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Dermatologists best suited to diagnose cellulitis, which resembles other conditions

Boston — Dermatologists are best positioned to accurately diagnose cellulitis, a common misdiagnosis for look-alike conditions ranging from stasis dermatitis to cutaneous cancers, according to Daniela Kroshinsky, M.D.

Many conditions resemble cellulitis, says Dr. Kroshinsky, assistant professor of dermatology and director of pediatric dermatology and inpatient education and research at Massachusetts General Hospital, Boston. "Therefore," she says, "utilizing a dermatologist is the best way to make sure that patients get appropriately diagnosed and treated."

In hospital settings, Dr. Kroshinsky says dermatologists could play a greater role in diagnosing cellulitis by consulting with emergency or internal medicine departments, ideally before patients are admitted. This way, "We could save patients from unnecessary stays and exposures to inappropriate antibiotics," she says.

In outpatient settings, Dr. Kroshinsky suggests that whenever possible, primary care physicians refer patients with suspected cellulitis for urgent dermatology visits. Several institutions and dermatology offices now offer urgent appointments for such purposes, she says.

Along with expanding the number of dermatologists and practices offering these appointments, "If community doctors had a list on hand of dermatologists who would participate in such a program — not only for cellulitis, but also for other urgent dermatologic conditions that come up in the primary care setting — it would be very beneficial for patients," she says. "The best person to make these diagnoses or recognize when we're dealing with a different diagnosis is a dermatologist."

Outside of dermatology, many physicians currently rely solely on clinical symptoms or physical examination findings to diagnose cellulitis, Dr. Kroshinsky says. "Many medical students are taught to look for redness, warmth, swelling and tenderness. But these clinical findings were originally assigned to describe inflammation in general. Somehow they became the sine qua non of cellulitis," she says. "If you don't have a differential (diagnosis) for other conditions that can look like cellulitis in the skin, then everything becomes cellulitis."

Different diagnoses

Dr. Kroshinsky says she commonly consults on cases that turn out to be Lyme disease. "We all know about the presentation of Lyme as a ring of erythema with central clearing," she says. "That's what most of our patients are taught to look for. But really, a much more common presentation of erythema migrans is homogenous erythema that can mimic cellulitis. Consultant teams are usually very surprised" that what they suspected was cellulitis is actually Lyme disease.

In another case, she says, "We were called to see a patient who had radiation to her skin years prior for an internal cancer. She was given an antibiotic that caused radiation recall. Usually, we think about that happening with chemotherapies, but we're seeing it happening with antibiotics as well — particularly the fluoroquinolones."

Accordingly, it's becoming a much more common phenomenon because years after radiation treatment, people are more likely to get antibiotics than chemotherapy, Dr. Kroshinsky says, adding that she and her colleagues also have consulted on many suspected cellulitis cases that led to the discovery of cutaneous and internal cancers.

Medical literature reveals misdiagnosis or "pseudo-cellulitis" rates of 14 to 33 percent, Dr. Kroshinsky says. "Our own data (unpublished) from Massachusetts General Hospital showed a rate of about 18 percent (Kroshinsky D, Bailey E. Medical Dermatology Society Annual Meeting. February 3, 2011. New Orleans)," she says. "It's quite variable, depending on whose study you look at."

Combining home-care regimens with office laser procedures helps dermatologists achieve better results when targeting almost any skin problem, says Ranella Hirsch, M.D., clinical assistant professor of dermatology, Boston University School of Medicine. Not only do patients benefit from the laser treatment, the home-care regimen can offer an "extra oomph," Dr. Hirsch says.

Because melanoma in children occurs very rarely, dermatologists should prioritize only those types of melanocytic nevi that can pose problems: Spitzoid nevi and large congenital melanocytic nevi (CMN), according to Elvira Moscarella, M.D.

Modern diagnostic skin evaluation tools such as dermoscopy and mole mapping with total body photography (TBP) have proven very useful in the diagnosis of suspicious cutaneous lesions and early recognition of malignant melanoma (MM). The combination of these two technologies can result in even more accurate assessment of the lesions viewed, according to Joseph Malvehy, M.D., coordinator, Melanoma Unit, department of dermatology, Hospital Clinic IDIBAPS, Barcelona, Spain, at the 2011 International Melanoma Congress.

The combination of a topical corticosteroid with a physiologic lipid-containing product is an effective approach for the management of atopic dermatitis and other steroid-responsive dermatoses because it simultaneously addresses disease-related inflammation and the barrier impairment that can be worsened by a topical corticosteroid alone, according to Matthew J. Zirwas, M.D.

During the last week of March, the U.S. Supreme Court will hear oral arguments on challenges made by 26 states and a small business organization that provisions of the new healthcare reform law are unconstitutional, a major step toward an eventual ruling by the high court later this year. A provision that directly affects many physicians also would be wiped out if the court rules against the entire law.