Analysis of cases of dermatological referrals and their systemic correlation in a tertiary care hospital in Gangtok: a prospective study

INTRODUCTION

Practice of dermatology in a teaching hospital is not merely limited to inpatient and out patients’ management but also boost up the clinical knowledge of young medical graduates and medical students.¹ Although dermatology is primarily an outpatient management speciality the inpatients of other specialities do also frequently require dermatologists opinion for various types of skin diseases whether they are associated with their systemic diseases or as the independent clinical entities.^2,3 Accordingly we have been receiving substantial number of referrals for our opinion and subsequent clinical management of skin diseases of inpatients from various other departments on everyday basis as reported in various earlier studies.^2,4,5 Under certain circumstances even the revised line of treatment of some of the diseases offered by the dermatologist has made a perceptible difference and positively modified the prognosis of the disease.^2,5 It is also well known that many dermatological diseases might also be directly or indirectly associated or related with the primary diseases for which the patient was admitted in the hospital or it may also be the dermatological manifestation of systemic diseases.^6,7 Since there is no a single publication on any such clinical correlation analytical study of dermatological ailments vies a vies systemic diseases amongst these referrals so far we made an attempt to undertake this as well at the present study.

Aim and objectives

• • To analyze the type of dermatological diseases referred from the indoor patients and its department wise classification.
• • Analyse these diseases into different category dermatoses.
• • Identify and differentiate these dermatological diseases into related or unrelated to systemic diseases for which the patient was admitted.

METHODS

Consecutive sampling was applied. It is a study conducted on 297 consecutive referrals of indoor patients from various other specialties with dermatological disease at a teaching hospital in Gangtok between August 2017 and February 2018. Chi square test was applied to find out any statistical significance.

RESULTS

In the present study we analysed 297 referrals in which an effort was made to classify types of dermatoses and came across following patterns of distribution with respect to different specialities (Table 1 and 2).

Out of 297 referrals majority, 145, were from the department of medicine and only one, the least number, from Gastroenterology. The second highest number 29 was from the department of paediatric. Details of the breakup of the referrals are given in Table 1. It is worth mentioning the fact that maximum number of cases we encountered were the viral infection with 39 cases which included herpes simplex, herpes zoster, verruca vulgaris, mollascum contagiosum, viral exanthematous rashes including measles and other viral rashes. Second most common was the bacterial infection and then the fungal infection (dermatophytes and candida thrush). Youngest age of the patient referred for dermatological consultation was a neonate with piabaldism and oldest one was of the age of 85 years old male. It is important to note that a case of basal cell carcinoma in the face of a male patient was referred from the respiratory medicine to dermatology department as insect bite. Subsequently the line of treatment was completely changed after we furnished our diagnosis. It was a great eye opener to the concerned referring department and a great benefit to the patient. Also as per the aim of our study we have also noted that 128 patients had dermatological manifestations of primary diseases or directly or indirectly related to it and the rest 169 fell in unrelated group.

DISCUSSION

In the study we have seen that 145 referrals were from the department of internal medicine and majority of them were with erythematous rashes and it was noted that the non-dermatologists could only make 30 percent of diagnoses correctly but common dermatological disorders were often misdiagnosed. Similar observation was also made in an earlier study.^2,3,5 Rest of other 70 percent diagnoses had to be revised followed by a complete alteration in treatment strategy. Similar studies done in Eastern India, and Northern India revealed similar statistical reports with changes with respect to categorisation of dermatological consults, being mostly from the internal medicine department which is closely followed by nephrology and paediatrics departments.^2,5 Similarly another study of 464 patients showed that only 32 percent dermatological diseases were correctly diagnoses by the non-dermatologist doctors.⁸ In our present study we also have similar observation. As a result all the studies recommended that an extensive training is necessary for young graduates in dermatology. Also another study conducted on 1560 referrals showed that majority of cases referred to dermatology were subjected to unnecessary investigations and treatments because of wrong diagnoses by the non-dermatologists of other specialties.⁴ Accordingly the authors reinforced their opinion that MBBS students also need to be imparted with more vigorous training in dermatology.

A retrospective study of 971 indoor referrals to dermatology showed almost two thirds (61 percent) of diagnoses made by other departments were wrong and it was opined that a continued and sustained refresher training was an absolute necessity for the residents doctors.⁵ In one study 464 referrals were analyzed where it was noted that only 32% non-dermatologists were able to make correct diagnosis, therefore it was stated that a rigorous training was necessary to the resident doctors in dermatology.⁸ In a Portuguese university hospital study of 282 inpatients referrals were analysed and noted that 33.7% referrals from internal medicine. It was reported that non dermatologists missed most of the diagnosed.⁹ Most studies showed quite a few number of drug related manifestations which were not found in our study.^10,11

CONCLUSION

In our study it has been noted that majority of referrals were from the department of General Medicine and Pediatrics but in large number of cases the diagnoses made by the non-dermatologists grossly differed from that of the final diagnoses offered by the dermatologists. This in fact was noted to be beneficial not only to the patients but also to the non-dermatologists. Dermatological referrals can also offer a quality treatment to the patients and an eye opener to other specialties doctors that dermatological illness many a times can also be a dermatological manifestation of systemic illnesses. A single case of so called insect bite which turned out to be a basal cell carcinoma after dermatological consultation also justifies the need for refresher course training to young graduates in dermatology.

ACKNOWLEDGEMENTS

We would like to acknowledge all the patients who provided clinical data to bring out this research work.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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