This issue of Seminars in Cutaneous Medicine and Surgery is dedicated to inpatient dermatology. During the past decade, the advent of managed care has drastically reduced the availability of inpatient beds for patients with dermatologic disease so that currently, most hospitalized patients requiring dermatologic care are seen by a consulting dermatologist. In addition, patients admitted to the hospital are generally much sicker than they were in the past. These changes have not only led to an increase in the responsibilities of the dermatologist providing consultation on hospitalized patients with skin disease, but they have also shifted some of the care of said patients to nondermatologist physicians and ancillary personnel unskilled in the unique requirements of patients with severe skin disease. At academic centers, the inpatient dermatology consultation service is typically supervised in rotating “monthly shifts” by dermatology faculty as part of his or her academic appointment to the institution. In the private practice sector, the dermatologist provides inpatient consultative services at the end of a busy and often tiring work day.
In a perfect world, the hospitalist model of inpatient dermatology would be the standard. In this paradigm, an individual dermatologist or fixed rotation of a dedicated group of dermatologists attends to hospitalized patients with skin disease. This arrangement facilitates (1) continuity of care for patients who are either frequently admitted with skin manifestations of systemic illnesses or have a severe primary cutaneous disease requiring hospitalization; (2) familiarity with the rapidly changing medical literature, as well as with the idiosyncrasies that arise in managing patients with complicated skin disorders; (3) more timely and accurate diagnoses and skillful hands-on treatment resulting in a higher standard of care for patients; and (4) medical education for all levels and fields of training, particularly in an academic setting.
Although the “dermatologist hospitalist” might be considered the modern “gold standard” for inpatient dermatology, and although several of our dermatology colleagues (many of whom are writing for this issue) are currently working to define and shape the field of inpatient dermatology, universal application of the hospitalist initiative may be impractical given the variety of settings in which modern dermatology is presently practiced. Keeping this in mind, I have attempted to construct this issue of Seminars in Cutaneous Medicine and Surgery to serve as a guideline for every practicing dermatologist on the approach to questions commonly posed to the dermatologist providing hospital consultations. Each topic is presented in a case-based format. The authors then identify the key points of the case; outline the clinical problem; discuss approaches to the evaluation; work through the differential diagnosis; determine necessary laboratory tests, studies, or procedures (eg, skin biopsy); and, where applicable, provide an update on management of the disorder under discussion. As the reader works through the issue, he or she will notice overlap between the discussions of differential diagnoses. This overlap is intentional and meant to replicate real-life practice where cutaneous morphology elicits a broad differential diagnosis and/or one disease may be protean in its cutaneous manifestations.
The issue begins with the discussion of the patient with fever and erythroderma by Dr. Lauren Hughey. This is followed by a review of the approach to the hospitalized patient with a blistering eruption by Dr. Michael Heffernan and colleagues. Dr. Jonathan Cotliar then discusses the approach to the patient with a presumed drug eruption. The approach to the morbilliform eruption in a patient who has undergone hematopoietic transplantation is reviewed by Dr. Sharon Hymes and colleagues. Drs. Roger Weenig, Lawrence Gibson, and Rokea el-Azhary, discuss calciphylaxis and nephrogenic systemic fibrosis. Drs. Daniela Kroshinsky, Marc Grossman, and I review the differential diagnosis of presumed cellulitis. The following article by Drs. Erin Mathes and Amy Gilliam presents the approach to the hospitalized pediatric patient with fever, arthritis, and a rash. Of note, an excellent review of fever and infectious purpura in the immunosuppressed patient is discussed by Drs. Steven Mays and Philip Cohen in the December 2006 issue of Seminars in Cutaneous Medicine and Surgery.
This issue of Seminars in Cutaneous Medicine and Surgery is dedicated to inpatient dermatology. During the past decade, the advent of managed care has drastically reduced the availability of inpatient beds for patients with dermatologic disease so that currently, most hospitalized patients requiring dermatologic care are seen by a consulting dermatologist.
Erythema (rash) and fever represents one of the most challenging cases for a dermatologist. Not only is the differential diagnosis broad, but it also includes life-threatening diseases that require quick and decisive action on the part of the physician.
Bullous skin diseases are characterized by the presence of blisters and/or erosions of the skin and mucous membranes.
The variety of causes of generalized blistering includes autoimmune, drug-induced, neoplastic, and infectious etiologies.
Diagnosis and management of adverse drug reactions constitutes a significant portion of U.S. health care costs. The clinical presentation of these reactions varies from self-limited, morbilliform drug eruptions to more severe, systemic reactions, such as drug hypersensitivity syndromes, Stevens-Johnson syndrome, and toxic epidermal necrolysis, which are associated with significant mortality.
The onset of a morbilliform eruption in the posttransplant period presents a diagnostic dilemma. Not only is the morphology nonspecific, but there are also no definitive diagnostic tests that differentiate one etiology from another. In addition, histopathology may be nonspecific.