Hospital Dermatology: Skin Conditions seen as a Consultant

Hospital dermatology is very different from what we see in clinic, and this week marks the end of my last weeknight /weekend call, hooray! For the nonmedical folk, “call” means we are on call as a consultant for any skin-related issues that arise in emergency room (ER) or hospitalized patients. For one calendar year we as residents take weeknight and weekend call, split evenly amongst the class. As 2016 draws to a close, I will be finishing my last evening call shift, something worth celebrating!

So far I’ve also done daytime consults, and I actually really enjoy being the dermatology consultant. I get to see so many interesting cases that come through, either acute ones through the ER or chronic conditions that have never been addressed. For any diagnosis we want to confirm, we can always biopsy the lesion, meaning we anesthetize the area with lidocaine and then shave a little sample of the lesion off and analyze it under the microscope. We can also do other diagnostic tests such as skin or nail scrapings to look for fungus, sending biopsy for tissue culture to see if microorganisms grow out of it, other scrapings to look for viruses, etc. The variety of skin conditions keeps things interesting.

Often my family or friends don’t understand why dermatologists are needed in the hospital. One person even asked me once, “Why is a dermatologist on call? Emergency acne?!” Not quite. Since I’m done with a year of evening/weekend call, I wanted to write about some of the things we tend to see in the hospital. None of these reflect actual patient cases, and some of these conditions I actually have never seen, but I have heard and read about them. Just to be clear: this post is not in any way shape or form meant to be taken as medical advice. If you’re having any of these symptoms please see a doctor or dermatologist in real life. If you’re interested in learning more about these conditions I linked to a few resources at the bottom.

Drug reactions: This is probably the most often reason why dermatologists are called in the hospital! You can think of allergic reactions to medications as a big category, but actually there are MANY TYPES of drug reactions that have subtle differences. For example, you have your usual “morbiliform drug rash” that looks like faint red spots on the body but then you also have “Acute Generalized Exanthematous Pustulosis” (AGEP) which looks like little tiny pimples everywhere. Different abnormal blood tests accompany each type of drug rash. Common culprits causing these rashes include antibiotics like penicillin or anti-seizure medications. Different medications cause different drug rashes though, so as a dermatology resident we need to memorize all the different medications that can cause each type of rash!

Stevens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN): This is the one that is truly life-threatening and is a real emergency. These two conditions exist on a spectrum; SJS is less than 10% body surface area of skin detachment and TEN is over 30%. That’s right…skin detachment. These patients look like burn victims because their skin is sloughing right off their bodies…all over their bodies. They also look very ill, have skin pain, and involvement of their mucous membranes. Causes include new medications (sulfur containing drugs such as Bactrim, penicillin, anti-seizure medications, and others) or infections like mycoplasma infection. These are emergencies and we need to see these patients RIGHT AWAY, biopsy them (you see dead epidermis under the microscope and some other findings) and then treat them with supportive care or get them to a burn unit. If you’re interested in derm emergencies, here is some more information.

Viral and bacterial infections: Lots of infections manifest in the skin, especially in kids. We get called sometimes for rashes that don’t look 100% typical for the virus or for complicated patients who are already very sick and the primary team would like our input. Examples of viruses that cause rashes include hand foot mouth disease (Coxsackie virus), rubella (togavirus), infectious mononucleosis (EBV), and others. A whole host of bacteria cause rashes and other skin findings. You may have heard of some of these conditions: staphylococcal scalded skin syndrome, toxic shock syndrome, scarlet fever, and more. The ones I just mentioned present with more characteristic rashes, but sometimes the findings are more subtle. For example, in bacterial endocarditis, we sometimes look for Janeway lesions, which are pinpoint spots of bleeding into the skin usually on the palms and soles. These are actually little foci of bacteria that are thrown in to the blood circulation from the heart. Dermatologists really have to be on the hunt and look at ALL the skin so we don’t miss any of these diagnostic clues!

Other types of infections are deeper, meaning in the bloodstream and disseminated to the skin, or only in certain areas of the body such as herpes. A common infection we get called for is cellulitis, an infection of the deeper layers of the skin. Another emergency (a surgical one, really) is necrotizing fasciitis, which is a rapidly progressing painful infection of the soft tissue and fascia that can result in amputation if not contained and treated in time.

Ulcers: There are many reasons for people to develop ulcers on their bodies, such as chronic venous insufficiency (poor circulation in the legs), trauma, diabetes, tons of infections, inflammatory conditions such as pyoderma gangrenosum, and more. Dermatology is sometimes consulted to rule out an underlying cause or to provide wound care recommendations.

Hives: unremitting, chronic, super itchy hives, medically termed “urticaria”. We see those too. We have to rule out a dangerous underlying cause for the hives, so if it’s a chronic condition with the individual lesions lasting for over 24 hours, then we may choose to biopsy it.

This is just a tiny window into what we may see in the hospital as a dermatology consultant; there are SO many more including blistering diseases like bullous pemphigoid and pemphigus vulgaris, vasculitis, internal lymphomas and leukemias that spread to the skin, erythema multiforme, bad lupus flares, lyme disease, severe fungal infections, chicken pox all over the body, shingles, different types of cancers, reactions to chemotherapy and other drugs, cellulitis cellulitis cellulitis, and so much more. The list goes on and on, but I just narrowed it down to these few for the purposes of this post.

If you’re ever in the position to call a consult (this is for the med folk!), here’s a pro tip about the type of information to include if you want to be proactive and sound smart:

Your name and role on the medical team:

Patient’s full name (spelled) and location in the hospital:

Medical record number:

Reason for consult: (This is really important. Always know the reason why you’re calling a consultant)

Your contact information:

Chief complaint:

The story about the patient (HPI):

Vitals:

Physical Exam:

Lab/Imaging findings:

That’s it! Have a happy end of 2016 and here’s to more interesting dermatology cases and tons of learning in the new year!