DermatologyThe specialty of family practice is interested in dermatologic care, with an emphasis on comprehensive and continuing care. Each family physician should be aware of the impact of skin problems on a patient and the family and should be willing to perform and capable of performing preventive and therapeutic roles in these cases. The appearance of skin problems may have significant emotional impact on individuals and families. Significant preventive factors include emotional, environmental and occupational effects that may disturb the skin. Interaction with the family of any patient who has skin problems should be stressed in the education of the family physician. In addition, family physicians must be taught to be aware of the damage that can be done to the skin by inappropriate care.

While this outline specifies certain knowledge and skills basic to the diagnosis and management of patients with skin disorders, the family physician should understand that additional areas of knowledge and skills may be essential to the appropriate care of a given patient. Therefore, these guidelines are not intended to limit the family physician's effort to acquire other important dermatologic knowledge and skills.

It is expected that the family physician will become proficient in the diagnosis and treatment of patients with many kinds of skin diseases. The family physician may find it appropriate to seek consultation from a dermatologist and to actively engage in the comanagement of the patient. In some cases, referral to a dermatologist for management is indicated.

Patient Care

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

A. Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families

B. Gather essential and accurate information about dermatological problems in their patients

C. Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment

D. Develop and carry out patient management plans

E. Counsel and educate patients and their families

F. Use information technology to support patient care decisions and patient education

G. Provide health care services aimed at preventing health problems or maintaining health

a. Preventive care

i. Routine skin care

ii. Avoidance of environmental causes

iii. Sunscreens

iv. Appropriate use of over-the-counter lotions

b. Genetic counseling c. Nutrition counseling d. Health promotion e. Patient education f. Work with health care professionals, including those from other

disciplines, to provide patient-focused care, using consultants when necessary

B. Perform competently all medical and invasive procedures considered essential for the area of practice

a. Perform appropriate physical exam for dermatological problems

b. Formulate an appropriate differential diagnosis

c. Acquisition, examination and interpretation of laboratory specimens i. Biopsy

ii. Culture iii. Scraping

d. Skin testing techniques and interpretation e. Use of mechanical devices (i.e., Wood's light) f. Systemic evaluation (if indicated) g. Description of distribution and character of lesions h. Surgical

i. Cauterization of skin lesions 1. Acid cautery 2. Electrocautery 3. Electrodesiccation and curettage

ii. Cryosurgery iii. Punch biopsy iv. Excision of skin lesions

v. Intralesional injection of corticosteroids vi. Incision and drainage

vii. Treatment of ingrown toenails i. Physical

i. Principles of ultraviolet light therapy j. Use of photographs to document progress k. Use of scales/indexes to grade disease severity

Medical Knowledge

Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. Residents are expected to demonstrate an investigatory and analytical thinking approach to clinical situations. In addition they should know and apply the following:

A. Basic components of dermatology 1. Normal anatomy, development and physiology 2. Risk factors

a. Congenital b. Acquired c. Aging

3. Prevention a. Patient education b. Compliance

4. Diagnostic guidelines a. Arrangement, distribution, type and pattern of lesions b. Type of lesion: primary/ secondary; macular/papular/

vesicular/nodular; tumor c. Specific lesion sites d. Seasonal variation/onset

5. Therapeutic considerations 6. Systemic evaluation (if indicated)

B. Common dermatologic problems 1. Skin problems

a. Papulosquamous disease 1. Seborrhea and dandruff 2. Psoriasis 3. Pityriasis rosea 4. Miliaria (prickly heat) 5. Lichen planus

b. Vesiculobullous diseases 1. Impetigo 2. Herpes simplex 3. Herpes zoster 4. Varicella 5. Pemphigoid

6. Pemphigus 7. Dyshidrosis 8. Erythema multiforme 9. Dermatitis herpetiformis 10. Epidermal necrolysis 11. Epidermolysis bullosa

c. Dermatitis 1. Contact 2. Atopic 3. Generalized exfoliative 4. Nummular 5. Stasis 6. Diaper rash

d. Macular eruptions 1. Viral exanthems 2. Drug reactions

e. Urticarial eruptions 1. Urticaria 2. Dermographism

f. Nodules 1. Erythema nodosum 2. Dermatofibroma 3. Granuloma annulare 4. Sarcoid 5. Cysts

g. Other pruritic conditions 1. Generalized

a. Scabies b. Dry skin (asteatosis) c. Secondary systemic disease

2. Localized a. Lichen simplex chronicus (localized

neurodermatitis) b. Pruritus ani c. Pediculosis (lice) d. Chigger and other insect bites

h. Cutaneous infections 1. Bacterial

a. Impetigo b. Erysipelas c. Lymphangitis d. Cellulitis e. Boil (e.g., furuncle, pustule, folliculitis, abscess,

carbuncle, ecthyma) f. Erythrasma

2. Mycobacterial

a. Atypical mycobacteria 3. Fungal

a. Superficial fungal infections b. Deep fungal infections

4. Viral a. Herpes simplex b. Herpes zoster c. Warts d. Molluscum contagiosum

5. Rickettsial a. Lyme disease b. Rocky Mountain spotted fever

i. Complexion and cosmetic problems 1. Acne vulgaris 2. Acne rosacea 3. Oily skin 4. Enlarged pores 5. Milia 6. Vascular lesions 7. Wrinkles 8. Keloid 9. Hyperhidrosis

j. Cutaneous injuries 1. Burns

a. Thermal b. Chemical c. Sunburn

2. Blister 3. Abrasion 4. Laceration 5. Bruise

a. Trauma b. Spontaneous purpura

6. Bites and stings k. Pigment disorders

1. Hyperpigmentation 2. Hypopigmentation

a. Pityriasis alba b. Vitiligo

3. Tinea versicolor l. New growths

1. Benign a. Inflammatory lesions

i. Acne cyst ii. Boil

iii. Hidradenitis

iv. Pyogenic granuloma b. Hyperplasia

i. Verruca (common, plantar, anogenital, flat) ii. Molluscum contagiosum

iii. Corn and callus iv. Epidermal cyst v. Skin tag (acrochordon)

vi. Xanthelasma c. Neoplasia

i. Seborrheic keratosis ii. Mole, nevus (intradermal, junctional)

iii. Compound, halo, blue, congenital) iv. Lipoma v. Dermatofibroma

vi. Keloid vii. Hemangioma

viii. Neurofibroma ix. Other, such as fibroma, leiomyoma

2. Premalignant a. Squamous cell carcinoma in situ (Bowen's disease) b. Actinic keratosis c. Disseminated superficial actinic porokeratosis d. Leukoplakia e. Keratoacanthoma f. Erythroplakia g. Premelanoma

i. Lentigo maligna ii. Giant congenital nevus

iii. Dysplastic nevus syndrome h. Radiation effects

3. Malignant a. Basal cell carcinoma b. Squamous cell carcinoma c. Melanoma

i. Major clinical categories ii. Prognostic and therapeutic guidelines

d. Paget's disease e. Cutaneous lymphoma f. Kaposi's sarcoma g. Metastases to the skin

m. Cutaneous manifestations of systemic disease, including human immunodeficiency virus infection and syphilis

n. Occupational skin disease 1. Hair problems

a. Fungal infection b. Nonscarring alopecia

i. Androgenetic (male pattern) ii. Alopecia areata/ totalis/universalis

iii. Telogen effluvium iv. Traction alopecia and trichotillomania v. Endocrine effects

vi. Discoid lupus erythematosus vii. Lichen planopilaris

c. Ingrown hair (pseudofolliculitis) d. Hypertrichosis

i. Localized ii. Virilizing causes of hirsutism

e. Texture alterations (hair dystrophy) 2. Nail problems

a. Trauma b. Disturbances associated with other dermatoses c. Disturbances associated with systemic illness d. Texture alteration e. Fungal infection f. Periungual and subungual conditions

i. Ingrown nail ii. Paronychia

iii. Hematoma g. Colored nails h. New growths i. Benign

i. Inflammatory ii. Neoplasia

j. Malignant

1. Melanoma 2. Squamous cell carcinoma

2. Mucous membrane lesions 3. Oral lesions

a. Thrush b. Mouth ulcers c. Sicca d. Oral hairy leukoplakia e. Geographic tongue f. Black hairy tongue g. Leukoplakia h. Cheilitis i. Lichen planus

Practice-based Learning and Improvement

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:

A. analyze practice experience and perform practice-based improvement activities using a systematic methodology

B. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems

C. Obtain and use information about their own population of patients and the larger population from which their patients are drawn

D. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness

E. Use information technology to manage information, access on-line medical information; and support their education

F. Facilitate the learning of students and other health care professionals

Interpersonal and Communication Skills

Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to:

A. Create and sustain a therapeutic and ethically sound relationship with patientsB. Use effective listening skills and elicit and provide information using effective

nonverbal, explanatory, questioning, and writing skillsC. Work effectively with others as a member or leader of a health care team or other

professional group

Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:

A. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitments to excellence and on-going development

B. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices

C. Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

Systems-Based Practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:

A. Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice

B. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources

C. Practice cost-effective health care and resource allocation that does not compromise quality of care

D. Advocate for quality patient care and assist patients in dealing with system complexities

E. Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

Implementation

The development of core cognitive knowledge and appropriate skill in the care of the skin, hair and nails should require experience in a structured educational component of a family practice residency program. There must be written goals and educational objectives. This component need not be a "block rotation," but the educational experience must be appropriately identified and structured. Most of this experience will be in an outpatient setting with qualified physician teachers and consultants.

Residents will obtain substantial additional dermatologic experience throughout the three years of their involvement in the family practice center. Family practice residents should be instructed regarding timely and appropriate consultation with and/or referral to a dermatologist.

Residents should be taught the difference between acquisition of consultations and the referral of patients to another specialist for management and ultimate return to the referring family physician. In addition, residents should be instructed regarding the interdependence of family practice and other specialties and the appropriate referral of patients both from the family physician to the dermatologist and from the dermatologist to the family physician.

Resources:

1. Habif, TP. Clinical Dermatology: a color guide to diagnosis and therapy. 3d ed. St. Louis: Mosby, 1996.

2. Sams, WM Jr, Lynch, PJ, eds. Principles and practice of dermatology. 2d ed. New York: Churchill Livingston 1996.

3. Sauer,GC, Manual of skin diseases. 7th ed. Philadelphia: Lippincott, 1996.

Adapted from AAFP and ACGME 2002

Published 12/86Revised and Retitled 11/93Revised 2/99