logo How to write a referral to a dermatologist

Introduction to dermatology

How to write a referral to a dermatologist

Objectives

To learn how to:

  • complete a referral form according to the requirements of the New Zealand Ministry of Health.
  • describe a dermatological case history including presenting complaint, test results and management to date; the patient’s current health concerns, medications and allergies.
  • describe significant dermatological examination findings (distribution, configuration, morphology, colour, surface and secondary changes).
  • learn to consult the Ministry of Health’s Referral Guidelines for Dermatology to assess the urgency of the referral.

Key points

  • Dermatological referral should include history of the presenting complaint, examination findings, investigations and treatment as well as current health problems, medications and allergies.

Introduction

A patient presents with a skin complaint. You decide to refer the patient to a dermatologist for further management. In this exercise, you will complete a standardised referral form to the local hospital’s skin clinic.

Referral form

The New Zealand Ministry of Health requires standard referral forms to have the following minimal information.

Referrals are increasingly in electronic format.

Case presentation

You are a general practitioner in an urban practice. Mrs Jones attends with her 14-year old son John. While Mrs Jones explains her concerns, you notice that John is clearly an unwilling patient, hunched forward with eyes everted. He wears a cap over his long hair, and does not take part in the conversation.

Mrs Jones reports that John has become very withdrawn over the last few months, and is spending long hours alone in his bedroom. On several occasions he has refused to go to school. Previously competing at a high level, he has dropped out of his sports teams and has insisted that she write a note excusing him from PE and swimming lessons. “His pimples have got quite bad this year, doctor; the medicine doesn’t seem to be working.”

You can see on his cheeks numerous inflammatory skin lesions. John reluctantly removes his hat and shirt for your inspection. The appearance of his face and back are illustrated below.

The medical records indicate a colleague prescribed him doxycycline 100mg daily three months ago. A brief review of systems indicates no other health concerns and John denies taking any other medications. 

Distribution, Configuration and Colour

Facial acne

Acne on upper back


_Which of the following can you identify from the illustrations?_ Distribution: # Dermatomal #! Follicular # Photosensitive #! Seborrhoeic Colour: # Erythema # Hypopigmentation # Hyperpigmention # Purpura

Morphology, skin surface, and secondary changes

Facial acne

Acne on upper back


_Which of the following can you identify from the illustrations?_ Morphology/Surface: #! Cyst #! Nodule #! Papule #! Pustule Secondary changes: # Atrophy #! Crusting # Lichenification #! Scar Explanation: Click on the images below to identify acne lesions.

In this case there are also closed and open comedones (whiteheads and blackheads). The diagnosis of acne is straightforward. This topic will be considered in detail in a later module of the Dermatology course.

Case management

You should follow local guidelines for primary care management of moderate acne. John has been using an appropriate acne cleanser obtained from the local chemist. You tell him to continue to wash with this twice daily. You continue doxycycline 100mg daily and add in benzoyl peroxide gel, to be applied once or twice daily to all affected areas.  You inform him of possible side effects of the antibiotics, and how to use the gel. You refer him to the web site DemNetNZ.org for further information about acne and its treatment.

You also arrange to see John again a few days later for an in-depth consultation regarding his mood problems. On this occasion his mother waits outside. John talks more freely and admits to symptoms consistent with significant depression in the last few months, provoked by embarrassment and cruel comments made by his schoolmates. However, he says he has been feeling better since the earlier consultation because he has heard the dermatologist may be able to cure his skin problem. He doesn’t want any specific medication for depression at this stage, but agrees to return for review if he is “feeling down”. In John’s presence, you ask his mother to let you know if she has further concerns. 

In view of the severity of his acne and emotional response, you decide to refer John to the skin clinic. It is important to include comprehensive history and examination data so that clinic staff can mark the referral appropriately for an appointment for first assessment.

Completing the referral form

The standard referral form or letter to the specialist must include:

_From the case history presented, list two diagnoses_ Short answer: 1. Acne. 2. Depression

The type of acne illustrated is known as “acne conglobata”or “nodulocystic acne”. Significant depression as a result of severe acne is not uncommon, particularly in adolescents. Early recognition and effective treatment of the acne is essential for long term emotional wellbeing.

The standard referral form or letter to the specialist must also include:

_From the case history presented, complete the text box with these details._ Short answer: 6-month severe acne on face / trunk with numerous inflammatory papules, pustules, nodules and scars. Significant depression, avoidance of sports/school. Otherwise well. Explanation: Doxycycline 100mg daily + benzoyl peroxide od commenced today. No other medications or known allergies. _How would you categorise this patient?_ * 1. Routine *! 2. Semi-urgent * 3. Urgent Explanation: This patient has severe acne and significant depression. The dermatologist assessing the referral should be alerted to this; most patients with acne are categorised “routine”. Urgent slots are intended for patients with haemodynamically unstable dermatoses, severe skin infections, severe bullous diseases or when hospitalisation is likely to be required. It may be very helpful to accompany the referral by images of the skin condition.

You have now completed the case referral exercise.