In common with other aspects of general practice the management of dermatological problems has changed considerably in recent years.
In particular:
• There is an increased expectation from patients, who want an accurate diagnosis and prompt treatment but also expect treatment for even the smallest lesion.
• The management of inflammatory skin conditions no longer requires many weeks of inpatient treatment.
“Daily dressing clinics” in hospital dermatology departments enable patients to continue their daily lives while being treated, but still require visits to hospital. In many practices facilities for carrying out dressings by the practice nurse have been developed.
• The demand for specialist services far outstrips supply. Consequently the majority of patients with skin conditions have to be treated by general practitioners.
One positive outcome is that there is a greater emphasis on shared care between general practice and hospital specialist departments.
This is facilitated by the appointment of dermatology liaison nurses who are able to supervise patient’s treatment in the community and, as the name suggests, liaise with both general practice and hospital departments using the resources of each as appropriate.
• General practitioners are increasingly developing special interests and many have part-time posts in specialist departments.
In the case of dermatology this enhances their clinical knowledge, which they can bring to bear on the problems in general practice.
Between 10% and 15% of consultations in general practice are for skin related problems, although the actual number of skin conditions seen is probably much higher than this.
In one general practice an analysis of 100 consecutive consultations showed that 38 involved some aspect of dermatology. Increasing knowledge of dermatology enables conditions to be diagnosed and treated.
Even if the diagnosis is not known it is important to be able to assess the probable importance of dermatological conditions and differentiate those for whom an urgent referral to hospital is required from those needing a specialist opinion to confirm the diagnosis and treatment but for whom there is no great urgency.
This is important with the large demands being made on hospital departments with diminished funding and increasing waiting times.
In this respect a good working relationship with the local hospital department is a great asset. Diagnosis of skin conditions in general practice
As in all aspects of medicine, knowing how the more common conditions present will provide a basis for recognising the unusual variants or less common lesions.
Psoriasis, eczema, and other forms of dermatitis usually present no problems. Where they do a review of the history often gives valuable clues.
Atopic eczema in childhood may explain the development of a widespread itching rash in a young adult and an otherwise unexplained rash may well be accounted for after a review of current drugs the patient is taking.
Knowledge of the dermatological conditions associated with systemic disease, and conditions that may mimic them, is clearly important.
A bilateral malar rash with photosensitivity in a woman should suggest the possibility of lupus erythematosus and appropriate investigations instituted.
However, a completely typical case of rosacea does not require extensive investigation.
The most useful diagnostic aids in general practice are:
• Skin scrapings and a sellotape strip should be sent for mycology whenever there is an area of itching inflammatory change, particularly in the flexures, that is not responding to treatment.
• A swab for bacteriology should be sent from any area of dermatitis that develops crusting and exudate.
• An incisional biopsy can be carried out to confirm a significant diagnosis, for example in a patch of Bowen’s disease
This is not usually needed to make a diagnosis of granuloma annulare, which has a very characteristic presentation.
All lesions removed by excision or curettage or cautery should be sent for histology.
• Patch testing is not practicable in general practice as a rule because of the large number of reagents and specialised nursing skills required. Patients suspected of having contact dermatitis should be referred to the appropriate unit.
The management of skin conditions in general practice
One great advantage of general practice is that there is continuity of care and the family doctor has a much more complete overall picture of the patient, their family and social circumstances than can be acquired in a hospital consultation.
Increasingly dressings and other treatments are being used by practice nurses in conjunction with the dermatology liaison nurse when necessary.
This applies to inflammatory skin conditions such as psoriasis and eczema as well as leg ulcers, but also to conditions such as Darier’s disease, dermatitis herpetiformis, and lupus erythematosus where regular supervision and blood tests may be required.
There is no reason why continuing treatment with drugs such as ciclosporin and methotrexate cannot be carried out in general practice once the diagnosis and treatment regime have been established.
Regular blood tests are mandatory when these drugs are being used.
Procedures in general practice
• Excisions and other forms of minor surgery are probably best undertaken by a member of the practice who has developed expertise in this area, and received some level of training.
It is particularly important to be aware of which lesions and anatomical sites are the most difficult for minor surgery.
It is probably wise not to attempt excisions over the sternum and shoulders, particularly in young people, where keloid scars will probably result.
In general it is best to refer any malignant lesion to a hospital department for excision.
• Curettage and cautery is a straightforward procedure for the removal of superficial and well defined lesions such as seborrhoeic keratoses and viral warts.
It is as well to send all specimens for histology to confirm the diagnosis and make sure that an unsuspected malignancy is not missed.
It is important that a clinical probable diagnosis is made so as to avoid excising lesions where such treatment is not required or when it is inappropriate.
• Cryotherapy is suitable for the treatment of warts, seborrheoic keratoses, solar keratoses, and conditions such as Bowen’s disease.
If there is doubt as to the diagnosis or the condition fails to respond to treatment a specialist opinion should be sought.
It usually most satisfactory to have a cryotherapy clinic for which liquid nitrogen is regularly supplied and a suitably trained nurse is available to carry out the treatment.
It is important that all patients are seen by by a doctor before treatment is started so that the diagnosis and suitability for treatment can be confirmed.
Self-help groups
There are now groups that provide an invaluable source of information and advice for a wide range of conditions.
