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Vol. 105. Núm. 8.
Páginas 799-800 (Octubre 2014)
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Vol. 105. Núm. 8.
Páginas 799-800 (Octubre 2014)
Case and Research Letter
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Analysis of Inpatient Dermatologic Consultations
Análisis de consultas dermatológicas de pacientes hospitalizados
S. Özyurt
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Corresponding author.
, K.H. Kelekçi, S. Şeremet, S. Özçelik
Dermatology Department, İzmir Atatürk Education and Research Hospital, İzmir, Turkey
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Tablas (3)
Table 1. Distribution of referrals according to specialty.
Table 2. Patients with a correct provisional diagnosis.
Table 3. Dermatologist's diagnosis.
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To the Editor:

Many patients admitted to hospital by doctors other than dermatologists have skin disease in addition to the illness that caused hospitalization; this leads to a considerable number of interdepartmental dermatology consultations. While some of these referrals produce significant changes in the patient's diagnosis, treatment, and prognosis, others are completely unrelated to the patient's principal disease.

We retrospectively analyzed 417 interdepartmental consultations to dermatology from a 5-month period in a tertiary hospital, the İzmir Atatürk Training and Research Hospital (IATRH) in İzmir, Turkey. No pediatric referrals were included. The male to female ratio of the patients was 1,16 and the average age at the time of consultation was 56.13 years. The most common referrals were from the internal medicine department (17%), followed by the neurology (9%) and obstetrics and gynecology (8%) departments. The distribution of consultations according to specialty is shown in Table 1.

Table 1.

Distribution of referrals according to specialty.

Specialty  n (%)  Specialty  n (%) 
Internal medicine  72 (17.3)  Nephrology  14 (3.4) 
Neurology  41 (9.8)  Hematology  13 (3.1) 
Obstetrics and gynecology  35 (8.4)  Orthopedics  11 (2.6) 
Physiotherapy  34 (8.2)  Otorhinolaryngology  7 (1.7) 
Heart and vascular surgery  32 (7.7)  Intensive care  6 (1.4) 
Psychiatry  28 (6.7)  Gastroenterology  6 (1.4) 
Endocrinology  23 (5.5)  Ophthalmology  5 (1.2) 
Cardiology  21 (5.0)  Urology  5 (1.2) 
Neurosurgery  20 (4.8)  Medical oncology  4 (1.0) 
General surgery  19 (4.6)  Plastic surgery  3 (0.7) 
Infectious diseases  18 (4.3)  Total  417 

The interdepartmental consultation forms submitted by the relevant specialist teams were often incomplete. The reason for hospital admission was missing from a third of these forms. The description of the skin lesions was either incorrect or absent on 87% of the forms; and when the lesions were described, lay terms were often used instead of specifying the elementary lesions. A dermatologic differential diagnosis was submitted in only 45% of cases, and in only 29% (122/417) was the provisional dermatologic diagnosis considered correct after evaluation by a dermatologist. In similar studies, a correct provisional dermatologic diagnosis was reported in 23.9% by Davila,1 25% by Adışen,2 38% by Falanga,3 39% by Walia,4 and 45% by Ahmad.5

A correct provisional diagnosis by the referring specialty was most common in cases of infectious disease, such as cellulitis, tinea pedis, and herpes labialis, followed by drug reactions and contact dermatitis. The provisional diagnoses most frequently correct are listed in Table 2.

Table 2.

Patients with a correct provisional diagnosis.

Correct provisional diagnosis  Number  Total  Correct, % 
Cellulitis  22  27  82 
Tinea pedis  10  35  29 
Herpes labialis  13  69 
Drug reaction  28  29 
Contact dermatitis  39  18 
Psoriasis  78 
Vasculitis  14  50 
Behçet disease  100 

The most common diagnoses proposed by dermatology staff were contact dermatitis (39 cases, 9.4%), fungal infection (35 cases, 8.4%), drug reactions (28 cases, 6.7%), and cellulitis (27 cases, 6.4%). In similar studies, the most common diagnoses were dermatitis, drug reactions, and dermatophyte and herpes infections.1–4,6–8 The dermatologic diagnoses of the 417 patients are shown in Table 3.

Table 3.

Dermatologist's diagnosis.

Skin disease  n (%)  Skin disease  n (%) 
Contact dermatitis  39 (9.4)  Psoriasis  9 (2.2) 
Fungal infections  35 (8.4)  Recurrent aphthous stomatitis  8 (1.9) 
Drug reactions  28 (6.7)  No dermatologic disease  8 (1.9) 
Cellulitis  27 (6.4)  Seborrhoeic dermatitis  7 (1.7) 
Xerosis cutis  15 (3.6)  Behçet disease  7 (1.7) 
Pruritus  15 (3.6)  Malignancy  7 (1.7) 
Vasculitis  14 (3.4)  Oral candidiasis  7 (1.7) 
Stasis dermatitis  14 (3.4)  Acneiform disease  6 (1.4) 
Herpes labialis  13 (3.1)  Rosacea  5 (1.2) 
Infections (folliculitis, furunculosis, paronychia)  13 (3.1)  Traumatic ulcer  5 (1.2) 
Neurodermatitis  12 (2.9)  Spontaneous and traumatic ecchymosis  5 (1.2) 
Urticaria  11 (2.6)  Vascular disease (thrombophlebitis, ischemia)  5 (1.2) 
Pressure sore  11 (2.6)  Autoimmune bullous disease  4 (1.0) 
Intertrigo  11 (2.6)  Seborrhoeic keratosis  4 (1.0) 
Herpes zoster  10 (2.4)  Radiodermatitis  3 (0.7) 
Miscellaneous  59 (14.1)  Total  417 

The problem that led to the dermatology referral was present before the patient's admission in 66% of cases. Most consultations (71.5%) were found to be unrelated to the disease causing hospital admission. A total of 119 (28.5%) referrals were defined as relevant because the dermatologic disease was considered to be related to the patient's principal disease or to its treatment; the diagnosis of the patient's principal disease was reached as a direct result of the dermatology consultation in 59 of these 119 patients, the treatment of the principal disease was determined on the basis of dermatology consultation in 30, and the established treatment was changed in 30 because of complications of the previous treatments.

The dermatological opinion was an aid to the diagnosis and/or treatment of the patient's principal disease in 89 cases. For example, after the dermatology consultation, a patient under investigation by neurologists for ophthalmoplegia of unknown etiology was diagnosed with motor neuron involvement by herpes zoster. In another patient, unnecessary surgery was avoided by the accurate diagnosis of herpes zoster causing unbearable abdominal pain.

Dermatological examination was sufficient to reach the diagnosis in most of the referrals. However, laboratory tests were required to make the final diagnosis in 67 (16%) patients. Skin biopsies were performed in 8.2% of cases; this was lower than the rate reported by Davila1 (20%) but higher than the rate described by Adışen (4.4%).2

In our experience, common dermatologic diseases are often not correctly diagnosed by physicians from other specialties. In addition, there is room for improvement in the formal description and in the differential diagnosis of skin diseases. Expert dermatologic assessment usually facilitates inpatient diagnosis and management. Better training should be considered for medical students and residents and possibly even for medical staff in other specialties.

M. Davila, L.J. Christenson, R.D. Sontheimer.
Epidemiology and outcomes of dermatology in-patient consultations in a Midwestern U.S. university hospital.
Dermatol Online J, 16 (2010), pp. 12
E. Adışen, S. Ünal, M.A. Gürer.
Dermatoloji konsultasyonları.
Turkderm, 40 (2006), pp. 126-129
V. Falanga, L.A. Schachner, V. Rae, P.I. Ceballos, A. Gonzalez, G. Liang, et al.
Dermatologic consultations in the hospital setting.
Arch Dermatol, 130 (1994), pp. 1022-1025
N.S. Walia, S. Deb.
Dermatology referrals in the hospital setting.
Indian J Dermatol Venereol Leprol, 70 (2004), pp. 285-287
K. Ahmad, B. Ramsay.
Analysis of inpatient dermatologic referrals: insight into the educational needs of trainee doctors.
Ir J Med Sci, 178 (2009), pp. 69-71
A.I. Lorente-Lavirgen, J. Bernabeu-Wittel, A. Pulpillo-Ruiz, J.M. de la Torre-García, J. Conejo-Mir.
Inpatient dermatology consultation in a Spanish tertiary care hospital: a prospective cohort study.
Actas Dermosifiliogr, 104 (2013), pp. 148-155
I.C. Fernandes, G. Velho, M. Selores.
Dermatology inpatient consultation in a Portuguese university hospital.
Dermatol Online J, 18 (2012), pp. 16
P.H. Itin.
Dermatologic consultations in the hospital ward: the skin, an interdisciplinary organ.
Dermatology, 219 (2009), pp. 193-194
Copyright © 2013. Elsevier España, S.L. and AEDV
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