When Are Inpatient and Emergency Dermatologic Consultations Appropriate?

There are limited clinical data concerning inpatient and emergency department (ED) dermatologic consultations. The indications for these consultations vary widely, but in one study (N=271), it was found that 21% of inpatient consultations were for contact dermatitis and 10% were for drug eruptions.¹ In the same study, 77% of patients who required a dermatology consultation eventually were given a different diagnosis or change in treatment after consultation. For example, of all consultations for suspected cellulitis, only 10% were confirmed after dermatology evaluation.¹

Hospitalists and emergency physicians continue to struggle with the assessment of dermatologic conditions, often consulting dermatology whenever a patient has a “rash” or skin concern. Dermatology is still not emphasized in medical education and often is taught to most medical students in an abbreviated fashion, which results in physicians feeling ill-equipped to deal with any dermatologic condition—either mundane or potentially life-threatening. A study in 2016 showed that a monthly lecture series given to hospitalists over the course of 5 years did not improve diagnostic accuracy in patients who were admitted with skin manifestations.² This further shows that there is a need for dermatologic experts in the hospital.

We need to develop better guidelines for physicians in the ED and on inpatient units to guide them on appropriate use of dermatologic consultation outside the ambulatory office and the clinic. A 2013 study showed that patients often were discharged immediately after a dermatologic consultation, furthering our hypothesis that many inpatient consultations can be delayed until after discharge.³

In an era in which medical costs are soaring and there is constant surveillance for ways to reduce costs without impairing quality of care, limiting unnecessary specialty consultations should be embraced. In 2009, $1.8 billion in Medicare claims was paid for dermatology-related admissions.³ A substantial savings to Medicare consulting fees for certain diagnoses, such as cellulitis or contact dermatitis, could be realized if patients were referred for outpatient assessment and treatment. In a study of 271 consultations, 54 patients also had a skin biopsy, which further increases dollars spent on inpatient care and is (usually) something that can be performed in the outpatient setting.¹ In another study, the more common recommended treatments were topical corticosteroids and supportive educational measures for patients and hospital staff,³ which further substantiates that most dermatology consultations are not truly emergent and can wait for outpatient consultation.

In addition, we are dealing with the COVID-19 pandemic in our hospitals and EDs. Many physicians, including dermatologists, would prefer to avoid unnecessary exposure to SARS-CoV-2 on inpatient units and in the ED. It certainly would be preferable to require consultants to come in to evaluate patients only when they truly need to be seen while in the hospital.

There also is limited dermatology training in other specialties, and the dermatology team can help fill this gap with educational programs and one-on-one teaching. Hospital teams have signaled this need, but there has been limited success with multiple teaching opportunities.⁴

We believe that this need for inpatient dermatology services can be filled with the newer subspecialty of hospital dermatology, which is not commonly present at most hospitals; a reason why the subspecialty has not been more popular is that there are few available data in the form of randomized clinical trials that can guide inpatient dermatologists with the care of rare hospital skin diseases.⁵ Having a dermatologic hospitalist available might allow for patients to be seen more readily, which ultimately will save lives and health care dollars and would increase real-time teaching and education for house staff, nursing, and attendings at the bedside.