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What PCPs need to know about early detection of serious skin conditions
Primary care physicians are responsible for detecting and managing a wide variety of conditions, and for some patients, the PCP may be the only doctor they visit with regularity. Because early detection of serious skin conditions like melanoma is crucial to preventing its spread and possible mortality, PCPs can play an important role as the first clinician to see signs of this potentially deadly disease.
According to a study conducted at the University of Pittsburgh Medical Center, skin care screenings performed as part of a routine PCP visit resulted in increased detection of melanoma in situ, a precursor of melanoma that is not competent for metastasis.
“Because the skin is our largest organ, and because the skin is visually possible to inspect in routine clinical examinations, I personally believe that a patient’s annual examination by their primary care physician is incomplete without a survey of the skin,” John M. Kirkwood, MD, professor of medicine, dermatology and clinical and translational science at the University of Pittsburgh School of Medicine and director of the Melanoma Center at UPMC Hillman Cancer center, told Healio Family Medicine.
“The survey of the skin is of inestimable value. Truly, it is the one chance to pick up new, changing or unusual pigmented lesions and other spots on the skin that represent early emerging cancer.”
PCPs can also play an integral role in managing a wide variety of other skin conditions, some of which may also have systemic manifestations.
“I think the primary care doctor’s role is in helping to triage what’s concerning and what warrants referral to a dermatologist,” Laura Korb Ferris, MD, PhD, associate professor of dermatology at UPMC’s Melanoma Center, told Healio Family Medicine. “The PCP is able to manage very common, low-risk conditions like acne or fungal infections of the skin and can also recognize when what they’re doing isn’t working and it’s time for the patient to see a specialist.”
The value of training
In the study performed at University of Pittsburgh Medical Center , PCPs were offered an online training course in skin cancer screening. They were then instructed to include an annual skin examination for all patients aged 35 and older as part of their routine visit. Patients who received the skin cancer screening were compared with unscreened controls.
The researchers found that in the group of patients screened by PCPs, melanomas were diagnosed more frequently vs. the control patients (1 per 1,078 in the screened group vs. 1 per 2,489 in the unscreened group). Melanomas identified in the screened group were also thinner at detection and more likely to be in situ.
“Melanoma in situ is a preinvasive melanoma,” Kirkwood said. “It is like cervical carcinoma in situ and many other in situ neoplasms, which are not yet invasive melanomas, and that is a huge plus.”
Kirkwood said educational programs like the Internet Curriculum for Melanoma Early Detection, or INFORMED, the one used in the University of Pittsburgh Medical Center study, have potential to provide the PCP with the skills needed to detect melanoma as early as possible.
“With training, whether it’s the INFORMED module or a derivative thereof, or whether it’s training that can be done person-to-person in seminar settings in other ways, the adequately trained primary care physician is the one person who can broadly implement early detection of melanoma,” he said. “What does this mean in terms of the potential to cure melanoma? The earlier you detect melanoma, the less likely it will have traveled to lymph nodes or to have metastasized anywhere.”
Kirkwood noted that the program has shown good results, but its impact is limited since it and other educational initiatives like it are not widely available to PCPs.
“Within our health system, we have 500 doctors that we’ve tried to educate through the internet, but this is just one health plan confined to one set of physicians,” he said. “This should be part of the family practice academy and the other general internal medicine reviews every year.”
Performing the exam
Kirkwood said he believes PCPs should conduct a 5-minute examination of their patients’ skin while the patient is fully disrobed.
As far as what they should look for, unusual pigmented lesions are often the entity we see that results, upon biopsy, in showing us melanoma,’ he said. “A mole which is different from other moles of a particular patient is immediately suspect. A pigmented lesion that is either new to the physician’s eye or changing to the physician’s eye, is also something to look for. These are the simple three that physicians should factor into their evaluations.”
Kirkwood cited the ABCDE method of melanoma detection: asymmetry, border irregularity, color, diameter and evolution, in terms of detecting melanoma at the earliest possible point.
“If you wait for the ABCDEs, you will have invasive melanoma, and we want to detect melanoma before it becomes invasive,” he said.
Ferris discussed the “Ugly Duckling Method,” which is focused primarily on taking notice of moles that might look different from other moles on a particular patient’s body.
“The PCP should be looking for the ‘Ugly Duckling’ sign, they’re looking for spots that are suspicious for melanoma, basal cell or squamous cell carcinoma,” she said. “So maybe patches or spots on the skin that are growing or bleeding easily. Anything that the patient points out as being new or growing rapidly should be considered.”
As much benefit as skin care exams by PCPs would seem to offer, the U.S. Preventive Services Task Force in 2016 gave these exams an “I” designation, meaning that there was insufficient evidence to recommend exams by PCPs on asymptomatic patients.
“I think the counterpoint to that is that skin examination, and even a skin biopsy, are not invasive procedures and don’t put the patient at risk from radiation. This is not colonoscopy or a mammogram we’re talking about.” she said. “This is having your patients disrobe for a less than 5-minute skin survey that has the chance to prevent mortality.”
In some cases, Ferris said, it may be beneficial for a PCP to do a skin biopsy on a suspicious lesion, provided they feel comfortable doing so.
“Probably, ideally, these patients should be sent to the dermatologist, and let the dermatologist decide what’s going on and do a biopsy if needed,’ she said. “But if they (the PCP) think the patient is unlikely to keep an appointment with the dermatologist, and they are comfortable with it, they should consider doing a skin biopsy.”
Ferris said PCPs are often very busy and are asked to provide assessment and care across a wide variety of conditions. For this reason, she said, PCPs might need to decide which patients would benefit most from a full skin examination.
“For example, if a patient has elevated blood pressure and uncontrolled diabetes, that patient may need to have these more urgent issues prioritized over a skin cancer screening examination,” she said. “Butfor a patient where sun exposure is one of their major health risks, doing the full skin check is great. I think you have to look at it from the perspective of each patient, determine who is at highest risk, and determine if your training is sufficient to identify skin cancer if you see it.”
A positive influence
Another benefit to PCPs assessing patients for skin cancer is that, as the physician with the most regular access to the patient, he or she can convey important information about skin cancer risk across a lifetime.
“We do know that sun exposure is the biggest risk for melanoma, basal cell, and squamous cell carcinoma — the ‘big three’ that we see,” Ferris said. “So, with our adult patients, we can remind them that summer’s coming up, and that they should make sure to protect their skin from the sun. This can mean wearing a hat, wearing sunscreen, and seeking shade when you’re outdoors.”
Similarly, she said parents should be informed of the risk to their children of sun exposure early in life, which is thought to be particularly damaging.
“For parents, it’s a matter of telling them that the sun exposure that kids get early in life is probably associated with an even higher risk of skin cancer than what they might get when they’re older,” she said. “So, this is the time that it’s important to really protect your kids. Sunscreen should be used in babies over 6 months of age. Get kids used to wearing hats and protective clothing at the pool. Encourage playing in the shade, finding a playground that has shade-covering is helpful.”
Ferris said promoting healthy sun protection habits from an early age is akin to promoting healthy eating habits in children.
“We try to model good health habits to them when they’re kids, because that’s a big determiner of the choices they’re going to make as an adult,” she said. “If you get a child to become used to wearing sunscreen and protecting themselves against sunburn, they’ll make better choices as adults, too.”
The PCP and psoriasis
Psoriasis is another skin condition that PCPs may be able to easily recognize during a routine examination.
“The diagnostic criteria for psoriasis are well-known,” Kirkwood said. “It presents as plaques and papules on the contact surfaces like the elbows, the knees, and so forth.”
Ferris said.
“That becomes an issue because they’ll get better temporarily, and then they’ll get much worse, and it makes them harder to treat.”
for cardiovascular disease, Ferris said, and PCPs should keep this in mind when assessing these patients.
toward lifestyle modifications that will reduce their cardiovascular risk,” she said. “Usually it’s weight loss and smoking cessation, but also we want to keep an eye on things like serum lipid levels. We see a higher rate of obesity and diabetes in patients with psoriasis, so we try to help them keep that under control.”
When to refer
While PCPs can make a significant difference in detecting and managing skin conditions in their patients, it is also important for the PCP to know when a patient would benefit from a referral to a specialist. In particular, Ferris said, referral may be wise for a patient who presents with signs of systemic illness along with the skin condition.
“If a patient has a rash and feels fine otherwise, that’s something the PCP can likely manage, but if that patient also has a fever, or they have joint pain, that’s definitely a sign that this might be more than just a little rash,” she said. “This is probably the kind of thing their dermatologist needs to see.”
Additionally, a patient who develops a rash after recently starting a new medication — within the past 3 weeks — might need to be checked by a specialist, Ferris said. Ultimately, she said, any condition the PCP has been treating without improvement should be referred.
“Sometimes it’s not that it’s a matter of life or death, but sometimes we see patients who have been struggling with a condition for 2 years, and they can’t seem to get better, even with treatment from their PCP,” she said. “Then they come and see us, and we know exactly what it is, and can get it better in one visit. So if your first or second treatment option doesn’t work, consider sending them to a specialist, because it might just get them the right diagnosis and the right treatment sooner.” – by Jennifer Byrne
Reference:
For more information: Laura Korb Ferris, MD, can be reached at 3602 Fifth Avenue #5A, Pittsburgh, PA 15213; email:
ferrlk@UPMC.EDU. John M. Kirkwood, MD can be reached at 5115 Centre Avenue, Pittsburgh, PA 15232; kirkwoodjm@upmc.edu
Disclosure: Neither Ferris nor Kirkwood report any relevant financial disclosures.