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Managing dermatology cases

A step-by-step guide to managing dermatology cases efficiently in primary practice, from booking appointments to monitoring and review

17 April 2018, at 12:03pm

A recent survey of the UK veterinary profession (Nielsen, 2014) revealed that dermatological disease was the most common complaint reported in companion animal practice, occurring in no less than 32% of dogs and 27% of cats presented. In referral practice, dermatology specialists routinely emphasise how important a thorough history can be in assessing a case and as the history often stretches back over several years and different clinicians, this can take time to gather, extending the consultation. The challenge therefore, in primary practice, is to cover the same ground effectively and efficiently in a much shorter time slot. 

Booking in 

The streamlining process starts with the initial client contact; reception staff should ensure that the following key details are obtained in addition to the standard contact and animal information: 

  • Nature and duration of problem.
  • Prior history and treatment – it is often useful to print out a long history as this can be reviewed far more rapidly on paper than on a computer screen and can be annotated to highlight details. If this is done in advance, it will allow the clinician to spend the valuable consultation time examining the patient.
  • Permission to see the case if it is coming from another practice and request history. 
Clinical challenge: What questions would you ask the owners of this eight-year-old crossbreed presenting with severe dorsal pruritus of 12 months’ duration?
Clinical challenge: What questions would you ask the owners of this eight-year-old crossbreed presenting with severe dorsal pruritus of 12 months’ duration?

This case is all about history. The pruritus was caused by a Malassezia overgrowth between the folds of skin on the back that quickly responded to shampooing. Your questions should have included request for information about the duration of the hair loss which would rapidly have led to breeding. This is a German Shepherd/Chihuahua crossbreed and has been bald since birth!

Appointment allocation 

It is important to decide who will see the case and how long will be allowed for the initial consultation. If there is a clinician in the practice with an interest in dermatology, they should be the first choice for a new case. If this is a follow-up, it should be booked in to see the clinician who last saw the case to ensure continuity. This is much more important than it may seem as it will shorten subsequent consultations, permit effective monitoring of progress and treatment and help to build the co-operative clinician/client relationship essential for long-term management. 

  • Normal appointment – the clinician should be advised in advance that a skin case is booked. 
  • Extended appointment – some practices routinely book a double appointment for new skins.

The goal at each visit should be to definitively eliminate one or more differentials

  • Special appointment – consider booking an extended appointment during a quieter period of the day. Many clients will respond very positively to the suggestion of special treatment.

Double or extended appointments should not be loss-leaders and need to be charged for appropriately, as a substantial proportion of the final cost to the owner will consist of consultation charges. 

Consultation priorities 

There will often be a limited time available and it will not be possible to review the whole history during the first consultation. Ensure that the owner understands this and that further visits will be required. Explain that a systematic, step-by-step process of investigation is needed to achieve a long-term solution and that effort and patience will be required. 

History and clinical examination – try to identify the principal problems that concern the owner and focus questions on the areas that will help you quickly understand those specific issues. 

Clinical pathology – some samples can be collected and examined within a short consultation. Other samples require longer as may a more detailed clinical examination. Admit the patient to do the job thoroughly. 

Action plan – the goal at each visit should be to definitively eliminate one or more differentials. A parasitic, infectious or allergic component can usually be readily recognised and addressed. Endocrine issues will require further investigation as will any suspicion of neoplasia. Anything that does not respond to empiric treatment or which cannot be readily and reliably categorised needs to be admitted for sampling or biopsy.

Follow ups – it cannot be over-emphasised how essential follow-up appointments are as each consultation builds upon the previous one. The same clinician should see the case on each occasion to avoid wasting time catching up. Progress will not be made if a problem can relapse before a revisit is booked and it is unreasonable to expect owners to recognise when treatment should change or be stopped.

The secret of successfully managing dermatology cases in practice is to break the consultation and investigation processes down into shorter, achievable phases which follow on from each other to maintain momentum and continuity. This places considerable emphasis on communication skills as the clinician must collect a concise history, clearly explain the goals and processes involved and maintain owner motivation and support. 

Monitoring progress 

Many dermatology cases require long-term monitoring as the underlying problem cannot be eliminated. Owners should be made aware that this may happen and know how to respond. This may involve changing treatment or contacting the practice.

Monitoring/maintenance review appointments – for long-term or life-long problems such as atopy and the endocrinopathies, regular monitoring revisits are useful as the clinician will gain a better understanding of the day-to day problems the case presents and be able to encourage and support the owner. It also provides an important opportunity to monitor treatment and make sure that an appropriate treatment protocol is adhered to and is not being altered or added to by the owner.

It cannot be over-emphasised how essential follow-up appointments are as each consultation builds upon the previous one

Relapses – the original clinician will have the clearest understanding of the clinical pattern and history, progress of the problem and details of management. These will not have to be repeated or looked up by someone new to the case. Failure to do this regularly leads to owner dissatisfaction and disillusionment and cases will be lost to follow-up, resulting in unnecessary prolongation. 

Problem cases 

  • Establish treatment continuity and check treatment dose, frequency and storage. 
  • Establish relapse interval and look for patterns that may have been overlooked. 
  • Check any assumptions that have been made to see if they are still valid. 
  • Consider a case review with colleagues. Sometimes a fresh pair of eyes is all that is needed to identify where further investigation, or an alternative interpretation, is required. Colleagues may recall seeing or reading about a similar case and be able to outline what was done to confirm the diagnosis and avoid any pitfalls. 
  • Telephone advice is available through most of the referral centres, both university-based and those in private practice. Excellent quality photographs are invaluable, as is a complete history and all relevant laboratory work. Remember most clinical software stores laboratory results as attachments that will not automatically be displayed when the records are emailed or printed. 
  • Referral to a specialist centre is always an option, but should not be left until the owner’s patience or finances are exhausted or the pathology has become irreversible.

Learn more
Dermatology
References
Author Year Title
Nielsen, T. D., Dean, R. S., Robinson, N. J., Massey, A.and Brennan, M. L. 2014 Veterinary Record, 174, 324.