Thanks to the insightful teaching of Seinfeld, we know dermatology’s scope exceeds that of “Pimple Popper, MD“. However, when an article published reviewed the rate of misdiagnosis of cellulitis in the hospital, pegged the costs half a billion dollars per year, and suggested a dermatologist be involved in every case where the skin ain’t look right – I was skeptical.
This publication details the results of a trial in which patients admitted with a diagnosis of cellulitis were randomized to either consultation of with a dermatologist within 24-hour of admission or to routine medical care. And, by consultation with a dermatologist – actually just one dermatologist, the senior author on the paper. Over the five year-study period, this dermatologist screened 1,300 patients for potential inclusion, yielding 175 for randomization. The primary outcome, a little unclear from the clinicaltrials.gov registration, is either antibiotic usage or inpatient length-of-stay.
Regardless, the dermatology consultation appeared to improve medical care, although the magnitude of the benefit is more difficult to pin down. The dermatologist identified approximately an excess of one-quarter of the cases to be “pseudocellulitis” – venous stasis dermatitis, erythema migrans, contact dermatitis, or some such ilk – leading to changes in therapy based on misdiagnosis. Both length-of-stay and antibiotic-free days displayed modest absolute gains in those evaluated by dermatology. The author further tabulated her other recommendations for treatment, including wound care, steroid treatment, and additional testing, and suggests there are many peripheral benefits to specialist involvement.
This is all fairly reasonable at face validity, although it is nearly impossible to generalize this single-institution, single-dermatologist, low-enrollment study to general practice. Given the scarcity of dermatology specialists in many settings, it would take some substantial innovation to find a cost-effective and high-value protocol for utilization.
“Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis”
https://jamanetwork.com/journals/jamadermatology/fullarticle/2672582
At least this emphasizes the importance of a differential diagnosis when considering cellulitis.
My favourite is “bilateral cellulitis.”
It could happen! The bacteria just jump from one shin to the other ….
Almost like the obvious CHF or ESRD patient referred to the ED for bilateral LE ultrasound to r/o DVT ….
Can’t read the pay-walled article but I would guess 90% of that 25% is stasis and not more exotic diagnoses like EM etc..
I’m usually impressed by just how unhelpful the formal derm consult is even for the less straight-forward cases. I wonder if the dermatology part is critical or if what’s needed is simply a 2nd tiebreaker opinion to go give the admitting doc some extra courage and even liability to go with common sense and go against the anchored cellulitis diagnosis.
I expect it’s more along the lines of a “tiebreaker opinion” rather than exotic irreplaceable expertise – a lot easier to go along with discontinuing antibiotics if your buddy also concurs. I think it’s reasonable to consider some role for early involvement of additional resources or expertise when there is diagnostic uncertainty, but I don’t think the value is there, routinely.
Agreed. We have a pretty cool antibiotic stewardship committee of ID docs that routinely scans charts of patients on antibiotics and they occasionally just call and say “hey I noticed your guy is still on blah.. what’s going on there?” Often I forgot or was on the fence to d/c the antibiotic anyway and it gives me that extra bit of courage to do the right thing.