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
- Basic components of dermatology Normal anatomy, development and physiology
Risk factors
Congenital
Acquired
Aging
Prevention
Patient education
Compliance
Diagnostic guidelines
Arrangement, distribution, type and pattern of lesions
Type of lesion: primary/secondary; macular/papular/vesicular/nodular; tumor
Specific lesion sites
Seasonal variation/onset
Therapeutic considerations
Systemic evaluation (if indicated)
- Common dermatologic problems Skin problems Papulosquamous disease Seborrhea and dandruff
Psoriasis
Pityriasis rosea
Miliaria (prickly heat)
Lichen planus
Vesiculobullous diseases
Impetigo
Herpes simplex
Herpes zoster
Varicella
Pemphigoid
Pemphigus
Dyshidrosis
Erythema multiforme
Dermatitis herpetiformis
Epidermal necrolysis
Epidermolysis bullosa
Dermatitis
Contact
Atopic
Generalized exfoliative
Nummular
Stasis
Diaper rash
Macular eruptions
Viral exanthems
Drug reactions
Urticarial eruptions
Urticaria
Dermographism
Nodules
Erythema nodosum
Dermatofibroma
Granuloma annulare
Sarcoid
Cysts
Other pruritic conditions
Generalized
Scabies
Dry skin (asteatosis)
Secondary systemic disease
Localized
Lichen simplex chronicus (localized neurodermatitis)
Pruritus ani
Pediculosis (lice)
Chigger and other insect bites
Cutaneous infections
Bacterial
Impetigo
Erysipelas
Lymphangitis
Cellulitis
Boil (e.g., furuncle, pustule, folliculitis, abscess, carbuncle, ecthyma)
Erythrasma
Mycobacterial
Atypical mycobacteria
Fungal
Superficial fungal infections
Deep fungal infections
Viral
Herpes simplex
Herpes zoster
Warts
Molluscum contagiosum
Rickettsial
Lyme disease
Rocky Mountain spotted fever
Complexion and cosmetic problems
Acne vulgaris
Acne rosacea
Oily skin
Enlarged pores
Milia
Vascular lesions
Wrinkles
Keloid
Hyperhidrosis
Cutaneous injuries
Burns
Thermal
Chemical
Sunburn
Blister
Abrasion
Laceration
Bruise
Trauma
Spontaneous purpura
Bites and stings
Pigment disorders
Hyperpigmentation
Hypopigmentation
Pityriasis alba
Vitiligo
Tinea versicolor
New growths
Benign
Inflammatory lesions
Acne cyst
Boil
Hidradenitis
Pyogenic granuloma
Hyperplasia
Verruca (common, plantar, anogenital, flat)
Molluscum contagiosum
Corn and callus
Epidermal cyst
Skin tag (acrochordon)
Xanthelasma
Neoplasia
Seborrheic keratosis
Mole, nevus (intradermal, junctional, compound, halo, blue, congenital)
Lipoma
Dermatofibroma
Keloid
Hemangioma
Neurofibroma
Other, such as fibroma, leiomyoma
Premalignant
Squamous cell carcinoma in situ (Bowen's disease)
Actinic keratosis
Disseminated superficial actinic porokeratosis
Leukoplakia
Keratoacanthoma
Erythroplakia
Premelanoma
Lentigo maligna
Giant congenital nevus
Dysplastic nevus syndrome
Radiation effects
Malignant
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
Major clinical categories
Prognostic and therapeutic guidelines
Paget's disease
Cutaneous lymphoma
Kaposi's sarcoma
Metastases to the skin
Cutaneous manifestations of systemic disease, including human immunodeficiency virus infection and syphilis
Occupational skin disease
Hair problems
Fungal infection
Nonscarring alopecia
Androgenic (male pattern)
Alopecia areata/totalis/universalis
Telogen effluvium
Traction alopecia and trichotillomania
Endocrine effects
Discoid lupus erythematosus
Lichen planopilaris
Ingrown hair (pseudofolliculitis)
Hypertrichosis
Localized
Virilizing causes of hirsutism
Texture alterations (hair dystrophy)
Nail problems
Trauma
Disturbances associated with other dermatoses
Disturbances associated with systemic illness
Texture alteration
Fungal infection
Periungual and subungual conditions
Ingrown nail
Paronychia
Hematoma
Colored nails
New growths
Benign
Inflammatory
Granuloma
Warts
Neoplasia
Malignant
Melanoma
Squamous cell carcinoma
Mucous membrane lesions
Oral lesions
Thrush
Mouth ulcers
Sicca
Oral hairy leukoplakia
Geographic tongue
Black hairy tongue
Leukoplakia
Cheilitis
Lichen planus
Skills
- Diagnostic skills Performance of history and physical examination with differential diagnosis
Acquisition, examination and interpretation of laboratory specimens
Biopsy
Culture
Scraping
Skin testing techniques and interpretation
Use of mechanical devices (i.e., Wood's light)
Systemic evaluation (if indicated)
Description of distribution and character of lesions
- Management skills Genetic counseling
Nutrition counseling
Preventive care
Routine skin care
Avoidance of environmental causes
Sunscreens
Appropriate use of over-the-counter lotions
Health promotion
Patient education
Use of photographs to document progress
Use of scales/indexes to grade disease severity
Use of consultations and referrals
- Therapeutic skills Medical Topical
Systemic
Surgical
Cauterization of skin lesions
Acid cautery
Electrocautery
Electrodesiccation and curettage
Cryosurgery
Punch biopsy
Excision of skin lesions
Intralesional injection of corticosteroids
Incision and drainage
Treatment of ingrown toenails
Physical
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.
