Skin conditions comprise 17% of all problems encountered in general practice.1 General practitioners (GPs) require a wide range of expertise for skin complaints, including diagnosis and management of acute and chronic skin conditions, skin cancer screening and diagnosis, performance of diagnostic biopsies and/or definitive excisional treatment, referral or collaborative care with non-GP specialists and preventive care.
Chronic skin disorders are estimated to affect 4% of the Australian population, with eczema and psoriasis being the most common chronic skin conditions, affecting 1% and 2.5% of Australians respectively.2 In the paediatric population, dermatitis/eczema was managed in 6.9 per 100 GP encounters.3 GPs should be aware of the medical and psychosocial dimensions of chronic skin disease, where a biopsychosocial approach is more likely to result in a more personalised and holistic management plan.
At least two in three Australians will develop skin cancer before the age of 70.4 Pre-cancerous and cancerous skin lesions, including melanoma, comprise 2.2% of encounters in general practice.1 Even in melanoma, GP involvement may include definitive management, where the GP has appropriate training and skill.5 Australia’s high survival rate for skin cancers reflects that access to effective primary care services for early detection and evidence-based treatment of skin cancers is successful.6 As most skin cancer is preventable, GPs have a crucial role in educating patients about sun-smart behaviours, as well as early detection of new or changing lesions.7
Skin conditions may be a manifestation of systemic illness, including erythema nodosum, cutaneous vasculitis, and cutaneous manifestations of autoimmune diseases.8 GPs are required to recognise seriously ill patients who may present with a dermatological condition or manifestations including meningococcal septicaemia. Patients who are immunosuppressed warrant additional skin surveillance. Infective illness may also present with iconic cutaneous signs, particularly in the paediatric population, including coxsackie, varicella and parvovirus. Skin lesions caused by Group A Streptococcus may precede the development of rheumatic fever and rheumatic heart disease which disproportionately affects Aboriginal and Torres Strait Islander peoples.9 However, amongst Aboriginal and Torres Strait Islander peoples, the three most common skin-related presentations are routine full skin check, eczema and actinic keratosis.10
Dermatology requires a particular diagnostic skillset. A structured and careful approach to the evaluation of skin lesions is required, including the ABCDEFG or Chaos and Clues approaches. Dermoscopy is an important diagnostic skill and, in a recent study, was used in 61% of registrar consultations involving skin changing the provisional diagnosis in 22% of instances.11
Procedural skills are key to management of skin conditions in general practice.12 Of the 10 most common problems managed with a procedural component, five are skin complaints including skin lacerations, solar keratosis/sunburn, warts, malignant neoplasms of the skin, and skin ulcers.1 The range of surgical skills required by GPs varies, with GPs in areas with particularly high prevalence of skin cancer performing increasingly technical procedures in the treatment of skin cancers.13 Such advanced technical skills require GPs to undertake additional specialised training. GPs will also need to understand the local burden of disease, availability of local medical expertise, and seek opportunities for formal training to meet community needs, particularly in rural and remote locations. It is important to appreciate the barriers that some patients may experience, particularly those from less socially advantaged backgrounds.
Referrals for skin complaints may be to dermatologists, general or plastic surgeons, paediatricians, or immunologists. As skin disorders are also associated with psychosocial impacts, allied health support also forms part of multidisciplinary care.14