Hospitalists sometimes come across skin problems in pediatric patients, and some of these issues fall outside the scope of their expertise.
“I find lesions incidentally that I recommend be referred to dermatologists for evaluation on an outpatient basis” more often than in inpatient dermatologic situations, says Logan Murray, MD, a pediatric hospitalist at the Barbara Bush Children’s Hospital at Maine Medical Center in Portland. “I recently managed a newborn with a 6 cm diameter brown patch in the lumbar area with fine, dark, vellus hair, which I suspect is a congenital giant melanocytic nevus,” he says. To properly evaluate the birthmark, he referred the patient’s parents to a dermatologist.
In these instances, it makes sense for a hospitalist to request that a dermatologist see the child and talk with the parents during hospitalization.
“We get many consults [that] are appropriate,” says Susan Bayliss, MD, a pediatric dermatologist at St. Louis Children’s Hospital. If a hospitalist can’t identify a particular skin issue and reassure parents, it’s time to call a dermatologist.
Distinguishing between acute and chronic dermatologic conditions is important. “The skin is often overlooked among hospitalists,” who are managing sicker patients nowadays, says Neera Agarwal-Antal, MD, head of the division of dermatology at Akron Children’s Hospital in Akron, Ohio.
One of the most dangerous and potentially fatal dermatologic emergencies is Stevens-Johnson syndrome, known in later stages as toxic epidermal necrolysis. Usually triggered by a drug-related reaction, the disease can cause large areas of skin to detach and lesions to develop in the mucous membranes. However, “the good news is most skin conditions are not acute or deadly,” Dr. Agarwal-Antal says.
Warts are very common and often can wait for examination in an outpatient setting. If an adolescent has significant acne, a hospitalist may ask gently, “Are you interested in doing something about your complexion?” To a patient who answers “yes,” a hospitalist could suggest over-the-counter benzoyl peroxide, says Dr. Bayliss, who is also professor of dermatology and pediatrics at Washington University School of Medicine in St. Louis.
“Pediatric dermatology is basically an outpatient specialty,” she adds. “Many kids have skin issues, but most of them do not need to be addressed by a hospitalist.” TH
Susan Kreimer is a freelance writer in New York.