Need for dermatology consultations in the hospital setting
The importance of the inpatient dermatologists’ consult has been called into question because of the ever-decreasing reimbursement by insurance companies in the United States. Both practicing dermatologist and health care companies alike appear to have placed a lower value on the benefits. However, upon further evaluation and research, Lisa Arkin, assistant professor of Dermatology and Pediatrics, University of Wisconsin School of Medicine and Public Health and the American Family Children’s Hospital, Madison, Wisconsin, USA showed compelling evidence that demonstrates the useful and necessary incorporation of dermatology consults in a hospital inpatient setting.
When research literature was reviewed in relation to adult dermatology inpatient consultations, Strazzula et al. 2015 reported an astounding 75% out of more than 1400 patients were misdiagnosed initially. As reported by Kroshinsky et al. 2016, the most common problems for misdiagnosis by the referring physicians were cellulitis, ulcers, and infection-related skin conditions. Notably, when dermatologists were consulted, the skin diagnosis was invariably corrected in more than 70% of cases necessitating a change in treatment and patient management for the newly diagnosed skin condition.
In addition to adult inpatient consults, the pediatric emergency room is also a frequent area where skin misdiagnosis may commonly occur necessitating the need for a dermatologist consult. A study by Moon et al. 2016 demonstrated the misdiagnosis of 145 pediatric patients by emergency room physicians and an altered diagnosis by the pediatric dermatologist consult. The most common misdiagnosing offenders in the pediatric population were infectious disease-related skin conditions, atopic dermatitis, and inflammatory skin conditions. As with the adult population, the change to a more definitive diagnosis by a pediatric dermatologist necessitated a change in treatment and subsequent management.
Dr. Arkin also presented data on the significant cost savings by having a pediatric dermatologist available in the pediatric emergency room. Through a retrospective analysis conducted by Beal et al. 2016, Arkin demonstrated the reduction in emergency room visits, reduction in misdiagnosed atopic dermatitis, and a costs savings of more than $90,000 in 130 patients who had access to a pediatric dermatologist compared to a cost of more than $140,000 in 205 patients admitted to the emergency room with no pediatric dermatologist available.
Babies with blisters
In additional to pediatric and adult inpatient consults, discussion also surfaced around neonatal needs, defining neonates as birth to 4 weeks old. Because of their delicate status, neonates have an increased risk of certain dermatologic conditions that raise mortality if not treated swiftly. Neonatal community acquired Staphylococcus aureus is one such condition that may present in neonates as scattered pustules on the face and forearms and cellulitis/abscesses. Its risk factors include NICU status (methicillin sensitive S. aureus [MSSA] and methicillin resistant S. aureus [MRSA] with mortality rates from ~10-12%) as well as infections at surgical sites. Topical treatments and close follow up should occur in limited pustulosis patients while systemic antibiotics should be used for cellulitis or deep tissue infection.
Neonatal herpes simplex virus (HSV) is another condition that presents in neonates as mucocutaneous lesions, but may have other nondescript sepsis-like symptoms such as decreased appetite, lethargy, presence or absence of fever, and seizures. Variants of this may also present such as 1) disseminated hepatitis, disseminated intravascular coagulation, and pneumonitis, 2) central nervous system disease with neurological symptoms, seizures, and positive cerebrospinal fluid findings, and 3) disease limited to cutaneous findings such as the skin, eyes, and mouth. Approximately one third of neonatal HSV patients have no cutaneous findings and this should be considered carefully during the differential diagnosis.
Collodion conditions are very rare, the most common being autosomal recessive congenital ichthyosis (ARCI), resulting from mutations in TGM1, ABCA12, ALOXE3, ALOX12B, NIPAL4. However, other phenotypes may present including lamellar ichthyosis, congenital ichthyosiform erythroderma, harlequin ichthyosis, and self-healing collodion baby. In the presence of any form of skin scaling covering the body, a differential diagnosis of a collodion condition should be considered. Care for these babies should include the monitoring of temperature, fluid status, electrolytes, and weight as they are at higher risk for hypernatremic dehydration. The membranes may restrict feeding, eyelid closing, and may even affect respiration. Treatment should include a humidified isolate (40-60%), diffuse use of bland emollients applied multiple times a day, avoidance of keratolytics, and pain control.
These data reinvigorate the need of referral physicians to utilize dermatological consults in inpatient hospital settings and demonstrate the unacceptable incidence of misdiagnosis, inaccurate treatments, and subsequent mismanagement. Early involvement of consulting dermatologists lead to an improved accuracy of diagnosis and may otherwise reduce the unnecessary and often overused antibiotic therapy often seen in the hospital setting as a result of misdiagnosed cellulitis. It should also serve as a strong reminder for health care administrators and insurance companies to acknowledge the need and importance of dermatology consults in a hospital setting. In addition, a higher reimbursement value should be assigned to this specialized dermatological care, that prevents misdiagnosis, improves outcomes, and overall leads to cost saving. Lastly, the need to closely monitor neonates is of paramount importance to reduce the mortality rate commonly associated with dermatological conditions in the youngest and most vulnerable patients.