Pattern of inpatient referrals to dermatology at a tertiary care centre of South Rajasthan.

BACKGROUND: Dermatologists besides providing service to patients in the outdoors, also play a vital role in the care of inpatients admitted to dermatology unit and other departments. AIMS: The aim of this study was to evaluate the pattern of referrals sent to the dermatology department by other departments.
MATERIALS AND METHODS: The study included all inpatients referred to dermatology department of a tertiary care centre of South Rajasthan during a 5-year period from October 2008 to September 2013.
RESULTS: A total of 1560 consultations with 1603 diagnoses were recorded. Most (770; 49.3%) consultations were received from internal medicine, followed by surgery (177; 11.3%), pediatrics (104; 6.7%), psychiatry (86; 5.5%) and gynecology (69; 4.4%) wards. Infectious skin diseases were most common (29.7%) followed by eczema (12.0%) and drug reactions (9.0%).
CONCLUSION: Dermatology referrals can enhance the dermatological knowledge of non-dermatologists to diagnose and manage common dermatoses thus improving overall patient care.

Introduction

The knowledge of dermatology among non-dermatologists is believed to be very poor.[1234] Patients admitted to non-dermatology units may often have numerous skin lesions besides the systemic disease for which they are hospitalized.[45] The dermatoses may be associated with significant morbidity and at times mortality.[6] These dermatology lesions could be detected as a coincidental finding during examination or develop during their stay in the hospital;[7] the development of adverse cutaneous drug reaction is a typical example of the latter. These inpatients with dermatoses often require expert dermatology consultation. The interdepartmental referral not only helps in patient care but also improves the diagnostic acumen and clinical knowledge of the clinician.[578910]

This study was conducted to determine the pattern of “inpatient referrals” to dermatology department among patients admitted in other wards at a tertiary care teaching institute of South Rajasthan.

Material and Methods

This study was carried out at the tertiary care teaching institute of South Rajasthan between October 2008 and September 2013. All the inpatients referred from non-dermatology wards to dermatology unit were initially evaluated by a dermatology resident; the case was then discussed with an attending consultant to arrive at a clinical diagnosis. In case of any diagnostic confusion, opinion of another consultant was sought. Specific investigations such as KOH examination, Gram's smear, Tzanck smear, slit skin smear, skin biopsy, and blood and radiological investigations were undertaken in selected cases, wherever deemed appropriate to substantiate the clinical diagnosis. Referral services were also provided to nonambulatory sick patients in intensive care units or other wards. Details of the referring unit, patients’ demographic profile, primary diagnosis for which patient was admitted, provisional diagnosis of dermatoses if made by the admitting consultant, and final diagnosis of dermatoses by specialist dermatologist were recorded in a proforma for analysis and interpretation.

Results

During 5-year period, a total of 1560 referrals were received. The average number of patients seen per month was 26, with a range of 20–32. There were 968 males (62.05%) and 592 females (37.95%), with a M:F ratio of 1.63. The mean age of the patients was 39.95 years (range: 1 day to 93 years). Majority of the patients (778; 49.9%) were in 19–45-year age group at the time of consultation [Figure 1].

Figure 1

Age and sex distribution of patients referred to dermatologists

The referral service of the dermatologist was sought by almost all the specialties. The referral was most frequently sought by the department of internal medicine (49.3%), thus accounting for nearly half of the total patients. This was followed by surgery (11.3%), pediatrics (6.7%), psychiatry (5.5%), and gynecology (4.4%) wards [Table 1].

Table 1

Distribution of interdepartmental consultations

A total of 1603 dermatological diagnoses were made among 1560 patients; 43 patients had more than one dermatoses. The dermatological disorders for which referrals were sought are shown in Table 2.

Table 2

Dermatological diagnosis made in referred patients (n=1560)*

Infections and infestations were the most common (29.7%) cause of referral and included fungal infections (160; 10.0%), viral infections (136; 8.6%), bacterial infections (83; 5.2%), parasitic infestations (81; 5.1%), and mycobacterial infections (16; 1.0%) [Figure 2]. This was followed by eczema (12.0%) and drug reactions (9.0%). The most common types of drug reactions were maculopapular rash, Stevens Johnson syndrome, and erythema multiforme. The most common incriminating drugs were carbamazepine, phenytoin, and nevirapine.

Figure 2

Pattern of infections and infestations in referred patients

Skin infections were the most common indication for referral by ophthalmology (55%), psychiatry (47.7%), and endocrinology (42.3%). Eczemas were the most common reason for referral by neurology (27.6%), cancer (20.0%), nephrology (18.1%), and endocrinology (17.3%). Drug reactions were the most common indication for referral by nephrology (31.8%), intensive care units (14.3%), otorhinolaryngology (11.9%), and medicine (11.7%).

Diabetes, human immunodeficiency virus, and tuberculosis were some of the associated comorbidities seen in 25, 12, and 10 patients, respectively. These patients presented with infective skin disorders, and drug reactions mainly.

Biopsy was done in 72 patients to substantiate the clinical diagnosis. These patients included Hansen's disease (28), connective tissue disease (16), immunobullous disorders (14), vasculitis (10), and miscellaneous conditions (4).

Discussion

Mucocutaneous manifestations are often important markers for diseases of internal organs.[5] Only a few studies have highlighted the role of dermatologists in providing referral services to other departments.

The referral pattern from different specialties has varied in different studies possibly due to differing pattern of dermatoses seen in different regions. In the present study, internal medicine accounted for the highest proportion of dermatological consultations (49.3%), as seen in several other published studies.[47810111213141516] It is possibly due to higher admission rates in internal medicine wards compared to others. Other reasons could be longer hospital stays and more likelihood of patients having multiple ailments and hence on multiple medications.[7] Surgery (11.3%), followed by pediatrics (6.7%) and psychiatry (5.5%) units accounted for other common referrals in the index as well as other studies.[478111215] However, in some studies,[101314] neurology unit has accounted for a significant number of referrals after internal medicine. In an Indian study,[2] from Secunderabad, surgery (29.8%) and internal medicine (29.7%) departments were responsible for more than half of the referrals to dermatologists.

It is difficult to compare the pattern of dermatoses seen in the reviewed studies because the classification and quantification criteria were not uniform. However, in most of the studies,[24610111213141617181920] the frequent dermatological diagnoses were infections, dermatitis and drug reactions. These were the most common diagnoses observed in our study too. Infections and infestations accounted for 29.7% of the total dermatological diseases in our study. Skin infections are frequent not only in the outpatient setting, but are also prevalent in inpatients probably due to immunosuppression seen in some admitted patients and a common reason for patient admission.[14]

Before referral to the dermatology unit, a tentative dermatological diagnosis was made in 33% patients only by the referring unit, and it was found to be correct in only 20% of the patients. In another Indian study,[2] the correct dermatological diagnosis was made in 39% of the patients. Other studies from Portugal,[4] US,[8] and Brazil[14] have reported that a correct diagnosis was made in 23.9%, 48%, and 33% of the patients, respectively. Further, we noticed that the some of the common and easily diagnosable conditions such as scabies, dermatophytosis, herpes zoster, molluscum contagiosum, psoriasis, and Hansen's disease were either missed or misdiagnosed by non-dermatologists.

Drug rash, dermatophytosis, viral infections, connective tissue diseases, and Hansen's disease were the common dermatological diagnoses in patients referred from the medicine department whereas scabies, viral, and bacterial infections were commonly found in patients from the surgical wards. Scabies, dermatophytosis, and insect bite hypersensitivity were the causes of referral from psychiatrists. Approximately one-fourth (26%) of gynecological referrals were due to venereal disease research laboratory (VDRL) test positivity in a titer of <1:8, which upon further dilution and Treponema pallidum hemagglutination (TPHA) test, revealed it to be biological false positive test during pregnancy. Out of the total 63 patients referred to us with a primary diagnosis of Hansen's disease, a final diagnosis of Hansen's disease, after thorough evaluation, could be made in 43 patients. Out of these, 15 patients were newly diagnosed while 28 were already known cases of Hansen's either on treatment or released from treatment. Twenty patients had alternate diagnoses, such as peripheral neuropathy due to causes other than Hansen's disease.

Dermatology is primarily a visual discipline. Most dermatoses can easily be diagnosed by a trained eye without expensive investigations that are often advised by non-dermatologists. Non-dermatologists usually tend to use combined topical preparations often containing steroids.[5] In addition to wastage of unwanted medication, these preparations add to the cost of therapy and may also pose the risk of sensitization and side effects. Moreover, this practice leads to modification of the original clinical picture, making subsequent accurate diagnosis difficult even by a trained dermatologist, as is commonly seen with topical steroid abuse.

Conclusion

Based on the present study as well as other reported studies, we conclude that a large number of common skin ailments are either missed or misdiagnosed by non-dermatology units. These patients are at times subjected to needless investigations and unnecessary medications. This problem can, to some extent, be addressed by frequent inter-departmental referrals and interactive inter-departmental teaching and training programmes, thus providing exposure to non-dermatology residents regarding diagnosing and managing common dermatoses. In addition, an effective training of undergraduate students in dermatology should be strictly ensured and enforced according to the guidelines of medical licensing authorities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.