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Am Fam Physician. 1999;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

    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)

  2. 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

  1. 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

  2. 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

  3. 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.

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