Dermatology Consult Service Research Articles

Acute Interstitial Inflammation on Skin Biopsies and Positive Tissue Cultures in Cellulitis Patients Are Associated a Worse Prognosis.

Cellulitis is a significant public health burden and lacks a gold standard for diagnosis. Up to 1/3 of patients are incorrectly diagnosed. The skin biopsy has been proposed as the gold standard. In this study, we evaluate the histopathologic characteristics and tissue culture positivity of biopsies in patients diagnosed with cellulitis seen by our inpatient dermatology consultation service. This retrospective cohort study examined patients who were hospitalized with a skin and soft tissue infection at our institution between 2011 and 2020 and underwent a skin biopsy. Those with a positive tissue culture were more likely to die within 30 days compared with those with negative tissue cultures (26% vs. 6%, P = 0.048). Patients who died within 30 days were more likely to have acute interstitial inflammation as a feature on histopathology (38%, P = 0.03). Single institutional design, unintentional exclusion of patients with organism-specific diagnosis, and selection for a medically complex patient population because of the nonroutine collection of biopsies. Positive tissue cultures and histopathology showing acute interstitial space inflammation on skin and soft tissue infection (SSTI) biopsies are associated with increased mortality and thus may serve as indicators of poor prognosis.

Psychiatric comorbidities on an inpatient dermatology consultation service: A cross-sectional analysis.

Despite the high prevalence of psychiatric illness in hospitalised dermatology patients, characterisation of psychiatric comorbidities on an inpatient dermatology consultation service in the United States has yet to be performed. To fill this gap in knowledge, we investigated the prevalence of and factors associated with psychiatric illness on the inpatient dermatology consultation service at the University of Southern California. Of the 429 patients seen by the dermatology consultation service between June 2021 to July 2022, 147 (34%) had psychiatric illness (defined as having at least 1 psychiatric diagnosis). Increasing age was associated with a decreased likelihood of psychiatric illness, while housing instability, chronic dermatologic disease, drug reaction, and pruritus without rash were associated with an increased likelihood of psychiatric illness. The high prevalence of psychiatric illness observed in hospitalised dermatology patients emphasises the importance of collaboration between consultant dermatologists and mental health specialists, particularly when specific sociodemographic or disease factors are present.

Inpatient Dermatology Consultation Services in Hospital Institutions.

Inpatient dermatology plays a key role in the hospital system. Dermatology-related admissions are frequent, and the correct diagnosis and management of cutaneous conditions is crucial to improving patient outcomes and decreasing health care costs. As a dermatology resident, it can be challenging to perform inpatient consultations, especially early in residency. Focusing on pre-rounding and must-ask questions of requesting providers as well as carrying an organized toolbox will be invaluable for every dermatology resident.

Concordance of diagnostic modalities in atypical skin and soft tissue infections in hospitalized patients.

Skin and soft tissue infections (SSTIs) have high rates of morbidity and mortality worldwide but lack reliable standards for diagnostic workup. As a result, atypical infections, more prevalent among immunocompromised patients, can be missed due to deviance from classic features only to be revealed later through inconsistently performed ancillary studies. Our objectives included to evaluate the sensitivities of clinical impression, histopathology, tissue culture, and molecular and non-molecular ancillary tests in diagnosing inpatient SSTIs, as well as to qualitatively discuss the unusual features making a subset of infections "atypical." To do so, we retrospectively reviewed the histopathologic reports and charts of inpatient dermatologic consults at a single tertiary care institution over a 3-year period. We identified a total of 111 cases of SSTIs evaluated by the inpatient dermatology consultation service with concurrent skin or soft tissue biopsy, with 32.4% representing atypical infections. Among these, clinical impression suggested infection in 9(25.0%), routine histopathology in 21(58.3%), specialized stains for microorganisms in 22(68.8%), and tissue culture in 15(68.2%). Due to incomplete picture that each modality by itself creates, we conclude that clinicians and pathologists should carry a low threshold for including SSTIs in their differential diagnoses and should evaluate with skin biopsy, special stains for microorganisms, and ancillary studies, particularly in critically ill individuals who necessitate timely diagnoses.

Post-discharge follow-up attendance after pediatric dermatology consultation in the emergency department: A retrospective analysis.

The emergency department (ED) is a frequent source of care for pediatric patients with dermatologic conditions, possibly owing to limited access to routine and urgent outpatient dermatology appointments. The demographics, clinical characteristics, follow-up scheduling practices, and attendance rates of 50 pediatric and 142 adult patients evaluated by the dermatology consult service in the ED were reviewed. High rates of follow-up attendance were observed in the pediatric and adult populations, with the majority receiving an appointment within 2 weeks. The dermatology consult service may play an important role in facilitating post-discharge access to outpatient care.

Valuing the Inpatient Dermatology Consult Service at a Single Academic Institution

Valuing the Inpatient Dermatology Consult Service at a Single Academic Institution

27971 Single institution experience with a dermatology hospitalist service

The dermatology hospitalist model was first defined by the Society of Dermatology Hospitalists in 2009; however, scant evidence exists to demonstrate its institutional benefit. Dartmouth-Hitchcock Medical Center established a formal dermatology consult service in early 2019, for which we named a director, ensured faculty continuity, and enacted earlier rounding times to communicate with primary teams. Here, we examine the value of an inpatient dermatology consult service at our institution. Both utilization and value of the service were determined for the year 2019 through analysis of the number of consults, consulting team, provisional diagnosis of primary team, final diagnosis of the dermatology service, performance of inpatient biopsy, and scheduled follow-up for hospitalized patients.

25508 Trichodysplasia spinulosa in setting of a pediatric cardiac transplant and immunosuppression

A 4-year-old female with a history of cardiac transplantation for dilated cardiomyopathy presented to the dermatology consultation service for a 2-month history of widespread hyperkeratotic papules. The eruption had initially appeared on the face with subsequent involvement of the trunk and extremities. The patient’s cardiac transplantation was a year prior, and her immunosuppressive medications included oral tacrolimus and mycophenolate mofetil. There were no over the counter or prescription treatments that had been used for the eruption.

27165 Virtual teledermatopathology clinicopathologic correlation rounds for inpatient skin biopsies: A quality improvement project

Three-quarters of dermatology programs have dermatopathology (DP) rotations, but these largely occur in the final year of residency. Standard teaching with microscopes and glass slides is limited by available space, inconvenient locations, and new need for social distancing during the COVID-19 pandemic. These barriers are particularly salient for inpatient consultative dermatology services, which biopsy a broad range of pathologies and provide value in rapid clinicopathologic correlation. Several studies have assessed modifying curricula with digital platforms and online databases of virtual slides, but the use of live interactive teledermatopathology (TDP) to actively review skin biopsies performed by the dermatology inpatient consult service has not been systematically evaluated. In this study, a retrospective chart review of a representative baseline 3-month period found that only 2 out of 36 (6%) biopsy slides were personally reviewed by the consultative dermatology team. Our intervention uses live-interactive video slide TDP rounds to review skin biopsies performed by the inpatient dermatology consult service, sampled during a 3-month study period. The primary outcome is proportion of slides reviewed by the inpatient consultative team compared with the historical control period. We use slide capture software in combination with a secure HIPAA compliant platform that integrates chat, video conferencing, and clinical images. One and a half months into the intervention, 25/27 (92.6%) biopsies have been reviewed by the inpatient consult team. Conference discussion and clinicopathologic correlation has likely led to a change in clinical and pathologic interpretation in at least three cases.

27250 A recurrent, painful, and vesicular rash in a dermatomal distribution

A 62-year-old female was seen on the dermatology consult service for evaluation of a painful, reoccurring, blistering rash near the right waistline. The patient described a history of repeated outbreaks (>15 episodes) over the course of a year prompting her to seek medical attention on multiple occasions in the emergency department and her primary care’s office where she was diagnosed with recurrent herpes zoster infection. Dermatological examination revealed crusted vesicles and hyperpigmentation with residual erythema noted in a T11 dermatomal distribution on the right abdomen.

Predictors of postdischarge follow-up attendance among hospitalized dermatology patients: Disparities and potential interventions

Predictors of postdischarge follow-up attendance among hospitalized dermatology patients: Disparities and potential interventions

Analysis of inpatient dermatology consultations in a veterans affairs hospital

To the Editor: The John D. Dingell Veterans Affairs (VA) Medical Center includes an onsite inpatient dermatology consult service that provides a unique opportunity to identify skin conditions associated with inpatient dermatologic requests. The aim of this study was to describe dermatology inpatient consultations in a VA hospital.

A Recurrent, Painful, and Vesicular Rash in a Dermatomal Distribution

A 62-year-old woman was seen on the dermatology consult service for evaluation of a painful, reoccurring, blistering rash near the right waistline. The patient described a history of repeated outbreaks (>15 episodes) over the course of a year prompting her to seek medical attention on multiple occasions in the emergency department and her primary care's office where she was diagnosed with recurrent herpes zoster infection. She was prescribed antiviral drugs but stated that they were of no benefit to her symptoms.

Cutaneous findings in hospitalized and critically ill patients with COVID-19: A case series of 15 patients

To the Editor: Worldwide reports describe cutaneous findings, including maculopapules, pseudo-chilblain, vesicles, urticaria, livedo, and multisystem inflammatory syndrome, as manifestations of coronavirus disease 2019 (COVID-19).1-5 Here, we report on the cutaneous findings observed in hospitalized COVID-19–positive patients at Columbia University Irving Medical Center by the adult dermatology consultation service between March 25, 2020, and May 1, 2020. Cases were included if COVID-19 was most likely associated with or contributed to skin findings observed after other potential causes were excluded.

Dermatology consultation service at a large metropolitan hospital system serving minority populations.

Dermatology consultations in the inpatient hospital setting can improve diagnostic accuracy and management. Characterize dermatologic diagnostic and treatment trends in the hospital setting and identify variables that may affect patient care. Retrospective chart review from 1 January 2012 to 31 December 2017 at Jackson Memorial Hospital (JMH) (Miami, Florida, USA), an academic non-profit tertiary care centre affiliated with University of Miami Miller School of Medicine, was performed. Patients who received dermatology consultations in the emergency department (ED) or inpatient settings were included. Patient demographics, admission information, provisional diagnosis and management plans by primary teams, final diagnosis, management plans and testing recommendations by the dermatology consults team, and follow-up information were collected. Analysis using Microsoft Excel of how time to consultation, admission length, inpatient versus ED setting and primary team affected diagnostic accuracy was also performed. The 1004 consultations for 812 patients (n=812) were reviewed (359 women, 453 men). Most patients were Hispanic (n=359; 44.2%) or African American (n=273; 33.6%). Mean admission length was 20.6days (range 0-439; median 6). The most common consulting service was internal medicine (n=452). In 387 cases (47.6%), primary teams did not give a provisional diagnosis. The most common provisional diagnoses were bacterial infection (n=93), viral infection (n=49) and drug reaction (n=44). The most common diagnoses by dermatology were viral infection (n=93), bacterial infection (n=90) and drug reaction (n=80). Dermatology consultation changed the provisional diagnosis in 55.7% of cases, more often in cases where consultation took place ≥2days after admission (P<0.05). Primary teams followed dermatology treatment recommendations in 85.2% of cases. Dermatology consultation improves diagnostic accuracy in skin disorders in the hospital setting and serves as a valuable resource for inpatient care. A notable aspect of data from this study is the unique patient population, predominantly comprised of underrepresented racial and ethnic minorities including Hispanics and African Americans.

Live-interactive teledermatology program in Taiwan: One-year experience serving a district hospital in rural Taitung County

Population aging and unequal accessibility of health care are increasingly important in developed countries. One strategy to overcome these issues is utilizing telemedicine, which is recently made possible technologically by the advancement of internet speed, high speed zooming cameras, and the information storages. In Taiwan, the telemedicine is granted legally by the amendment for Taiwan's Physician Act in 2018. Kaohsiung Chang Gung Memorial Hospital (Kaohsiung CGMH) is the first hospital in Taiwan to provide the telemedicine service connecting to Cheng Kung Branch of Taitung Hospital since Nov 2018. Consultation services from Dermatology, ENT, and Ophthalmology have been delivered in the live-interactive and face to face module every week. Dermatology consultation comprises the majorities. In the first year, there were totally 426 dermatology consultation services. Eczema, fungal infections, and scabies infestation were the three most common diseases in the beginning. The disease diagnosis became more diverse after several months, including some ready-to-treat diseases pending correct diagnosis, such as pediculosis, psoriasis, and urticaria. Coupled with dermoscopic images, diseases such as hair loss, pediculosis capitis, skin tumor, and scabies, were diagnosed promptly. The subjective patient improvement rate was more than 75% year-round and the case closure rate was more than 85% year-round. Teledermatology is a promising approach to serve the remote medical-underprivileged regions. The teledermatology is anticipated to help underserved regions, nursing homes, prisons, and in situations with severe pandemic infections, such as COVID-19.

Real-time teledermatology clinics in a tertiary public hospital: A clinical audit.

Our metropolitan hospital provides a real-time videoconference teledermatology clinic to enable patients in rural and remote Queensland to access a specialist for dermatology care. Retrospective clinical audit of all patient referrals to the videoconference teledermatology clinic for a two-year period. A total of 483 consultations for 178 patients were conducted by the teledermatology clinic. Most patients were from remote and very remote regions of Queensland with a mean distance from our metropolitan hospital to the patient's town of residence of 1295km. The most common reason for referral, as per the referral form, was rash (32%), followed by acne (12%) and dermatitis (11%). Most (78%) referrals came from general practitioners. Around 8% of patients seen in the teledermatology clinic were converted to in-person review; 81% of patients were managed via teledermatology, and 10% of patients did not attend the scheduled teleconsultation. The outpatient teledermatology clinic run through the Telehealth Centre of a metropolitan hospital is an effective way of delivering a general dermatology consultation service to rural and remote patients in a timely manner.

Implementing and Optimizing Inpatient Access to Dermatology Consultations via Telemedicine: An Experiential Study.

Background/Introduction: In-house dermatology consultation services for hospitalized patients are not universally available in acute care hospitals. We encountered an unanticipated access gap for in-person dermatology consultations in our tertiary care hospital that routinely cares for complex high acuity patients with multiple comorbidities. To bridge this gap in specialist expertise in a timely manner, we expeditiously designed and implemented a telemedicine-supported inpatient dermatology consultation service. Methods: We conducted a retrospective review of 155 teledermatology consultations conducted between November 2017 and March 2019 as well as periodic prospective multidisciplinary process improvement meetings to optimize service-associated process maps and workflows. Results: Teledermatology consultations changed the working diagnosis of the primary team in 52.3% of cases and most commonly recommended medical management (61.9% of cases). In total 100% of patients accepted telemedicine support and rated their experience as positive. The first three periodic process improvement meetings led to significant improvements in teledermatology-related process maps and workflows. Discussion: Diagnostic concordance rates between the primary team and the teledermatologist were similar to those reported in the literature for in-person dermatology consultations. Important process improvements include establishing central responsibility of preparing and overseeing the consultation process, mandating the presence of a primary team representative during consultation and patient chart review by the teledermatologist before teleconsultation. Conclusion: Inpatient teledermatology consultation services can be instituted timely and continuously improved to reliably and effectively bridge access gaps, improve diagnostic accuracy and differentiate therapeutic approaches while maintaining patient satisfaction.

Diagnoses of hospitalized patients with skin abnormalities prompting biopsy by consulting dermatologists: A 3-year review from a tertiary care center.

BackgroundDermatologists play an important role in diagnosing and managing hospitalized patients with cutaneous abnormalities. Skin biopsies remain an indispensable tool for aiding dermatologists in accurate diagnosis and treatment. We aimed to determine the range of conditions, and the most common conditions, prompting skin biopsy by dermatology hospital consultation (HCON) services to aid in evaluation of hospitalized patients.MethodsAll hospitalized patients seen by a single tertiary care center dermatology HCON service between 2015 and 2018 who had associated skin biopsies were identified. Histologic features and clinical diagnoses of each patient were classified into 13 histologic reaction pattern categories.ResultsEight hundred and thirty one inpatients evaluated by our dermatology HCON service had 914 skin biopsies. The most frequent diagnostic categories prompting biopsy were vasculopathic (17.6%), interface dermatitis (16.5%), infectious (12.6%), and spongiotic dermatitis (10.9%). The most frequent diagnostic categories included drug reaction (13.2%), leukocytoclastic vasculitis (8.5%), skin cancer (5.4%), graft‐vs‐host disease (3.5%), connective tissue disease (3.3%), and calciphylaxis (3.0%).ConclusionOur study suggests a variety of serious diseases affecting inpatients prompts biopsy by dermatology consultation services. Educational curricula for dermatology and pathology residents, fellows, and staff designed with these data may enhance knowledge that improves the quality of inpatient dermatology care.

Characterisation and diagnosis of ulcers in inpatient dermatology consultation services: A multi-centre study.

Accurate and prompt diagnosis of skin ulcers is critical to optimise management; however, studies in hospitalised patients are limited. This retrospective review of dermatologic consultations included 272 inpatients with skin ulcers between July 2015 and July 2018 in four U.S. academic hospitals. The median age was 54 years and 45% were male. In 49.3% of the patients, skin ulcers were considered the primary reason for admission. Ulcers of 62% were chronic and 49.6% were located on the lower extremities. Pyoderma gangrenosum (17.3%), infection (12.5%), and exogenous causes (11.8%) were the leading aetiologies; 12% remained diagnostically inconclusive after consultation. Diagnostic agreements pre-dermatology and post-dermatology consult ranged from 0.104 (n = 77, 95% CI 0.051-0.194) to 0.553 (n = 76, 95% CI 0.440-0.659), indicating poor-modest agreement. This study highlights the diagnostic complexity and relative incidences of skin ulcers in the inpatient setting.