Dermatology Clinic

Dermatology Referral Guidelines for MAP Handbook

Brief summary of appropriate Emergent/URGENT referrals

• Patients that should be referred to the emergency department or an emergent SAME DAY dermatology consult.:
  • Patients with a severe acute (or acute on chronic) rash with or without blisters that involves a large surface area (>10% of the body) and mucus membranes (eyes, nose, mouth, or genitals), fever, or internal organ involvement
  • Immunosuppressed patients with new (< 2 weeks) onset of nodule(s)/papule(s)/plaque(s) that are concerning for an infection
• Other conditions not requiring emergent evaluation, but rather, urgent (<2 weeks) referrals:
  • Acute severe rashes that are NOT accompanied by mucous membrane or internal organ involvement
  • Rapidly progressive ulcers
  • Skin lesions concerning for skin cancer. Please include if the patient has a personal or family history of skin cancer and the duration and associated symptoms. No prior testing needed.  If worrisome for melanoma specifically, please mention that in the referral and request that patient be seen within 1 week
  • Any processes that appears to be scarring (this may include hair loss, rashes, etc). Please include any previous treatments and testing that may have already been performed.
  • New blistering diseases
  • Rashes concerning for lupus or other connective tissue disease

For same day or urgent referrals, patient’s provider should call the on-call dermatology resident (daytime consult pager number is 512-205-2748) who can facilitate making a timely appointment for the patient. Currently our dermatology clinics at CommUnityCare are held on Tuesday mornings (Southeast Health and Wellness Clinic) and Wednesday mornings (North Central Clinic).

Brief summary of appropriate ROUTINE referrals

• For all routine referrals, please include any recent laboratory studies performed, prior skin biopsy results, and previous treatments tried (if any). Routine referrals may include, but are not limited to:
  • Rashes of unclear etiology
  • Chronic urticaria (>6 weeks)
  • Acne (severe; or moderate if failed appropriate initial treatment)
  • Rosacea
  • Atopic dermatitis
  • Contact dermatitis
  • Psoriasis
  • Boils in axillae/groin or hidradenitis suppurativa
  • Chronic ulcers
  • Actinic keratoses or skin cancer surveillance in high-risk individuals
  • Hair loss (if severe and significantly affecting QOL)
  • Molluscum/Warts (including anogenital condyloma) if refractory to treatment
  • HIV lipoatrophy
  • Subcutaneous nodules (Cyst and lipoma)
  • Venous stasis dermatitis
  • Vitiligo
  • Melasma (if severe and significantly affecting QOL)
  • Nail dystrophy that is not onychomycosis or refractory to treatment
  • Tinea (refractory to treatment)

Please do NOT refer the following to Derm clinic:

•  Skin tags
• Removal of known benign lesions that are not symptomatic (i.e. seborrheic keratosis)
• Keratosis pilaris
• Acute urticaria (<6 weeks)
• Pilonidal cyst or sinus (refer to general surgery)
• Acute skin infections in immunocompetent patients such as impetigo or tinea
• Mild acne, melasma, and hair loss with minimal impact on pt’s QOL
• Skin cancer surveillance for patients with no concerning lesions and minimal risk factors for skin cancer
• Dermatologic concerns in pediatric patients (refer to pediatric dermatology)

Documentation required for scheduling referral

• Completed referral form with problem list, updated medication list, and specific reason for consultation.
• Please include any pertinent laboratory studies or imaging and any previous skin biopsies.

General recommendations

• Dermatology is a subspecialty that relies heavily on visual recognition of patterns to facilitate appropriate work-up and treatment. Because of this, minimal recommendations for work-up or treatment prior to evaluation by dermatology will be described here, as early dermatology evaluation of an unknown cutaneous manifestation is appropriate.
• Specific first-line recommendations for common and unambiguous cutaneous manifestations will be included below; all other entities may be referred to dermatology.
• Please ensure medication list is updated and correct at the time of referral.
• Consider uploading photographs of the cutaneous lesion or eruption at the time of presentation to the patient’s medical record. Alternatively, providers can encourage or even assist patients in taking clear photographs on the patient’s smartphone.

PCP Interim Care Plan Recommendations

Rashes of unclear etiology

• Recommend bland emollients at least twice daily (examples include Vaseline, Aquaphor, CeraVe or Cetaphil creams/ointments. Avoid lotions).
• If pruritic, patients can try over-the-counter Sarna lotion
• Use fragrance-free cleansers while bathing and moisturize immediately afterwards
• Have patient document rash with photographs through its evolution, if possible
• Early referral to dermatology as soon as issue is seen

Chronic urticaria

• Characterized by pink, evanescent wheals that usually resolve over several hours and are migratory, often idiopathic (duration > 6 weeks)
• Start scheduled cetirizine 10 mg once daily
• If not improving after one month refer to dermatology

Acne vulgaris

• 1st line treatment for mild comedonal and inflammatory acne is benzoyl peroxide wash plus a topical retinoid such as tretinoin 0.05%.
• 1st line treatment for moderate inflammatory acne is oral doxycycline 100 mg QD to BID daily combined with a topical retinoid and benzoyl peroxide wash daily. Typically, antibiotics treatment is continued for 3-4 months, then tapered once acne is better controlled.
• Severe acne should be referred to dermatology.
• Zaenglein et al, J Am Acad Dermatol 2016;74:945-73

Rosacea

• Recommend avoidance of triggers including alcohol, coffee and other warm drinks, spicy foods, sun exposure, emotional stress. Patients should be encouraged to wear sunscreen (SPF 30 or higher) daily.
• For mild rosacea, initiate topical metronidazole 1% once daily. Consider addition of sodium sulfacetamide cleanser or lotion, applied twice daily.
• For moderate rosacea, doxycycline 100mg daily to BID can be used in conjunction with topical metronidazole. Once better control is obtained, this can be decreased to 40mg daily.
• Monitor for eye involvement. If patients endorse symptoms of foreign body sensation, dryness, conjunctivitis, etc, consider referral to ophthalmology.
• Two et al, J Am Acad Dermatol. 2015 May;72(5):761-70

Atopic dermatitis

• For all atopic dermatitis, use bland emollients at least twice daily (examples include Vaseline, Aquaphor, CeraVe or Cetaphil creams/ointments. Avoid lotions).
• Use fragrance-free cleansers while bathing and moisturize immediately afterwards
• If not controlled with above measures, initiate a low-potency topical steroid such as hydrocortisone 2.5% twice daily for flares (up to two weeks at a time) on face and intertriginous regions and a mid-potency topical steroid such as triamcinolone 0.1% twice daily to trunk and extremities. Such steroids may be applied twice weekly to “hot spots” for maintenance in between flares. Ointments are generally preferred as creams may burn when applied to inflamed skin.
• Atopic dermatitis not improving with the suggested initial regimen detailed above should be referred to Dermatology.
• Eichenfeld LF et al, J Am Acad Dermatol 2014;71:116-32.

Contact dermatitis

• Often presents with erythema, vesiculation and pruritus in a geometric or linear configuration
• Contact dermatitis is most commonly caused by Rhus dermatitis (poison ivy, oak or sumac)
• If mild to moderate, start potent topical steroids (i.e. fluocinonide) to affected areas twice daily for two weeks; if severe and requiring systemic steroids, patient will require 2-3 week course of systemic steroids

Psoriasis

• Start a low-potency topical steroid such as hydrocortisone 2.5% twice daily for flares (up to two weeks at a time) on face, genital region, and intertriginous regions and a mid-potency topical steroid such as triamcinolone 0.1% twice daily to trunk and extremities for flares. Start moderate strength topical steroids (i.e. triamcinolone 0.1% cream) twice daily PRN
• Should be seeing PCP yearly for evaluation for cardiovascular risk factors, depression, and joint pain to evaluate for psoriatic arthritis
• Refer to dermatology of BSA > 5% or scalp, genital, or palmoplantar involvement

Boils in the axillae or groin (or hidradenitis suppurativa)

• Start topical benzoyl peroxide wash and clindamycin 1% lotion
• In patients with recurrent boils in the axillae or groin area, one must consider a diagnosis of hidradenitis suppurativa. Referral to dermatology is indicated in this case or if patient carries a diagnosis of hidradenitis suppurativa.

Chronic ulcers

• Employ good wound care; if concerning for venous ulcer start compression stockings and foot elevation; if concerning for arterial ulcer obtain Ankle-Brachial Indices (ABI)
• If concern for infection, a tissue culture may be needed. Please refer to dermatology for biopsy for tissue culture (rather than swab of surface of skin).

Skin cancer surveillance

• Basal cell carcinoma (BCC) is the most common type of skin cancer, usually develops on skin that sustains sun exposure and can present as a “pimple” or sore that doesn’t heal, or as a new scar without history of prior trauma. These tumors should be biopsied by dermatology and surgically excised to prevent local tissue destruction. These types of tumors do not usually metastasize. (Bichakjian C et al, J Am Acad Dermatol 2018;78:540-559)
• Squamous cell carcinoma (SCC) is another common skin cancer strongly correlated with sun-exposure occurring commonly on the head, neck, and upper extremities. They can present as pink, scaly papules, hypertrophic erosive lesions, or crateriform nodules. These tumors should be biopsied by dermatology with further work-up performed pending results. SCC of the head and neck have a higher likelihood of metastasis and death than SCC of other locations (Alam M et al, J Am Acad Dermatol 2018;78:560-579)
• Melanoma is the most serious type of skin cancer because it can grow quickly and metastasize. Lesions concerning for melanoma are those with asymmetry, irregular, scalloped or poorly defined borders, color variation within the lesion (brown, black, tan, white, red, blue), diameter > 6 mm, or changing lesions. A lesion concerning for melanoma should be urgently referred to dermatology for biopsy, with subsequent management pending confirmation and stage (Mayer JE et al, J Am Acad Dermatol 2014;71:599-609; http://www.cancer.gov/types/skin)
• Patients with non-melanoma skin cancers (NMSC) should be evaluated by dermatology every six months for two years following a skin cancer diagnosis, and more frequently following a melanoma diagnosis

Hair loss

• Etiologies of hair loss are quite broad. If severe or appears to be scarring, early referral to dermatology is encouraged
• For mild-moderate male or female pattern alopecia, topical minoxidil 5% is a reasonable initial treatment

Warts (including anogenital)

• Start over-the-counter 40% salicylic acid to affected areas nightly (except for anogenital warts)
• If liquid nitrogen is available, start in office treatments every 3-4 weeks
• Plantar and periungual warts have limited response to destructive modalities such as cryotherapy. At-home use of salicylic acid for several months is often the most effective treatment

HIV Facial Lipoatrophy

• HIV facial lipoatrophy can have significant impact on quality of life. Patients can be referred to the UT Dell Dermatology Resident Sculptra Clinic for facial injection of poly-L-lactic acid filler (FDA approved therapy). This is at no cost to the patient.
• Burgess et al, J Am Acad Dermatol. 2005 Feb;52(2):233-9; Jagdeo et al, J Am Acad Dermatol. 2015 Dec;73(6):1040-54.e14.

Subcutaneous nodules (Cyst, Lipoma)

• For uncomplicated subcutaneous nodules including suspected cysts and lipomas, referral to dermatology for excision is appropriate.
• Consider referral to general surgery for deep nodules (poorly circumscribed, attached to bone, nonmobile, etc) and nodules in high risk areas. Do not refer patients with pilonidal cysts to dermatology.

Venous Stasis Dermatitis

• For patients with bilateral lower extremity venous stasis with dermatitis, we recommend leg elevation, compression stockings (20-30 mmHg). Also encourage diet modification and exercise.
• Consider triamcinolone 0.1% cream twice daily PRN if pruritus or erythema.

Vitiligo

• Consider checking thyroid function studies as other autoimmune endocrinopathies may occur in conjunction with vitiligo.
• Consider early referral to dermatology

Melasma

• Patients should be encouraged to follow strict sun protection including wearing sunscreen (SPF 30 or higher) containing physical blockers (iron oxide and zinc oxide). Broad-brimmed hats should be worn when outside.
• Consider referral to dermatology if severe and affecting patient’s QOL

Onychomycosis and nail dystrophy

• Consider sending nail clipping for histopathology or fungal culture in unclear cases
• If suspecting onychomycosis or confirmed fungal etiology, a 3-month course of oral terbinafine can be completed. We suggest obtaining baseline creatinine and LFTs prior to initiation and repeating LFTs after 6 weeks of treatment.
• Successful treatment results in proximal clearing of the nail after completion of terbinafine. If proximal clearing is not achieved, consider referral to dermatology.

Tinea

• For tinea pedis, start 1% terbinafine cream twice daily for 2-3 weeks.
• For tinea corporis or cruris, start 1% terbinafine cream twice daily for 2-3 weeks. If extensive, consider a two-week course of oral terbinafine.
• Consider referral to dermatology if not responding to treatment

Keratosis Pilaris

• Small pink follicular papules typically involving the lateral arms and occasionally, legs.
• First line treatment includes daily application of over the counter keratolytic agents such as ‘Gold Bond Rough and Bumpy’ and ‘Amlactin’.
• Encourage bland emollients at least daily (examples include Vaseline, Aquaphor, CeraVe or Cetaphil creams/ointments).
• Use fragrance-free cleansers while bathing and moisturize immediately afterwards.

Documentation required for referral

•  Past medical history
• Current medication list
• Most recent progress note describing condition for which patient is being referred
• Recent labs (if pertinent)
• Recent scans or X-rays (if pertinent)