Lack of satisfactory response to treatment after a reasonable amount of time (usually 2-3 days).
  3. Location on the face or other high risk of complications.
  4. Unusual or severe pain.
  5. Infection spread to other family members, contacts.
  6. Recurrent or repeat episodes.

Inflammatory Dermatoses

Inflammatory dermatoses are difficult to distinguish from each other and from certain malignant skin diseases. Primary care physicians may be able to diagnose and treat mild cases of some of the following diagnoses:

  1. Contact dermatitis
  2. Drug and other allergic eruptions
  3. Seborrheic dermatitis
  4. Atopic dermatitis
  5. Dyshydrotic eczema
  6. Lichenoid eruptions
  7. Rash
  8. Sarcoidosis
  9. Urticaria
  10. Pigmentary disorders
  11. Solar and radiation induced dermatitis
  12. Pyoderma gangrenosum, Sweets syndrome
  13. Chronic Lymphoid and granulomatous infiltrates
  14. Angioedema
  15. Autoimmune disorders including connective tissue disease and immunobullous disorders.

A referral is suggested to a dermatologist when:

  1. Diagnosis is in doubt.
  2. Lack of satisfactory response to treatment after a reasonable amount of time.
  3. Primary care physician has a patient with moderate-to-severe case of any of the above diagnoses or does not feel comfortable to adequately treat.
  4. Sudden exacerbation of any of the above.
  5. Location on the face or other high risk complications.
  6. Unusual or severe pain or itch.
  7. Immunosuppression
  8. Lupus erythematosus
  9. Bullous disease
  10. Chronic or moderate to severe atopic dermatitis
  11. Suspected contact dermatitis
  12. Vasculitis
  13. Purpuric eruptions

Occupation-Related Dermatoses

Occupation-related dermatoses may be difficult to distinguish from other skin diseases. The cause, relationship to the workplace, degree of disability, suitable alternative to avoid allergens and ability to return to work are critical parts of the evaluation.   Some of the following clinical conditions have to be considered in the Occupational dermatosis evaluation:

  1. Dermatitis caused by metals, chemicals, plants, radiation, infection, acne mechanica and chloracne, etc.
  2. Blistering or hyperkeratotic disorders
  3. Chronic skin disease worsened by occupational exposure

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 2-3 days)
  3. Questions regarding relationship to work and ability to return to work
  4. Location on face or other high risk complications
  5. Unusual or severe pain or itch

A wide range of inherited skin disorders can be symptomatic and disabling. Many are diagnostic of associated syndromes with systemic ramifications.

Referral to a dermatologist is suggested when:

  1. Diagnosis is uncertain
  2. Lack of satisfactory response to treatment after a reasonable amount of time (usually 1-2 months).
  3. Question of associated systemic disease
  4. Location on the face or other high risk of complications
  5. Unusual or severe associated pain or itching
  6. Severe disfigurement

Pre-Cancerous Skin Lesions and Skin Cancers

The dermatologist should be the primary referral destination for evaluation of patients presumed to have skin cancers or pre-cancerous lesions, regardless of size or location of the lesion. The dermatologist is able to manage all of the lesions requiring treatment and may recommend either medical or surgical treatment. Referral for large, complicated or facial lesions to dermatologic or other surgeons for specific procedures, including Mohs micrographic surgery, is appropriate.

The dermatologist will advise the primary care physician of additional visits and the need for additional referrals to provide the best result. A patient who has had skin cancers removed should be monitored in regular intervals by a dermatologist.

Regular follow-up of skin cancer patients is important since most patients will develop additional lesions over time. The primary care physician should authorize a periodic visit or ongoing care by the dermatologist for high-risk patients.

A referral is suggested in any of the following situations:

  1. When any form of skin cancer is suspected.
  2. Patient is at high risk for recurrence or new skin cancer.
  3. When a biopsy might be indicated, a referral should include authorization for the biopsy and not for the office visit only. It is unfair to the patient and the dermatologist to do the consultation and then require a separate visit for the biopsy.

Psoriasis

Psoriasis is a disease which causes major morbidity and is a readily treatable problem.   If the physician is specifically trained, mild cases of psoriasis may be managed by a primary care physician.

Referral is suggested in any of the following situations:

  1. Diagnosis is in question.
  2. Lack of satisfactory response to topical treatment after a reasonable amount of time (usually 3-4 weeks).
  3. Pustular lesions are present.
  4. Arthritis is present.
  5. When special treatments such as phototherapy (UVB or PUVA), immunosuppressives, retinoids, intra-lesional corticosteroids, etc are being considered.
  6. Location on face or interfering with function.
  7. Unusual or severe itch
  8. Affects greater than 10 % BSA.
  9. Biologics are used.

Systemic therapy for moderate to severe psoriasis (other than phototherapy) also requires periodic monitoring of patients. This monitoring may be weekly, monthly or quarterly for maintenance therapy for all systemically administered medications.

Skin Signs of Systemic Disease

Skin signs of systemic disease may include many clinical entities seen in medical practice.   These include:

  1. Hirsuitism
  2. Pruritus
  3. Connective Tissue Disease.
  4. Skin Signs that may indicate systemic disease such as blistering or ulcerations.
  5. Skin manifestations of neoplastic, hereditary, autoimmune, vasculitic, metabolic, infectious or inflammatory disease.
  6. Dermatoses of pregnancy.

Systemic disease often have cutaneous signs which may be valuable clues to the underlying condition. They may also be symptomatic or interfere with function and therefore require treatment.

Referral Suggested in Any of the Following Situations:

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

Soft Tissue and Mucosal Pathology

Soft tissue and mucosal disorders may be symptomatic, functionally disabling, or may suggest underlying disease.

Referral Suggested in Any of the Following Situations:

  1. Diagnosis is in question.
  2. Lack of satisfactory response to treatment after a reasonable amount of time (usually 2-3 days).
  3. Unusual or severe pain or itch
  4. Immunosuppression or other suspicion that the condition may be related to underlying systemic disease.
  5. Interference with function.

Warts

Although warts, especially in adults, may be associated with immunosuppression, come common viral warts eventually disappear without any treatment. Other warts may represent a public health problem and a few may predispose to malignancy. For those common warts that need medical management, the primary care physician who is trained may initiate conservative methods of treatment.

When warts are large or numerous, or if ablative procedures appear more appropriate, the patient should be referred to the dermatologist. Genital warts in males often may be managed either by dermatologists, urologists or by the primary care physician.   Genital warts in females often may be managed by dermatologists, gynecologists, or primary care physicians.

Referral Suggested in any of the Following Situations:

  1. Diagnosis is uncertain.
  2. Warts are large, numerous or symptomatic.
  3. Primary care physician does not have office facilities or training to treat eg. use of liquid nitrogen or other ablative procedures).
  4. Lack of satisfactory response to treatment after a reasonable amount of time (usually 1-2 months).
  5. Location on face, genitalia, or other high risk of complications.
  6. Unusual or severe pain or interference with function.

Molluscum Contagiosum

Molluscum contagiosum, although a benign process in some children, will commonly spread in the patient and in other children and may be associated with immunosuppression in adults. Multiple lesions of molluscum contagiosum, especially on the face, may be a cutaneous marker of HIV infection or another immunodeficiency.

Referral Suggested in any of the Following Situations:

  1. Diagnosis is in question.
  2. Primary care physician does not have office facilities or appropriate experience to treat.
  3. Lack of satisfactory response to treatment after reasonable amount of time (usually 1 month).
  4. Number of lesions is increasing.
  5. Location on face or other high risk of complications.
  6. Immunosuppression.
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