Dermatology

Overview

Dermatologic diseases are one of the most common complaints encountered in primary care. During your rotation you will spend 3 full days per week working with Dr. Jane Rowe, a Board Certified Dermatologist. There you will see numerous patients and gain hands-on experience performing dermatologic procedures. In addition, for one half day every week, Dr. Rowe has arranged for residents to see their own panel of patients in her office where they will evaluate the patient and develop a differential diagnosis and a treatment plan regarding the patient's dermatologic complaint(s).

This is consistently rated as an outstanding rotation.

Altoona Family Physicians
Dermatology

Competency-based Goals and Objectives

Resident Year: PGY 2

AFP Faculty Contact: Laura Siems, MD

Specialty Contact: Jane Rowe DO

Please call the office (946-1655) prior to the start of the rotation to make arrangements of where and when to report on the first day.

Rotation description and general goals:

Dermatology is a primarily outpatient rotation required in the second year of residency. During this rotation, residents will see patients with Dr. Rowe, a board-certified dermatologist, in her office. The resident will learn preventative and therapeutic measures as they impact the care of the skin. There will be ample opportunity to learn procedures such as skin biopsy, excision of a variety of skin lesions, techniques in suturing, and cryotherapy under Dr. Rowe’s supervision. The clinical rotation is supplemented by scheduled noon conferences throughout the year, required and suggested readings, and longitudinal care at the family medicine center.

Resident Evaluation:

Written evaluation will be provided by Dr. Rowe at the end of the rotation. The resident also provides written evaluation at the end of the rotation.

SAMPLE SCHEDULE:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
AM Noon PM	Derm Conf Derm	AFP Conf AFP	AH-Ostom Derm	AFP Conf AFP	Derm Conf Derm
AM Noon PM	Derm Conf Derm	AFP Conf AFP	Derm Derm	AFP Conf AFP	Derm Conf Derm
AM Noon PM	Derm Conf Derm	AFP Conf AFP	Derm Derm	AFP Conf AFP	Derm Conf Derm
AM Noon PM	Derm Conf Derm	AFP Conf AFP	Derm Derm	AFP Conf AFP	Derm Conf Derm

Derm = Dr. Jane Rowe’s office

AFP = Altoona Family Physicians

AH = Altoona Hospital

AH-Ostomy = Wound and ostomy clinic; 8 am – noon; 3^rd Floor Towers

Conf = Noon teaching conference 12:30 – 1:15 pm

A week of vacation time may be taken during this rotation

Competency 1: Patient Care: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

	Perform a thorough history and skin exam and be able to adequately describe the findings
	Distinguish findings that are normal, transient, and clinically insignificant from those that require further observation and treatment
	Gain experience in common procedures such as biopsy, lesion removal, incision and drainage, and cryotherapy
	Be aware of the impact of skin problems on a patient and be able to counsel patients about treatment options and about prevention with respect to common skin conditions, such as preventing sun damage and recognizing worrisome skin findings

Competency 2: Medical Knowledge: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to:

	Recognize and understand the epidemiology of the most common lesions and rashes in children and adults, referring to the AAFP Recommended Core Educational Guidelines for Family Practice Residents for guidance (attached)
	Define terms that describe the morphology, configuration, texture, location, color and pattern of skin lesions
	Understand the indications for topical and oral dermatologic medications and be familiar with acne medications, antibiotics, antifungals, and antivirals as they pertain to the skin
	Demonstrate appropriate topical steroid selection based on indication, potency and vehicle (cream, ointment, etc)

Competency 3: Practice Based Learning and Improvement: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to

develop skills and habits to be able to meet the following goals:

o identifies strengths, deficiencies, and limits in one’s knowledge and expertise;

o set learning and improvement goals;

o identifies and performs appropriate learning activities;

o systematically analyzes practice using quality improvement methods, and implements changes with t

	Locate, appraise and assimilate evidence from scientific studies that relate to the health problems of patients who are seen on the Dermatology rotation
	Use information technology to manage information, access on-line medical information and support their own education.

Competency 4: Interpersonal and Communication Skills: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to:

	Create and sustain a therapeutic and ethical relationship with patients
	Provide appropriate patient education on dermatologic diagnoses and treatment plans based on the literacy level of patients and their caregivers
	Help communicate the dermatologist’s treatment plan with the patient’s primary care physician

Competency 5: Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to

	Dress appropriately based upon the standards of attending physicians in the office setting
	Be prompt in arriving at the office
	Maintain confidentiality at all times
	Complete any readings or other adjunct educational materials provided by the attending dermatologist
	Demonstrate sensitivity and responsiveness to patients’ perceptions of illness and include patient preferences in formulation of treatment plans
	Demonstrate sensitivity and responsiveness to the patient’s culture, age, and other special circumstances
	Demonstrate personal accountability to the well being of the patient including following up on lab results, maintaining comprehensive and legible notes, and seeking answers to patient care questions

Competency 6: Systems-Based Practice: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

	Understand the indications for referral to a dermatologist and how those referrals are generated
	Describe ways in which the primary care provider and specialist can work as a healthcare team when providing care to patients with chronic skin conditions
	Demonstrate sensitivity to the costs of clinical care in dermatology and take steps to minimize costs without compromising quality
	Understand the formulary implications for medication selection based upon insurance coverage or lack of coverage for any given patient
	Recognize and advocate for patients and families who may need assistance in dealing with system complexities

Required Reading

FP Essentials 345: Skin Disorders Update (monograph available in the conference room)

Additional Resources

Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy

Pfenninger JL and Fowler G. Procedures for Primary Care

Online Resources

http://library.med.utah.edu/kw/derm/ - Dermatology Image Bank in Utah

http://telemedicine.org/stamfor1.htm - Electronic Textbook of Dermatology

www.dermis.net - useful materials from Univ. of Heidelberg, Germany

Knowledge Guidelines

AAFP Core Educational Guidelines

Conditions of the Skin

A. Basic components of dermatology

1. Normal anatomy, development, and physiology

2. Risk factors

a. Congenital

b. Acquired

c. Aging

3. Prevention

a. Patient Education

b. Compliance

4. Diagnostic guidelines

a. Arrangement, distribution, type and pattern of lesions

b. Type of lesion: primary / secondary; macular / popular/ vesicular / nodular; tumor

c. Specific lesion sites

d. Seasonal variation / onset

5. Therapeutic considerations

6. Systemic evaluation (if indicated)

B. Common dermatologic problems

1. Skin problems

a. Papulosquamous disease

1. Seborrhea and dandruff

2. Psoriasis

3. Pityriasis rosea

4. Miliaria (prickly heat)

5. Lichen planus

b. Vesiculobullous diseases

1. Impetigo

2. Herpes simplex

3. Herpes zoster

4. Varicella

5. Pemphigoid

6. Pemphigus

7. Dyshidrosis

8. Erythema multiforme

9. Dermatitis herpetiformis

10. Epidermal necrolysis

11. Epidermolysis bullosa

c. Dermatitis

1. Contact

2. Atopic

3. Generalized exfoliative

4. Nummular

5. Stasis

6. Diaper rash

d. Macular eruptions

1. Viral exanthems

2. Drug reactions

e. Urticarial eruptions

1. Urticaria

2. Dermatographism

f. Nodules

1. Erythema nodosum

2. Dermatofibroma

3. Granuloma annulare

4. Sarcoid

5. Cysts

g. Other pruritic conditions

1. Generalized

a. Scabies

b. Dry skin (asteatosis)

c. Secondary systemic disease

2. Localized

a. Lichen simplex chronicus

b. Pruritus ani

c. Pediculosis (lice)

d. Chigger and other insect bites

h. Cutaneous infections

1. Bacterial

a. Impetigo

b. Erysipelas

c. Lymphangitis

d. Cellulitis

e. Boil (furuncle, pustule, folliculitis, abscess, carbuncle, ecthyma)

f. Erythrasma

2. Mycobacterial

a. Atypical mycobacterial

3. Fungal

a. Superficial fungal infections (intertrigo)

b. Deep fungal infections

4. Viral

a. Herpes simplex

b. Herpes Zoster

c. Warts

d. Molluscum contagiosum

5. Rickettsial

a. Lyme disease

b. Rocky Mountain spotted fever

i. Complexion and cosmetic problems

1. Acne vulgarus

2. Acne rosacea

3. oily skin

4. enlarged pores

5. milia

6. vascular lesions

7. wrinkles

8. keloid

9. hyperhidrosis

j. Cutaneous injuries

1. Burns

a. Thermal

b. Chemical

c. Sunburn

2. Blister

3. Abrasion

4. laceration

5. bruise

6. bites and stings

k. Pigment disorders

1. Hyperpigmentation

2. Hypopigmentation

a. Pityriasis alba

b. Vitiligo

3. Tinea Versicolor

l. New Growths

1. Benign

a. Inflammatory lesions

i. Acne cyst

ii. Boil

iii. Hidradenitis

iv. Pyogenic granuloma

b. Hyperplasia

i. Verruca (common, plantar, anogenital, flat)

ii. Molluscum contagiosum

iii. Corn and callus

iv. Epidermal cyst

v. Skin tag (acrochordon)

vi. Xanthelasma

c. Neoplasia

i. Seborrheic keratosis

ii. Mole, nevus (intradermal, junctional, compound, halo, blue, congenital)

iii. Lipoma

iv. Dermatofibroma

v. Keloid

vi. Hemangioma

vii. Neurofibroma

2. Premalignant

a. Squamous cell carcinoma in situ (Bowen’s disease)

b. Actinic keratosis

c. Disseminated superficial actinic porokeratosis

d. Leukoplakia

e. Keratoacanthoma

f. Erythroplakia

g. Premelanoma

i. Lentigo maligna

ii. Giant congenital nevus

iii. Dysplastic nevus syndrome

h. Radiation effects

3. Malignant

a. Basal cell carcinoma

b. Squamous cell carcinoma

c. Melanoma

i. Major clinical categories

ii. Prognostic and therapeutic guidelines

d. Paget’s disease

e. Cutaneous lymphoma

f. Kaposi’s sarcoma

g. Metastases to the skin

m. Cutaneous manifestations of systemic disease, including HIV infection and syphilis

n. Occupational skin disease

2. Hair Problems

a. Fungal infection

b. Nonscarring alopecia

1. androgenic (male pattern)

2. alopecia areata / totalis / universalis

3. telogen effluvium

4. traction alopecia and trichotillomania

5. endocrine effects

6. discoid lupus erythematosus

7. lichen planopilaris

c. Ingrown hair (pseudofolliculitis)

d. Hypertrichosis

1. localized

2. virilizing causes of hirsutism

e. Texture alterations (hair dystrophy)

3. Nail problems

a. Trauma

b. Disturbances associated with other dermatoses

c. Disturbances associated with systemic illness

d. Texture alteration

e. Fungal infections

f. Periungal and subungal conditions

1. ingrown nail

2. paronychia

3. hematoma

g. Discolored nails

h. New growths

1. benign

a. inflammatory

i. granuloma

ii. wart

b. neoplasia

2. malignant

a. melanoma

b. squamous cell carcinoma

4. Mucous membrane lesions

5. Oral lesions

a. Thrush

b. Mouth ulcers

c. Sicca

d. Oral hairy leukoplakia

e. Geographic tongue

f. Black hairy tongue

g. Leukoplakia

h. Cheilitis

i. Lichen planus