AAFP Core Educational Guidelines

Conditions of the Skin: Recommended Core Educational Guidelines for Family Practice Residents



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Am Fam Physician. 1999 Sep 15;60(4):1258-1264.

This document has been endorsed by the American Academy of Family Physicians and developed in cooperation with the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine. These revised guidelines represent suggestions and comments from the Committee on Interdisciplinary Dermatologic Education of the American Academy of Dermatology.

The 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 co-management of the patient. In some cases, referral to a dermatologist for management is indicated.

Knowledge

  1. Basic components of dermatology

    1. Normal anatomy, development and physiology

    2. Risk factors

      1. Congenital

      2. Acquired

      3. Aging

    3. Prevention

      1. Patient education

      2. Compliance

    4. Diagnostic guidelines

      1. Arrangement, distribution, type and pattern of lesions

      2. Type of lesion: primary/secondary; macular/papular/vesicular/nodular; tumor

      3. Specific lesion sites

      4. Seasonal variation/onset

    5. Therapeutic considerations

    6. Systemic evaluation (if indicated)

  2. Common dermatologic problems

    1. Skin problems

      1. Papulosquamous disease

        1. Seborrhea and dandruff

        2. Psoriasis

        3. Pityriasis rosea

        4. Miliaria (prickly heat)

        5. Lichen planus

      2. 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

      3. Dermatitis

        1. Contact

        2. Atopic

        3. Generalized exfoliative

        4. Nummular

        5. Stasis

        6. Diaper rash

      4. Macular eruptions

        1. Viral exanthems

        2. Drug reactions

      5. Urticarial eruptions

        1. Urticaria

        2. Dermographism

      6. Nodules

        1. Erythema nodosum

        2. Dermatofibroma

        3. Granuloma annulare

        4. Sarcoid

        5. Cysts

      7. Other pruritic conditions

        1. Generalized

          1. Scabies

          2. Dry skin (asteatosis)

          3. Secondary systemic disease

        2. Localized

          1. Lichen simplex chronicus (localized neurodermatitis)

          2. Pruritus ani

          3. Pediculosis (lice)

          4. Chigger and other insect bites

      8. Cutaneous infections

        1. Bacterial

          1. Impetigo

          2. Erysipelas

          3. Lymphangitis

          4. Cellulitis

          5. Boil (e.g., furuncle, pustule, folliculitis, abscess, carbuncle, ecthyma)

          6. Erythrasma

        2. Mycobacterial

          1. Atypical mycobacteria

        3. Fungal

          1. Superficial fungal infections

          2. Deep fungal infections

        4. Viral

          1. Herpes simplex

          2. Herpes zoster

          3. Warts

          4. Molluscum contagiosum

        5. Rickettsial

          1. Lyme disease

          2. Rocky Mountain spotted fever

      9. 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

      10. Cutaneous injuries

        1. Burns

          1. Thermal

          2. Chemical

          3. Sunburn

        2. Blister

        3. Abrasion

        4. Laceration

        5. Bruise

          1. Trauma

          2. Spontaneous purpura

        6. Bites and stings

      11. Pigment disorders

        1. Hyperpigmentation

        2. Hypopigmentation

          1. Pityriasis alba

          2. Vitiligo

        3. Tinea versicolor

      12. New growths

        1. Benign

          1. Inflammatory lesions

            1. Acne cyst

            2. Boil

            3. Hidradenitis

            4. Pyogenic granuloma

          2. Hyperplasia

            1. Verruca (common, plantar, anogenital, flat)

            2. Molluscum contagiosum

            3. Corn and callus

            4. Epidermal cyst

            5. Skin tag (acrochordon)

            6. Xanthelasma

          3. Neoplasia

            1. Seborrheic keratosis

            2. Mole, nevus (intradermal, junctional, compound, halo, blue, congenital)

            3. Lipoma

            4. Dermatofibroma

            5. Keloid

            6. Hemangioma

            7. Neurofibroma

            8. Other, such as fibroma, leiomyoma

        2. Premalignant

          1. Squamous cell carcinoma in situ (Bowen's disease)

          2. Actinic keratosis

          3. Disseminated superficial actinic porokeratosis

          4. Leukoplakia

          5. Keratoacanthoma

          6. Erythroplakia

          7. Premelanoma

            1. Lentigo maligna

            2. Giant congenital nevus

            3. Dysplastic nevus syndrome

          8. Radiation effects

        3. Malignant

          1. Basal cell carcinoma

          2. Squamous cell carcinoma

          3. Melanoma

            1. Major clinical categories

            2. Prognostic and therapeutic guidelines

          4. Paget's disease

          5. Cutaneous lymphoma

          6. Kaposi's sarcoma

          7. Metastases to the skin

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

      14. Occupational skin disease

        1. Hair problems

          1. Fungal infection

          2. Nonscarring alopecia

            1. Androgenic (male pattern)

            2. Alopecia areata/totalis/universalis

            3. Telogen effluvium

            4. Traction alopecia and trichotillomania

            5. Endocrine effects

            6. Discoid lupus erythematosus

            7. Lichen planopilaris

          3. Ingrown hair (pseudofolliculitis)

          4. Hypertrichosis

            1. Localized

            2. Virilizing causes of hirsutism

          5. Texture alterations (hair dystrophy)

    2. Nail problems

      1. Trauma

      2. Disturbances associated with other dermatoses

      3. Disturbances associated with systemic illness

      4. Texture alteration

      5. Fungal infection

      6. Periungual and subungual conditions

        1. Ingrown nail

        2. Paronychia

        3. Hematoma

      7. Colored nails

      8. New growths

        1. Benign

          1. Inflammatory

            1. Granuloma

            2. Warts

          2. Neoplasia

        2. Malignant

          1. Melanoma

          2. Squamous cell carcinoma

    3. Mucous membrane lesions

    4. Oral lesions

      1. Thrush

      2. Mouth ulcers

      3. Sicca

      4. Oral hairy leukoplakia

      5. Geographic tongue

      6. Black hairy tongue

      7. Leukoplakia

      8. Cheilitis

      9. Lichen planus

Skills

  1. Diagnostic skills

    1. Performance of history and physical examination with differential diagnosis

    2. Acquisition, examination and interpretation of laboratory specimens

      1. Biopsy

      2. Culture

      3. Scraping

    3. Skin testing techniques and interpretation

    4. Use of mechanical devices (i.e., Wood's light)

    5. Systemic evaluation (if indicated)

    6. Description of distribution and character of lesions

  2. Management skills

    1. Genetic counseling

    2. Nutrition counseling

    3. Preventive care

      1. Routine skin care

      2. Avoidance of environmental causes

      3. Sunscreens

      4. Appropriate use of over-the-counter lotions

    4. Health promotion

    5. Patient education

    6. Use of photographs to document progress

    7. Use of scales/indexes to grade disease severity

    8. Use of consultations and referrals

  3. Therapeutic skills

    1. Medical

      1. Topical

      2. Systemic

    2. Surgical

      1. Cauterization of skin lesions

        1. Acid cautery

        2. Electrocautery

        3. Electrodesiccation and curettage

      2. Cryosurgery

      3. Punch biopsy

      4. Excision of skin lesions

      5. Intralesional injection of corticosteroids

      6. Incision and drainage

      7. Treatment of ingrown toenails

    3. Physical

      1. Principles of ultraviolet light therapy

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 out-patient 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

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

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

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


Copyright © 1999 by the American Academy of Family Physicians.
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