The role of the GP in dermatology
As a GP, your role is to:
- diagnose, treat and advise on common skin conditions efficiently
- recognise the importance of the psychosocial impact of skin problems
- prescribe appropriately and safely
- appreciate the complexity of care that is needed with some skin problems
- share management with secondary care where needed.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether it is acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic, environmental and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education including self-care prognosis.
Symptoms and signs
- Birthmarks
- Blisters
- Dry skin and scaling
- Erythema
- Hair loss and hirsutism
- Hyperhidrosis
- Hyperpigmentation, hypopigmentation and depigmentation
- Lichenification
- Nail dystrophies
- Pruritus
- Purpura and petechiae
- Pustules and boils
- Rashes and eruptions
- Scaly and itchy scalp
- Skin lesions, including dermal and subcutaneous lesions
- Ulceration, including leg ulcers and pressure sores
Common and important conditions
- Acne rosacea, rhinophyma, perioral dermatitis
- Acne vulgaris, including indications and side effects of isotretinoin
- Blistering diseases including pemphigoid, pemphigus and porphyria
- Dermatological emergencies such as Stevens-Johnson syndrome, toxic epidermal necrolysis, erythroderma and staphylococcal scalded skin syndrome
- Eczema: infantile, childhood, atopic, seborrhoeic, contact allergic, irritant (including occupational), discoid, varicose or asteatotic
- Hair disorders, including alopecia, hirsutism, fungal infection, infestations (including lice)
- Hidradenitis suppurativa
- Hypopigmentation (such as vitiligo) and hyperpigmentation (such as acanthosis nigricans)
- Infections: viral (such as warts, molluscum contagiosum, herpes simplex and zoster), bacterial (for example, staphylococcal + MRSA (methicillin-resistant staphylococcus aureus), streptococcal), fungal (such as skin, nails), spirochaetal (for example Lyme disease, syphilis), tuberculosis (TB), infestations (such as scabies, lice), travel-acquired (for example, leishmaniasis)
- Lichen simplex, lichen planus, granuloma annulare, lichen sclerosus, morphoea
- Light-sensitive disorders such as polymorphic light eruption, porphyria, drug reactions
- Light treatments such as ultraviolet B (UVB) and psoralen + ultraviolet A (PUVA)
- Pityriasis rosea and pityriasis versicolor
- Pruritus, either generalised or localised, including underlying non-dermatological causes (for example, thyroid disease, iron deficiency, pregnancy)
- Psoriasis: plaque, guttate, flexural, scalp, nails, pustular and erythrodermic; associated morbidity, including physical (such as cardiovascular disease) and psychological (such as depression)
- Seborrhoeic keratosis
- Skin manifestations of psychiatric conditions, such as dermatitis artefacta and trichotillomania
- Skin manifestations of internal disease, including pyoderma gangrenosum, systemic lupus erythematosus (SLE), discoid lupus erythematosus (DLE), necrobiosis lipoidica, erythema nodosum, erythema multiforme, neurofibromatosis type 1, dermatitis herpetiformis, dermatomyositis, vitamin and mineral deficiencies such as scurvy
- Skin tumours, including:
- benign lesions (for example, pigmented naevi, dermatofibroma, cysts)
- malignant lesions (such as malignant melanoma, squamous cell carcinoma, basal cell carcinoma, mycosis fungoides, Kaposi’s sarcoma, metastatic tumours)
- lesions with malignant potential (for example, solar keratoses, Bowen’s disease, cutaneous horns and keratoacanthomas)
- Ulcers and their causes, for example, arterial, venous, neuropathic, pressure, vasculitic, malignant
- Urticaria, angioedema and allergic skin reactions, including adverse drug reactions
- Wounds (such as burns and scalds), scar formation and complications
Examinations and procedures
- Common terminology used to describe skin signs and rashes (such as macule, papule)
- Examination of the rest of the skin, nails, scalp, hair and systems such as joints, where appropriate (for example, in psoriasis)
- The need to recognise skin conditions across a range of skin types
Investigations
- Skin and nail sampling, immunological tests including patch and prick testing, biopsy, photography and dermoscopy
- Relevant blood tests for underlying causes of skin conditions (such as lupus, thyroid disease)
Service issues
- Dermoscopy: indications, availability in practice, when to refer
- Waiting times for local specialist services
- Role of and access to other health professionals (such as specialist nurses, tissue viability nurses, podiatrists)
Case discussion
Jane Smith is 36 years old. She is a teacher and lives with her long-term partner. They have two daughters, aged 10 and eight. She suffers from psoriasis, has borderline hypertension and a high body mass index (BMI) of 31 kg/m2. She smokes 20 cigarettes a day, as does her partner. As you are the whole family’s GP, you are aware that their relationship has been unhappy from time to time.
Jane has tried steroid creams of varying potency, and more recently she has been using a vitamin D analogue ointment but finds this quite ‘irritant’ and so has abandoned it. She has previously had light therapy but tells you that a further course would be very inconvenient as she works all week.
You ask her how having psoriasis makes her feel and she bursts into tears. ‘No one has ever asked me that before,’ she says. Jane feels that her psoriasis looks awful, and she is conscious that she leaves a trail of skin scales wherever she goes. She refuses to take her daughters swimming and is so unhappy about exposing her body that she cannot get undressed in front of her partner. They have not made love for years. Recently she struggled to hide her tears when her daughter said, ‘Why do you never wear pretty skirts like my friend Kirsty’s mum?’
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How do my own values and experiences influence my attitudes to treating skin problems? How hard should I work to help Jane if she seems unmotivated? |
An ethical approach This is about practicing ethically with integrity and a respect for equality and diversity. | How can I balance my patients’ needs with the availability of commissioned services? How can I maintain confidentiality between members of the same family who are all patients at the surgery? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | What further questions would I ask to explore Jane’s ideas, concerns, and expectations? How might I help Jane to develop her own motivation to lose weight or stop smoking? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What tools could I use to measure severity (such as Dermatology Life Quality Index (DLQI) or Pain Disability Index (PDI))? Given the increased cardiovascular (CV) risk in patients with psoriasis, what tests or examinations could I perform to get an objective idea of Jane’s overall CV risk (such as QRISK3)? How would I explain this risk to Jane in a way that she could understand easily? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What other body systems would I examine in this case, and what would I be looking for? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | Am I confident I can diagnose psoriasis and distinguish it from other common skin conditions? Am I confident that I would know when to step-up or step-down treatment? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What topical treatments might I prescribe for the various affected areas? How would I approach discussions about the inheritance of psoriasis? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | Should I consider referring Jane for consideration of oral second-line therapies (such as methotrexate or ciclosporin)? If so, what advice would I give prior to referral (noting that she is a smoker and has borderline hypertension)? If her treatment is going to be topical, how is she going to treat her back and other hard-to-reach places? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | What resources might be available in the primary health care team to help me manage this patient? Are there any other members of the team who could help? Are there any services I could signpost Jane to that might offer help with her relationship? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | How could I design a quality improvement project in my surgery around psoriasis? What advice would I give regarding the use of topical steroids in psoriasis? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What advice might I give about a prepayment prescription? How can I record the distribution of her psoriatic plaques on the computer software? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | Jane is a smoker. Should I use this opportunity to discuss this with her? What is the additional risk of chronic, moderate or severe psoriasis accelerating atherosclerosis? How will I discuss cardiovascular system risk factors? What might be the potential differences between my agenda as the doctor and Jane’s agenda as the patient? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | Do we provide sufficient support in the community for lifelong dermatological conditions? When I look around my environment, what things do I see that promote or discourage good skin health? What are the attitudes of society to people with skin conditions? |
How to learn this area of practice
Work-based learning
Skin diseases are common, and many are chronic. They will therefore form a large part of your work as a GP. The patient is likely to be an expert on their own skin and can often tell you a lot about their condition. It can be helpful to develop a ‘longitudinal consultation’ by inviting the patient to come back to discuss their skin problem.
It is very easy to fall into the trap of dismissing many skin diseases as trivial (acne, for example), but patients often tell us that they have difficulty raising the issue of their skin problem, even with a health professional. The truth is that it can have a considerable impact on their lives and their psychosocial wellbeing. Recognising this and treating the condition well and sensitively makes an enormous difference.
Consider discussing with practice members referrals that are made to dermatology specialists by yourself and your colleagues to establish what exactly you and your patients are hoping to achieve from the referral. Review your referral again after the patient has been seen to decide whether the same benefit might have been achieved from resources available in primary care.
Consider arranging a Patient Satisfaction Questionnaire (PSQ) for patients with eczema or psoriasis in order to review your delivery of care. An annual DLQI assessment takes less than a minute to complete and would demonstrate to your patient that you are interested in the possible detrimental effect of their disease on their quality of life.
Also consider regularly auditing your patients who are on repeat prescriptions for psoriasis treatments. Have you considered whether they might have psoriatic arthritis, which they have previously dismissed as ‘wear and tear’?
Attending community-based and GP with an Extended Role (GPwER) clinics can provide valuable learning opportunities. You can also reflect on each case and ask yourself: ‘Why was referral deemed necessary and what value-added input has the specialist provided?’
Self-directed learning
Dermatology is high on the learning needs of most GP specialist registrars. As a result, you will find that talks on the subject are regularly included in many continuing education programmes. The Primary Care Dermatology Society (PCDS) aims to educate and disseminate high standards of dermatology in the community. It runs a regular series of ‘Essential Dermatology’ days up and down the country, as well as educational events on minor surgery and dermoscopy (skin surface microscopy for increasing the accuracy in diagnosing both pigmented and non-pigmented lesions). Other useful resources are available on the British Association of Dermatologists website and DermNet is a good source of pictures and information on a wide range of skin problems.
Learning with other healthcare professionals
Experienced GPs will have seen a lot of skin disease, so ask them for their thoughts. Our nursing colleagues too are a reservoir of knowledge. As well as dermatology nurse specialists, health visitors and district nurses also have valuable dermatological knowledge.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Recognition of photographs of skin lesions from a diverse UK population
- Management of psoriasis
- Differential diagnosis of alopecia
Simulated Consultation Assessment (SCA)
- A woman who has patchy hair loss (photograph supplied)
- A man with dark skin has dry itchy skin with areas that have become darker and roughened (patient will provide photograph)
- A waiter with excessive sweating on palms and axillae, affecting his work
Workplace-based Assessment (WPBA):
- Consultation Observation Tool (COT) about a teenager with moderately severe acne
- COT about a mother whose baby has widespread infantile eczema
- Audio COT with a woman who has a rash that she thinks looks like Lyme disease following a weekend camping.