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How to cite this article: Fuentes-Suárez A, Domínguez-Soto L. Underestimation of dermatology based on ignorance and its impact on patient’s health. Rev Med Inst Mex Seguro Soc. 2015 Mar-Apr;53(2):250-3.
SOCIAL MEDICINE
Received: June 26th 2014
Accepted: October 29th 2014
Underestimation of dermatology based on ignorance and its impact on patient’s health
Adán Fuentes-Suárez,a Luciano Domínguez-Sotob
a,bServicio de Dermatología, Hospital General “Dr. Manuel Gea González”, Distrito Federal, México
Communication with: Luciano Domínguez-Soto
E-mail: dermagea@gmail.com
With the emergence of medical specialties in different areas of medicine, assessment of patients became narrow and specialized. There is also the perception that some specialties are more difficult than others. Dermatology has long been seen by most physicians non dermatologists as a relaxed area, without real emergencies or requirement of great intellectual effort. Some specialists, erroneously think that everything can be cured with topical steroids and/or antifungal creams. Although several skin diseases are common complains seen by the general practicioner, very few time and credits are granted to cover these diseases during the years of undergraduate training. Thus, the primary care physicians and others medical specialists believe that skin diseases are not life threatening and hence irrelevant. Nonetheless, they feel competent enough to prescribe a variety of treatments for skin diseases that may lead to iatrogenesis.
Keywords: Iatrogenic disease; Dermatology; Skin diseases; Dermatoses
It is widely recognized that doctors who are not dermatologists are general ignorant of skin diseases and their annexes. This ignorance has direct repercussions on the corresponding underappreciation of dermatologists, as it is erroneously thought that dermatological ailments do not kill or endanger life. This, of course, is wrong in general terms, because the fact that there are few dermatoses that do have those characteristics does not mean that dermatology is irrelevant in the management of the patient.
This underappreciation-ignorance-underappreciation cycle has several explanations: perhaps the first point to consider is the short time that is given to imparting knowledge of dermatology at the undergraduate level. In our country there was a time when this area was optional. Today, although the situation is not as bad as it was, the number of credits that are granted for dermatology remain very limited in relation to other specialties. This leads to future doctors not considering dermatology as a specialty that they can further develop in graduate school.
Historically, at least in Mexico, dermatology has followed the European style of medical education and, consequently, the delivery of assistance, which was done by the establishment of various medical and/or surgical wards dedicated to diverse medical specialities and working (at least in the beginning) independently. Although intraconsultations were occasionally requested with other specialists when the case so warranted, the well-established multidisciplinary medical approach required today didn't exist.
If on the other hand we consider that dermatological physiology and pathophysiology began to be studied scientifically belatedly, in the second half of the twentieth century by authors such as Aaron Lerner, Stephen Rothman, one William Montagna, Alfred2,3 Kligman4 and Thomas B. Fitzpatrick, both from the United States and Europe, before whom skin was considered a protective membrane, eminently sensorial and tactile, whose function was solely to capture external stimuli, then we can understand that the dermatologist once took refuge in a complicated nomenclature, excessive in synonyms with no reason to be and abundant in classifications that helped build a world of skin diseases that only dermatologists knew, and about which the remaining non-dermatologists did not care at all. Thus, the dermatologist remained isolated in "their world" for a long time, without being taken into account b7 the rest of their colleagues.
From the moment in which medical residencies and specialization courses in various branches of medicine supported by the Division of Graduate Studies, Facultad de Medicina, UNAM were established, and with the support of the main hospitals in the health sector, the outlook of dermatology changed, as the applicant who wants to acquire the knowledge and skills for this specialty must attend at least one year of internal medicine before undergoing the three years required in the specialty of dermatology, which ensures that students acquire basic knowledge of other subspecialties.
The doctor that concludes the four years of internal medicine can properly resolve metabolic, cardiac, infectious, gastroenterology, endocrine problems, etc. (and can even can choose a subspecialization in any of these disciplines), but this is not so with skin problems that are presented. The problem is that the doctor does not even know how to properly assess the problem and does not adequately attend to the patient (meaning that they are encouraged to give treatment without diagnosis or refer the patient to other specialists before referring them to a dermatologist).
Going back to the main purpose of this text, which has already been mentioned, and on the basis of our argument above, the dermatologist is still undervalued their views are dismissed with excessive frequency. In continuation, we will look at other important points to reach our purpose.
A very important factor is that 85-90% of dermatological conditions presented at daily hospital consultations (outpatient consultation) consist of cases of skin diseases (acne, viral warts, ringworm, onychomycosis, vitiligo, melasma, psoriasis) that doctors of first contact, whether specialists or not, think they understand and can treat. While on the other hand, the remaining 10-15% is made up of more than 800 clinical-pathologic entities that are absolutely unknown but are more than often mistaken for more common skin conditions.
Therefore, it happens very often that the doctor (whatever their speciality) that faces a dermatosis, and we refer exclusively to what happens in hospitals in the health sector given that in private practice there are many other factors, is unable to recognize that that they do not know the diagnosis and will then most likely prescribe a treatment, almost always based on corticosteroids and/or anti-fungals with the ridiculous hope of "nailing it" (and thus justifying the payment of their fees).
As we said, in hospitals where multidisciplinary medicine should always be practiced for the benefit of our patients, this multidisciplinary approach does not happen and the last to be consulted is the dermatologist, who in many cases will have a clinical diagnosis and/or differential diagnosis before the patient undergoes laboratory tests, which ultimately prove unnecessary and could have been avoided or limited if someone would have thought to consult a dermatologist in a timely manner. In these cases, the impact is on the costs that the patient must cover and the possible length of hospital stay. Also, iatrogenesis is frequently provoked by this procedure, and it is not uncommon for there to be much more severe consequences on the health of our patients.
As an example, the following images show an intradermal melanocytic nevus associated with blue nevus (Figure 1), a seborrheic keratosis (Figure 2) and superficial basal cell carcinoma pigmented (Figure 3). All three are tumors that can be cause for consulting any doctor, even if it is by chance or “by passing by”, and doctors lacking adequate dermatological knowledge will not take them seriously enough to refer the patient to a specialist, or worse, will give an inadequate treatment.
Figure 1 Irregular, asymmetric and raised neoformation, black color, irregular borders with satellitosis.
Figure 2 Flat and ulcerated neoformation covered with blood crust; erythematous.
Figure 3 Erythematous patch. The color is homogenous, brown; irregular form.
As the pictures show, the diagnosis can easily be confused, which could be detrimental to the patient's health and sometimes even put their lives at risk.
Figure 4 shows a case whose context develops most often in the inpatient setting. This is a patient only showing frankly purpuric maculopapular lesions that may seem unimportant to the doctor who is not a dermatologist, seeing as the patient also has abdominal pain, microscopic hematuria and fever.
Figure 4 Dermatosis symmetrically affecting both (a) thighs and (b) legs. Consisting of multiple petechiae and papules from 1 to 3 mm, non-confluent.
This particular case (admitted to our hospital) was diagnosed as appendicitis, and the patient underwent surgery. After the result of a normal appendix, interconsultation of dermatology was requested due to the persistence of the "spots", the resident specialist integrated the general symptoms with the dermatosis and made the diagnosis of Henoch-Schönlein. Clearly, the surgical procedure could have been avoided had the dermatosis been integrated from the beginning.
One way to begin changing the underappreciation of dermatology is to understand that the skin is an organ that is just as complex in its physiology and pathophysiology as the heart, liver, kidney, etc.; it also requires understanding that this organ has its own diseases (inflammatory, autoimmune, infection, tumor, granulomatous, genetic and drug reactions), and not forgetting that in many cases skin lesions may be the first sign or indication of an internal or systemic disease.
Today's advances in the field of immunodermatology are incessant and new discoveries that greatly impact diagnosis continually appear. In the same way, increasingly specific treatments to meet multiple dermatosis arise as new advances are made in molecular biology, as the skin presents an ideal organ for the development of research in general, due to the fact that it is visible.
Finally, the fundamental objectivity of dermatology helps to simplify the diagnostic and therapeutic approach for the benefit of our patients. Hopefully in the future we can all realize that we have much to teach but also much to learn. The day we have enough modesty to do so, we will have taken a very important step for multidisciplinary care that will benefit us all, especially our patients.
References
- Rothman S. Physiology and biochemistry of skin. Chicago: University of Chicago press;1954.
- Montagna W. The structure and function of skin. New York: Academic Press;1956.
- Ellis RA, Montagna W. Histology and cytochemistry of human skin. XV. Sites of phosphorylase and amylo-1,6-glucosidase activity. J Histochem Cytochem. 1958;6(3):201-7.
- Kligman AM, Fulton JE, Plewig G. Topical vitamin A acid in acne vulgaris. Arch Dermatol. 99(4):469-76.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.
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