Common Dermatologic Conditions Encountered by the Family Physician
Author: Emily Perez, MS4. Date Published: 25 September, 2023.
Dermatologic complaints are encountered by dermatologists and non-dermatologists alike. From 2001-2010, over half of all dermatologic visits were seen by non-dermatologists. In this same timeframe, dermatologists saw 47.1% of all skin-related visits. Family practitioners saw 20.5% of all skin-related visits, the most of any non-dermatology specialty [1]. Thus, it is important for family practitioners to be comfortable diagnosing and treating dermatologic conditions, especially in a rural area where a board-certified dermatologist may not be available. The aim of this article is to identify the ten most common dermatologic conditions encountered by a family physician.
The most common skin condition encountered by family physicians is contact dermatitis [1–3]. In the case of irritant contact dermatitis, the skin’s lipid barrier is compromised. The patient will typically have a dry, erythematous rash with an indistinct border and may have fissuring. Allergic contact dermatitis involves the recruitment of previously sensitized T cell lymphocytes after exposure to a specific antigen. This patient may have a rash with a distinct border. Acute allergic contact dermatitis will have erythema, edema, vesicles or bullae whereas chronic allergic contact dermatitis will have lichenification of the skin with scaling or fissures. With any contact dermatitis, determining the offending agent is critical for complete treatment and prevention of future outbreaks. The most common cause of contact dermatitis in the United States is poison ivy, oak, or sumac; worldwide the most common cause is nickel. The diagnosis is made clinically but can be assisted by tissue biopsy or patch testing for agent identification. In addition to avoiding the causative agent, treatment includes topical steroids, barrier creams, ointments, cold compresses, and hydroxyzine or diphenhydramine [4].
Cellulitis and abscess are two bacterial infections of the skin commonly encountered by family physicians [1,3]. Cellulitis is a local infection of the skin that extends into the subcutaneous tissue and cutaneous lymphatics. It is most often caused by S. aureus and group A streptococcus. An abscess is a collection of pus that is walled off in a painful, fluctuant mass. It is most often caused by S. aureus. Diagnosis of both conditions is made clinically. Cellulitis is treated with oral or intravenous antibiotics, while an abscess needs to be incised and drained with or without antibiotic treatment to follow [4].
Verruca vulgaris and herpes zoster are two viral infections of the skin often seen in family practice [1,3]. A verruca vulgaris, often referred to as a wart, is a lesion consisting of a mass of keratinocytes confined to the epidermis in response to a local viral infection of HPV. There are several strains of HPV that cause different kinds of warts; some strains may lead to a malignant lesion while others remain benign. The diagnosis is clinical and treatment options are numerous. Spontaneous resolution is possible after weeks to months, and conservative therapy is preferred over aggressive treatment to prevent scarring. Options include liquid nitrogen, topical salicylic acid, topical apple cider vinegar, duct tape, topical 5-fluorouracil, imiquimod cream, light electrocautery, blunt dissection, debridement, or laser therapy. Herpes zoster, commonly known as shingles, is a reactivation of a latent infection with varicella zoster virus that lies dormant in the dorsal ganglia after initial chicken pox illness. This is a painful vesicular rash in a dermatomal pattern. Shingles can be prevented with the varicella vaccine as a child and the zoster vaccine as an adult. It can be treated with acyclovir or valacyclovir. The pain is treated with NSAIDs or acetaminophen before resorting to opioids, tricyclic antidepressants, or a nerve block. Gabapentin, pregabalin, lidocaine patches, or capsaicin can be used to treat postherpetic neuralgia [4].
Tinea and candidiasis are local fungal infections of the skin which are also commonly treated by family physicians [1,3]. Tinea is an infection of dead keratinocytes of the stratum corneum of the skin, nails, or hair caused by dermatophytes microsporum, trichophyton, or epidermophyton. Tinea will present as annular plaque with red, scaly, raised active border and central clearing. Diagnosis is made clinically, and treatment consists of topical antifungals such as ketoconazole, clotrimazole, terbinafine, naftifine, butenafine, or miconazole. Oral fluconazole or terbinafine may be used if the rash is extensive or not resolved with topicals. The drug of choice in children with tinea capitis is oral griseofulvin. Candidiasis is an invasive rash caused by Candida albicans, a budding oval yeast. It is an erythematous, denuded, cigarette-paper, scaling, with advancing border affecting warm, moist areas of skin which can cause vulvovaginitis, balanitis, oral thrush, or intertrigo. It is also a diagnosis that is made clinically, and treatment consists of topical clotrimazole, miconazole, fluconazole, or nystatin. Oral fluconazole may be used for recurrence [4].
Benign tumor/neoplasm and epidermal cyst are common benign lesions encountered in family practice [1–3]. The most common benign neoplasms are seborrheic keratosis and benign nevus. Seborrheic keratosis is a proliferation of immature keratinocytes with no malignant potential. Appearance is variable, but often a seborrheic keratosis appears warty, “stuck on”, and well circumscribed. Diagnosis is clinical and treatment is not needed unless the lesion becomes irritated, in which case it can be treated with topical steroids for itching, or liquid nitrogen or shave removal for complete resolution of the lesion. A benign nevus or “mole” has many possible appearances. Indications that a nevus may not be benign are asymmetry, border that is jagged or irregular, color that is not uniform, diameter greater than 6 mm (about the size of a pencil eraser), or a mole that is evolving in size, shape, or color. Nevi that can be confidently described as benign do not require treatment and can be observed for changes. Any doubt should warrant a biopsy for further evaluation. An epidermal cyst is a smooth, round, mobile, protruding mass that may have an opening like a blackhead. Diagnosis is clinical. Cysts may not require treatment but can be incised and drained or excised with complete removal of the sack if they are bothering the patient [4].
The most common dermatologic conditions seen in family medicine are contact dermatitis, cellulitis, abscess, verruca vulgaris, herpes zoster, tinea, candidiasis, benign tumor (seborrheic keratosis), benign nevus, and epidermal cyst. Family physicians should be comfortable diagnosing and treating these conditions as part of their outpatient practice.
References:
1. Wilmer EN, Gustafson CJ, Davis SA, Feldman SR, Huang WW. Most common dermatologic conditions encountered by dermatologists and nondermatologists. Cutis. 2014;94(6).
2. Grada A, Muddasani S, Fleischer AB, Feldman SR, Peck GM. Trends in Office Visits for the Five Most Common Skin Diseases in the United States. Journal of Clinical and Aesthetic Dermatology. 2022;15(5). doi:10.1016/j.jid.2022.05.361
3. Awadalla F, Rosenbaum DA, Camacho F, Fleischer AB, Feldman SR. Dermatologic disease in family medicine. Fam Med. 2008;40(7).
4. Habif TP. Clinical Dermatology A Color Guide to Diagnosis and Therapy Sixth Edition.; 2015.
