Keywords

FormalPara Key Points

  • At least 15% of GP (general practitioner) consultations involve dermatology problems.

  • Dermatology in primary can be very different from that seen in hospital dermatology departments.

  • Most dermatology textbooks are written by hospital based doctors and tend to include rare and dramatic skin complaints that are not normally managed by GP’s.

  • GPs can manage their patients holistically, dealing not only with the physical problems, but also the psychological and social aspects of their skin problems.

  • Give realistic expectations as to how long it will take for a treatment to work.

1 Introduction

Skin, hair and nail problems are very common in the community. Studies have estimated that the overall proportion of the population with any form of skin disease was 55%, with 22.5% considered worthy of medical care (that is, moderate or severe) by a member of the primary care team such as a general practitioner, nurse practitioner , public health nurse or community pharmacist [1]. Skin diseases account for 12–23% of all symptoms based requests for advice from community pharmacists [2]. At least 15% of GP consultations involve dermatology problems [3, 4].

There are more diagnoses in dermatology (>2000) than in any other speciality in medicine. Despite this, there are only ten common dermatology problems that make up 80% of skin problems seen in general practice [5, 6] (Table 1.1). This list will change depending on the population studied. There are many elements that need to be accounted for like ethnicity, availability to diagnostics and treatment services among others [7].

Fig. 1.1
figure 1

Atopic eczema and psoriasis overlap in a 16 year old

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Table 1.1 The 10 most common dermatological problems that make up 80% of skin problems seen in general practice
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Most GPs should be able to confidently diagnose and manage most patients with mild to moderate forms of these 10 problems. In general, when faced with an unusual rash or lesion it is more likely to be an unusual presentation of a common problem, rather than a rare dermatology diagnosis.

2 The Patient’s Perspective

The dermatology problem may be presented as the primary reason for the patient attending or may be part of a list of problems the patient brings to the GP. There are even situations where a patient may be embarrassed or reluctant to discuss their skin problems with their GP with the mistaken belief that the problem is trivial or that they should not be wasting their GP’s time. The patient may tag a significant dermatology problem onto the end a busy consultation dealing with other unrelated problems. It is good practice to establish all the reasons the patient is attending at the start of the consultation (“are there any other problems”) so the doctor can decide which problems are a priority and which may have to be left to another visit if there is not enough time.

It takes time to properly examine the skin and a GP should have it in order to diagnose and propose solutions to the patient. Conditions like acne or psoriasis can be quick to diagnose but explaining the aetiology and the managment strategy to the patient is time consuming.

Writing a quick prescription without having time to deal with the patient’s concerns, lifestyle changes and any non-prescription items is often doomed to fail.

For chronic skin conditions, patient empowerment is a must. People should know and understand their condition and learn how to live with it, knowing how to contact their GP should their condition get worse or if there is an emergency.

3 Websites and Apps

We live in a world with a lot of information available. This accessibility can be good because it empowers the patient on his/her own skin condition; it can have the drawback of giving incorrect information or the worse scenario of a skin condition. GPs can help in reducing fear and anxiety associated with skin problems by guiding the patient to a good website that will explain the diagnosis and treatment in simplistic terms (see Chap. 67 on useful patient resources and websites).

4 Patient Information Leaflets

As treatment plans can be complicated, and the patient will only remember a small amount of what you tell them, patient information leaflets (PILs) explaining the treatments are very useful (Chap. 66).

5 The GP Perspective

GPs have the rare opportunity to see skin diseases in their early stages. This is why the description of certain diseases found in classical textbooks are not always how they present in GP’s clinical practice. For example nodular BCCs (basal cell carcinoma) do not always present as the classical testbook description of a pearly white ulcerated nodule with raised rolled edges.

many GPs, non-dermatologist hospital practitioners, pharmacists and nurses struggle with dermatology problems because of the lack of proper training in this area both at the undergraduate and postgraduate level. There is a lack of a simplified and accessible knowledge addressed to these professionals who are the first at attending a population with skin conditions.

Managing basic concepts and simple skills will allow non dermatologist to deal correctly with a large number of skin problems. The need for properly trained GP’s becomes more imperative as the number of patients with skin problems increase (the population is living longer; elderlies tend to have more skin diseases) and the number of dermatologists stays stagnant (even reduced by the outflow into cosmetic medicine).

A properly trained GP will not refer patients with relatively simple skin problems to dermatology OPD (outpatient department). This will reduce overcrowding, long waiting times and lack of time for the dermatologists to get involved in training in dermatology in primary care. Teledermatology will further help GP’s in getting advice on cases where there is no certainty.

The diagnosis and treatment of most dermatology problems rarely requires complicated or expensive imaging modalities such as CT scans or operating theatres with general anaesthesia. Treatment usually involves simple topical or oral treatments and many lumps and bumps can easily be excised or removed with basic surgical skills that are well within the scope of many GPs once the correct diagnosis is confirmed.

But simplicity comes from experience. Even treating a viral wart requires proper training and equipment.

6 Primary Care Dermatology

Dermatology in primary care can be very different from that seen in hospital dermatology departments [8]. In primary care diseases are often seen at an early stage when the clinical signs are vague and ill-defined. Patients may have overlap of more than one skin problem (e.g. acne and rosacea or psoriasis and atopic eczema) (Fig. 1.1). The clinical features may be altered by the patient’s own interventions (self medications, scratching, etc.). Others patients have chronic skin problems that are unresponsive or only partially controlled with hospital treatments.

It is important to realise that while the skin specialist knows more about skin diseases, the GP has the advantage of knowing more about the patient ! GPs are ideally suited to manage patients with simple straight forward skin diseases as they can manage the patient holistically, dealing not only with the physical problems but also the psychological and social aspects of their skin problems. It is vital that skin problems are not dismissed as trivial or unimportant by the doctor. It is important to show empathy and understanding of the distress that skin problem can cause to the patient. Primary care is probably the most appropriate place for chronic disease management and this is true for many common mild to moderate chronic dermatology problems . GPs should try to empower patients with chronic skin problems to manage at least some parts of their skin problem themselves. Nowadays, apps can help patients to manage their treatments, get advice on changing moles, etc.

Some skin problems may involve other organ systems (atopic children may have asthma and allergic rhinitis as well as eczema) and the GP can manage all aspects of the illness rather than just the skin component. Also many skin conditions can have associated underlying pathology (e.g. diabetes, arthritis, depression, etc.) and GPs can manage the skin diseases holistically, dealing with all the underlying ailments as well as the skin problem.

Nurses , pharmacists and GPs are ideally placed to promote skin wellbeing by applying health promotion and disease prevention strategies appropriately, including sun protection, occupational health advice and hand care.

This book will hopefully make dermatological knowledge for the most common skin conditions accessible and practical in a simplified manner.